UNITED STATES OF AMERICA

WASHINGTON,  D. C.
OPO  16—67244-1 
 
 
            DUPLICATE

  From the PiibBe Ubyiry of the City of
Boston.
?r PBJM.N rjcs DEKT
      PUBLIC   LIBRARY
                 or TH«
CITY   OF   BOSTON.
   ABBREVIATED  REGULATIONS.

  One volume can be taken at a time from the
Lower Hall, and one from the Bates Hall.
  Books can be kept out 14 days.

  A fine of 2 cents for each volume  will be
incurred for each day a book is detained more
than 14 days.
  Any book detained  more than a week be-
yond the time limited,  will be sent for at the
expense of the delinquent.
  No book is to be lent out of the household
of the borrower.
  The Library hours for the delivery and re-
turn of books are from 10 o'clock, A. M., to
8 o'clock, P. M., in the Lower Hall; and from
10 o'clock, A. M., until one half hour before
sunset in the Bates Hall.
  Every book must, under penalty of one  dot
lar, be returned to the Library at such time
in August as shall be publicly announced.
  The card must be presented whenever  a
book is returned.  For renewing a book  the
card must be presented,  together with  the
book,  or with the shelf-numbers of the book. 
 
PRESENTtD TO THE
^/vtt of ^C^v^
"1  ^
^
^y  /Quwv/Cr^f! '/U'%4s,._//'C. /;
• tfrrr,;.,,/. _ & ifa'O, Jf _MM._  . k, t&tfu£ 
 
DICTIONARY
                               OP


  PRACTICAL.  MEDICINE:

                           COMPRISING

                 GENERAL  PATHOLOGY,

THE NATURE AND TREATMENT  OF DISEASES, MORBID STRUCTURES,
    AND THE DISORDERS ESPECIALLY INCIDENTAL TO CLIMATES, TO THE SEX,
                AND TO THE DIFFERENT EPOCHS OF LIFE;

                              WITH

  NUMEROUS PRESCRIPTIONS FOR THE MEDICINES RECOMMENDED
      A CLASSIFICATION OF DISEASES ACCORDING TO PATHOLOGICAL PRIN-
           CIPLES, A COPIOUS BIBLIOGRAPHY, WITH REFERENCES;

                             AND AN

             ^pptntHv ot ^Cpjirorjetr iformulae:

     THE WHOLE FORMING A LIBRARY OF PATHOLOGY AND PRACTICAL MEDICINE,
                 AND A DIGEST OF MEDICAL LITERATURE.
BY  JAMES COPLAND,  M.D.
Consulting Physician to Queen Charlotte's Lying-in Hospital; Senior Physician to the Royal Infirmary
    for Diseases of Children ; Member of the Royal College of Physicians, London; Member
          of the Medical and Chirurgical Societies of London and Berlin, etc
      EDITED, WITH ADDITIONS,

BY  CHARLES A.  LEE,  M.D.
                      I00 33J
VOL. VI.          ^ '      JJ/'
y\
               NEW-YORK:

HARPER  &  BROTHERS,  PUBLISHERS,
               82 CLIFF STREET.
                       184 8. 
C78fd
  v. 6-


Entered, according to Act of Congress, in the year 1846, by
             Harper & Brothers,
In the Clerk's Office of the Southern District of New York.
/✓■7/ 
CONTENTS.
PALATE—Inflammation of -

PALPITATION, of the Heart,

PANCREAS—Disorders incident to
    Inflammation of
    Atrophy—Organic Lesions
    Bibliography and References -

PARALYSIS—Definition   -
    Pathological changes
    Palsy of Muscles, &c.
    Hemiplegia   -
    Concussion of the Brain -
    General  Palsy-   -
    in Infants and Children  -
    Shaking  Palsy    ...
    General  History of Palsy
    Complications, &c, of  -
    Diagnosis    ....
    Catalepsy    ....
    Treatment of Palsy
    Bibliography and References -

PAROTID GLAND—Diseases of -
    Treatment of -
PELLAGRA—Definition of -
    Treatment, &c.

PEMPHIGUS—Description of
    Causes and Treatment  -

PERIOSTEUM—Inflammation of
    Diagnosis, Causes, &c.  -
    Treatment, &c.
 4
 5
 7
11

12
13
14
17
20
21
24
25
27
29
32
42
45
54

55
57

59
63

64
68

69
71
72
PERITONEUM—Diseases of     -    -   73
    Chronic Inflammation of-     -    -   78
    Lesions in, &c.                     84
    Diagnosis    -----   91
    Treatment.....95
    Bibliography and References  -    -  105

PESTILENCE.....105

-------=----, CHOLERIC—Nosology,
  &c........107
    Progress and Mortality  -     -    -  109
    Description.....m
    Diagnosis.....117
    Causes, &c......us
    Treatment.....137
    Bibliography and References  -    -  151

  ---------, H^MAGASTRIC    -  152
    Description, &c.   ....  154
    Diagnosis—Prognosis   ...  162
    Causes, &c......169
    Its infectious Nature    ...  172
    Pathological Inferences ...  200
    Treatment, &c.    ....  203
    Yellow Fever, &c.  -    -    -    -  211
    Bibliography and References  -    -  216

----------, SEPTIC—Description -  217
    Symptoms, &c.    ....  221
    Causes of Plague  -                228
    Treatment, &c.    ....  255
    Bibliography and References  -    -  260

PESTILENCES—Protection from     -  261

PHLEGMASIA ALBA DOLENS -    -  279
    History and Description -    -    -  280
    Causes.....-  284
    Treatment.....287
    Bibliography and References  -    -  291

PITYRIASIS—Varieties of -    -    -  291
    Causes—Treatment    ...  295

PLEURA—Diseases of -    -    -    -  297
    Chronic Pleurisy   ....  308
    Pathology of  -    -    -    -    -  318
    Treatment.....327

-------,  STRUCTURAL  LESIONS
  of.......336
    Treatment, &c.    ....  339
    Bibliography and References  -    -  340

PLEURODYNIA—Causes—Description   341

PNEUMATHORAX—Symptoms of    -   342

POISONS—Symptoms—Treatment    -   346
    Corrosive poisoning     ...   369 
* 
DICTIONARY
OF
PRACTICAL   MEDICINE.
\r     ^
  PALATE.—Syn. Palatum, P. mnlle et durum.
    Palais, Ft.  Der  Gaumen,  Germ.   Palato,
    Ital.   The fauces.
    1. The mucous membrane covering the isth-
  mus faucium, the soft palate or uvula, may be
  simply relaxed, or inflamed, or ulcerated.  The
  hard palate—the bones of the  palate may be
  also diseased—may  be  inflamed  or ulcerated
  and carious, but chiefly as a symptom  of se-
  rious constitutional disease, especially of syph-
  ilis, more rarely of scurvy.
    I. Relaxation of  the  Palate and Uvula.
  —Relaxed throat—Relaxed sore throat—Catarrhal
 relaxation of the throat—Relaxation of the fauces.
     Classif.—I. Class, I. Order (Author).
   Defin.— Uneasiness or soreness in  the fauces,
 often with slight cough, without fever.
   2. This affection occurs 'primarily; but it also
 attends catarrhal and  other inflammations of the
 mucous membrane covering those parts and the
 tonsils and pharynx.   It is also symptomatic
 of catarrhal affections, of chronic bronchitis, of
 the several states of indigestion, and of numer-
 ous other diseases.   The  anterior  fauces, or
 velum palati, appears more or less relaxed, very
 humid or watery, with little or no increase, or
 only with slight increase of vascularity, and the
 uvula is elongated, and hangs down upon the
 base of the tongue, often reaching to the epi-
 glottis, and is sometimes also cedematous.  More
 or less uneasiness in  the throat, somewhat in-
 creased on deglutition, and occasionally a dry,
 tickling cough, particularly when  the relaxed
 uvula irritates the epiglottis, are  complained
 of.  Indeed, the elongation  of the uvula is gen-
 erally the cause of the chief uneasiness attend-
 ing relaxation  of the palate or fauces, which
 often becomes a chronic disorder, especially in
 leucophlegmatic habits, and in persons who live
 irregularly and intemperately.
   3. This affection, when it appears primarily,
 is generally caused by the same influences as
 produce inflammatory attacks of the palate or
 fauces (J) 6), and catarrhal affections.  It  rare-
 ly continues limited  to these parts, but extends
 to the adjoining surfaces, to the  pharynx, epi-
 glottis, and larynx,  causing a tickling cough,
 with slight mucous expectoration.   It is fre-
 quent in  spring and autumn, especially during
 humid states of the air, and usually, with re-
 laxation or irritation of the  Schneiderian mem-
 brane, constitutes a  principal part of  the com-
mon catarrhal affection.  (See Art. Catarrh,
v7.)
  4. The  treatment necessarily  depends upon
the causes of the affection, and upon the nature
of the disorders of  which  it is symptomatic.
If a part of, or connected  with, the  common
      III             i
  catarrh, the treatment advised for that disorder
  (§ 16, et seq.) should be employed, and a warm
  embrocation may be applied to  the  neck or
  throat.   If it be a symptom of indigestion, ton-
  ics and astringent  gargles,  after biliary and
  intestinal secretions are evacuated, are gener-
  ally useful.   In  persons subject to dyspepsia,
  in those of a relaxed habit of body, and in the
  irregular liver, relaxation of the soft palate and
  uvula often becomes chronic, whatever means
  of cure be prescribed, especially if the liver be
  at the same time torpid, or otherwise disorder-
  ed.  In those persons the elongation is often
  attended by oedema  of the uvula, and is produc-
  tive of the most unpleasant part of the symp-
  toms.  Amputation of the part has, therefore,
  been often recommended, and too often allowed.
 Several persons who have had the uvula re-
 moved, have consulted me on account of disor-
 ders which had  either continued  or appeared
 after this part had been extirpated.   The func-
 tion of  the uvula is evidently to convey the
 mucus and saliva over, and thereby to lubricate
 the base of the tongue and epiglottis ; and when
 it is no longer, or is imperfectly discharged, not
 only those parts, but also the pharynx and glot-
 tis, become the seat of a chronic irritation more
 serious  than that caused by  an  elongation,
 which a judiciously-directed treatment to the
 original source of disorder would remove.
   5. If the elongation continue after such treat-
 ment, the hydrochloric or nitric acids, or both
 conjoined, may  be given  in  the decoction of
 bark, or in sirup with a tonic tincture, and as-
 tringent gargles  may be employed. If these
 fail, the uvula may be touched by a solution of
 the nitrate of silver,  or by a powder containing
 the sulphate of alumina or sulphate of zinc.
 II.  Inflammation of the  Palate.—Syn. Pal-
  atitis, Isthmitis, Hildenbrand.  Isthmitis sim-
  plex ; Angina simplex; Cynanche simplex;  An-
  gina gutturalis ; Angina mitis ; Angor Fau-
  cium ;  Inflammatio Palati; Injlammatio Fau-
  cium,  Auct. var.  Angine simple, Palatite, Fr.
  Die Rachenbraune,  Halsentzundung, Entziin-
  dung der Fauces, Germ.   Sore throat, Quinscy,
  Inflammatory Sore-throat.  Inflammation of the
  Fauces.
     Classif.—III. Class, I. Order (Author).
  Defin.—Redness of the soft palate, generally
with elongation of the  uvula, pain on swallowing,
and slight fever.
  6.  i. The  Causes   of Palatitis are  chiefly
those productive of Catarrh (§ 4, etseq.).  The
disorder  is most  prevalent in  spring and  au-
tumn, in  which seasons especially  it is some-
times epidemic.  It is an endemic in the vicinity
of rivers, lakes, canals, and stagnant pools and 
2
PALATE—Inflammation op tub.
marshes.  It may affect all ages and both sex-
es, but it is more frequently observed in young
persons and in sanguine temperaments  than in
others.   Cold and  humidity,  vicissitudes of
temperature, weather, and season, cold  applied
to the extremities, or currents of air passing
over the face and neck, and exposure of the
neck or throat,  especially  after having been
overheated,  or to the night-dews and fogs, are
the most common causes,  particularly of the
catarrhal form of the complaint.  The ingestion
of too hot or too cold, or of acrid substances,
and the abuse of spirituous liquors, may also
occasion inflammation of the fauces, in either
its simple or its associated states.
  7.  Disordered states of the stomach and bow-
els, or accumulations of vitiated secretions in
the biliary organs, or of excrementitious mat-
ters  in the  circulation,  remarkably predispose
to this affection.  Palatitis, in either of its
forms, is sometimes caused by, or is symptom-
atic of, disorder  in these quarters, and it  oft-
en attends, or ushers  in, the eruptive  fevers.
Palatitis, in a chronic, specific,  and generally
complicated  form, accompanies  constitutional
syphilis, and in its acute and diffused slates it is
frequently caused by the use of mercurials, es-
pecially if exposure to cold in any form  concur
to develop their effects.
  8.  ii. Symptoms.—Inflammation is seldom
confined  to  the  soft palate,  constituting  the
simplest form of palatitis or angina; but  fre-
quently extends  more or less to the surfaces
of adjoining parts, to those of the  tonsils  and
pharynx, and occasionally to those of the pos-
terior nares, of the upper part of the oesopha-
gus, and even of the glottis, although in a slight-
er degree.  This is more especially the case in
respect of catarrhal palatitis and in some  epi-
demic visitations of the  complaint.
  9.  a. The symptoms vary not only with the
extent of surface that is affected, but with the
constitution and habit of body  of the patient,
with the character  of the affection,  with  the
limitation of it to the mucous membrane, or
with its extension to  the suh-mucous cellular
tissue.  On  inspection, the soft  palate—the ve-
lum and pillars of the fauces, are seen red and
somewhat swollen.   Slight heat, pain, and un-
easiness, with dryness at first, are complained
of, and are increased on swallowing.  The uvu-
la is much elongated, and hangs down upon the
base of the tongue.  There is generally a tick-
ling or hawking cough from this cause, or from
the extension of the inflammatory irritation to
the lips of the glottis.   There are often more
or less mucous expectoration, and hoarseness
of voice or speech.  The tongue is loaded, and
red at its point and edges.  The pulse is accel-
erated, the bowels confined, and  the appetite
impaired.    Chills and flushes continue to be
felt,  alternately,  for two or three days.   After
the first or second day, a more abundant secre-
tion of mucus takes place from the fauces  and
their vicinity, and in a few days more the com-
plaint ceases.
  10. b.  Such is the usual course of the simple
and  more mild palatitis, particularly in  its ca-
tarrhal form.  But the  inflammation often is
more severe, and  is  attended  by a lower or
more asthenic fever, or it continues a longer
period than  that  just stated.  It may extend to
or more immediately  affect the  Eustachian
 tubes, the pharynx, &c, and thus be corrmlica
 ted with pain in one or both ears, and deafness,
 or with pharyngitis, and even, although rarely,
 with oesophagitis, especially when the stomach
 and liver are much disordered.  In some cases
 the inflammatory irritation, of a catarrhal or
 more phlegmonous character, subsides in the
 fauces, while it continues in  the  pharynx, oc-
 casioning painful or difficult deglutition, or even
 the forcible regurgitation of substances attempt-
 ed to be swallowed, through the nostrils.  The
 inflammatory or  catarrhal irritation, however,
 more frequently extends  to  the  glottis,  and
 thence, in delicate persons, sometimes to the
 bronchi, occasioning  cough, and  catarrhal or
 slight, or even acute bronchitis ; but in these ca-
 ses the pharynx is generally mediately affected.
   11. c. In other complicated  instances, in ad-
 dition to redness of the surface of the tonsils
 and fauces, the tonsils are enlarged, chiefly ow-
 ing to effusion of lymph and  serum under the
 mucous membrane in the connecting cellular
 tissue; and, in many cases, more or less tu-
 mefaction of the fauces is produced by the
 same cause.   (See art. Tonsils.)  When the
 disease is thus more  deeply seated, more pain,
 uneasiness, and difficulty of swallowing are ex-
 perienced, and the patient opens his mouth
 with an increase of pain.  A copious secretion
 of mucus, mixed with a ropy saliva, takes place,
 and as this becomes less abundant and thicker,
 it sometimes also appears slightly puriform, es-
 pecially in children.  In these acute states, the
 symptomatic inflammatory fever is usually more
 fully developed ;  and, if they are complicated
 with inflammation of the tonsils,  as they very
 frequently are, this fever assumes a highly in-
 flammatory character, particularly in  children
 and young persons.
   12. d. In cold,  humid, and low situations, sel
 dom in sporadic or in few instances, more fre-
 quently in an epidemic form,  the inflammation
 is, apparently, more confined to the mucous
 membrane of the  palate and adjoining parts
 than in others, or in  the common sporadic or
 phlegmonous cases ;  and a grayish albuminous
 fluid is effused upon the inflamed surface, which
 immediately concretes into a false membrane.
 In this complication,  the constitutional disturb-
 ance is extremely great, the powers of life oft-
 en quickly sink,  and  the inflammation spreads
 rapidly over, if it does not simultaneously at-
 tack the  mucous surface of the whole throat,
 of the  soft  palate, tonsils, pharynx, and  even
 the Eustachian tubes, often extending, also, to
 the larynx and trachea, thereby inducing one of
 the forms of croup.  (See art. Croup, $ 16.)  In
 some cases, the  inflammation spreads down
 the oesophagus also,  particularly in  children.
 (See art.  Throat )
    13. e. In the thrush and in other aphthous
 affections, the soft palate is implicated in com-
i mon with the other  parts of the throat and
 mouth, but this association of palatitis is fully
 considered in  the  article  Thrush.   Palatitis,
 moreover, may supervene upon  erysipelas of
 the face, and assume a very acute and diffuse
 character, the inflammation extending to the
I pharynx and larynx,  and placing the patient in
i the most imminent danger.
    14. /. The chronic  states of  palatitis differ
 from the simple and  more common form chief-
 ly in the slighter grade and longer continuance 
PALATE—Inflammation of the—Treatment.
3
of the complaint.  The surface appears irregu-
larly red, or is reddened in patches, points, or
striae.   Sometimes the vessels are more en-
larged  and  conspicuous than usual, and the
patches or points are of a more livid or dark
hue.  In some, dryness of the mouth and throat
is complained of, and in others the  mucous se-
cretion  is irregularly increased.   This form of
the complaint is generally prolonged by chron-
ic disorder of the digestive organs, and by ca-
chectic  states of the system, or by constitution-
al disorder.   Of the specific forms of inflamma-
tion of  the palate, as the acute form caused by
mercury, and the chronic form consequent upon
the syphilitic infection, it is unnecessary to treat
at this place.  (See art. Throat.)
   15. g. The duration of the acute states of pal-
atitis is seldom long, and generally terminates
in a few days by resolution.  These states sel-
dom pass into suppuration unless they are very
acute or phlegmonous, or are caused by some ac-
rid or powerfully stimulating substance brought
in contact with the palate and  fauces.  They
rarely terminate in gangrene unless in malig-
nant scarlatinA,  and much  more rarely in the
membranous angina alluded to above ($ 12) as
occurring epidemically, especially in certain lo-
calities.  (See art. Throat.)  I have observed
this termination take place in two  or three  in-
stances of erysipelas of the head and face, ex-
tending down the nostrils to the fauces.  These
cases occurred in persons addicted to  spiritu-
ous liquors, whose liver and other digestive or-
gans were much disordered.
   16. Ulceration occurs chiefly in the more chron-
ic states of the disorder, which are usually of
long and very indefinite duration, owing to their
dependance upon the constitutional maladies
alluded to above ($ 14), on which maladies spe-
cific inflammation and caries of the  bone of the
palate may also supervene.   Ulceration may oc-
cur also in  the  asthenic or more complicated
and malignant states  of acute inflammations of
the throat, but not so frequently as it was for-
merly supposed  to occur.  (See art. Throat.)
   17. iii. The Prognosis of palatitis is common-
ly favourable, unless it  assumes a very asthen-
ic and complicated character, or extends to ad-
joining surfaces, owing to  impaired vital ener-
gy, to disorder of the  digestive and assimilating
organs, or to contaminated states of the circula-
ting fluids, in which circumstances it is apt to
induce  dangerous laryngitis.  When it is asso-
ciated with, or is symptomatic of, the  diseases
named  above ($ 14, 15), the  prognosis will al-
together depend upon the nature of the prima-
ry malady, the state  of the constitutional de-
rangement, and the appearance of  the local af-
fection.
   18. iv. Treatment.—a. There are few cases
of palatitis which are not more or  less benefit-
ed by  an emetic, especially if its operation be
duly promoted by diluents or the tepid or warm
infusion of chamomile flowers, or if the affection
be simple and mild, or caused  by gastric or bil-
ious disorder.  The emetic should generally be
followed by an active purgative  and the warm
pediluviurn, a diaphoretic medicine being given
at bedtime, and continued as the presence of
fever may  suggest.  These remedies,  in the
slighter cases, will generally remove the com-
plaint ; but, in the more acute, they may be in-
sufficient, and general or local depletions may
be also required, particularly when the patient
is strong or plethoric, and the complaint com-
plicated with  tonsillitis.  Antimonial  diapho-
retics, the solution of the acetate of ammonia,
and the spirits of nitric  ether will generally be
of service in these cases ;  and when  blood-let-
ting, general or local, has been resorted to, sin-
apisms, or embrocations, will be applied to  the
neck  or throat with marked  benefit.   In  the
more acute or phlegmonous cases, particularly
in robust and  plethoric  persons, the  blood-let-
ting will advantageously precede the emetic ;
and it should  be also  followed by a brisk  ca-
thartic, or a powder containing calomel and an-
timony,  given  at  bedtime,  and  a purgative
draught in the morning.
  19.  b. In this early or acute stage of the com
plaint, astringent or stimulating gargles are sel-
dom  beneficial; but the vapour of warm water
impregnated with camphor, or the  vapour of
chamomile flowers and  poppy-heads, or of an
infusion of hops, &c, passed through the mouth,
will often be of service.   Afterward, warm gar-      I
gles, with small quantities of nitrate of potash,
of the hydrochlorate of ammonia and camphor,
will be of use.
  20. c.  After  the  acute symptoms have been
removed, and relaxation of the parts, or a chron-
ic state of  irritation or congestion remains, gar-
gles, containing the muriatic or sulphuric acid,
or the sulphate of alumina, and one or more of
the tinctures  of myrrh, bark, capsicum, &c,
will then prove beneficial.  When the uvula is
elongated, gargles, with  the nitrate of silver, or
a stronger solution of this salt, applied to  the
part by means of a small brush, or the applica-
tions  already noticed (§ 5), are then most effi-
cacious.   If an cedematous state  of the palate
continue after the acute stage has subsided, or
if it have existed from the commencement, the
terebinthinate  embrocation (F. 311) I have so
frequently  recommended  may be applied on
warm flannel  around the throat, or a blister
may be applied on the  back and sides of  the
neck.
  21. d. If the inflammation proceed to suppu-
ration, giving rise to a small abscess in the cel-
lular  tissue of the velum, &c, an early outlet
should be given to  the  matter, and afterward
similar means to those already advised ought
to be employed, or varied with the circumstan-
ces of the case, particularly  the external appli-
cations mentioned above (§  20).
  22. e. If the disease assumes the asthenic, or
diffused, or complicated  form alluded to (§  13),
or if membranous exudations form upon the in-
flamed surface, permanent stimulants and ton-
ics in the former case, and discntient and re-
solvent applications in the latter, as fully shown
in the article  Throat,  are imperatively requi-
red, as the only means of preventing fatal sink-
ing of the powers of life in the one, and exten-
sion of the disease to  the larynx and trachea
in the other.  (See arts.  Catarrh, Croup, Scar-
let Fever, Throat, Thrush, and Tonsils, for
important pathological connexions of diseases
of the palate.)
  Biblioo.  and Refer.—J. A. Foglia, De Fauci urn Ul-
ceribus, 4lo.  Neap., 1563.—/. A. de Fonscca, De Angina
et Carutillo Puerorum, 4to.  Comp., 1618.—Th. Barthoh-
nus, Exercitat. de Angina Puerorum, <tc, 12mo.  Paris,
1646. — S. P. Hilscher, De  insigni  Raucidinis Remcdio
(Vaporc Aqua calida.), in Halleri Dissert, ad Med.  pert.,
vol. i. Jcme, 1747.—/. Wall, Method of Treating the Sore 
jnal Disorders of the.
-4                      PANCREAS—Fincti

 Throat, 8vo. Worcester, 1751; and in Med. Tracts, Ox-
 ford. 1780.—/. Chandler, Of the Disease called a Cold ; also
 of the Putrid Sore Throat, <fec, 8vo. •Lond., 1761.— F. Pen-
 rose, Dissert, on the Inflammatory, Gangrenous, and Putrid
 Sore Throat, 8vo.  Lond., 1766.—S. Bard, Researches on
 the Nature, Onuses, <fcc, of Sore Throat, 8vo. New-York,
 1771.—W. Saunders, Observations on Sore Throat and Fe-
 ver, 8vo. Loud., 1778.—R. Haunders, Observ. on the Sore
 Throat in the North of Scotland in 1777, 8vo.  Lond., 1778.
 —T. Reeve, An Essav on the Erysipelatous Sore Throat,
 6vo.  Lond., 1789.—Renauldin. Diet, de Sc. Med., t. ii.—
 V. AT ab Hildenbrand, Institut. Pructico-Medicae, &c.,t. iii.,
 p. 136.—Roche, Diet, de  Med. et Chirurg, Pratiques,, t. ii.
 —Sasche, Encyclop. Wcirterh., b. ii.— Symonds, in Libr. of
 Medicine, vol. iv., p. 46.—(See, also, Biblioo. and Refer.
 to arts. Catarrh, Croup,  Scarlet Fever, Throat,
 and Tonsils.

   PALPITATION.—See article Heart—Func-
 tional Disorders of.
   PANCREAS.—Syn.  UavKpeac (from nav, all,
 and Kpeac, flesh).  Pancreas, Fr.   Gekrbsdriise,
 Pankreas, Germ.  Pancreas, Ital.
   1. The diseases of the  Pancreas have attracted
 but little  attention, partly from the belief in
 their rare occurrence, and partly from the dif-
 ficulty of recognising  them during life.   The
functions of this viscus  have been  rather infer-
 red than demonstrated.  The similarity of the
 secretion produced by the pancreas  to saliva has
 been shown by Mage.vdif., Tiedemann, Gmelin,
 Lassaigne, Leuret, and others.  But the pan-
 creatic fluid contains  no  mucus,  while saliva
 does.  The former  seems to contain  a little
 free acid, the latter is nearly neutral.  No anal-
 ysis, however, of the pancreatic fluid from the
 human subject has been furnished of sufficient
 accuracy to be confided in ; and all we know
 respecting it is, that it resembles the saliva, but
 differs somewhat from  it in chemical composi-
 tion.   The precise amount of function perform-
 ed by the pancreas not having been ascertain-
 ed, it has  been supposed that the fluid secreted
 by  it dilutes  the  chyme,  and assists in the
 change of chyme into  chyle.  This office, at
 least, may be conceded to  it; but  it is not im-
 probable that it also aids in the complete con-
 version of chyle into blood, or in the formation
 of haematozine, as great emaciation and anaemia
 have been present in cases where chronic dis-
 ease and obstruction of this viscus  have been
 found after death.  Drs. Tiedemann and Gmelin
 think that it assists in  annualizing  vegetable
 food not containing azote, as it contains a large
 quantity of highly azotized  principles.
   2. Formerly several diseases were consider-
 ed to have their seat in the pancreas.   Fer-
 nelius believed that this viscus was concerned
 in the production of diarrhoea, dysentery, ca-
 chexia, atrophy, languor, slow fevers, &c, and
 Riolanus added to these hypochondriasis and
 some other chronic disorders.  Morgagni and
 Portal have adduced several instances of its
 change of structure ; but some recent writers
 have made but little mention of  its diseases.
 Although these diseases are seldom observed,
 and but rarely detected during life, owing to
 the want of precise knowledge of the functions
 of the organ, and to the situation and relations
 of it in respect of other organs, yet there are
 several reasons for inferring that they are more
 frequent than has been generally supposed.   I
 shall,  therefore,  notice, 1st. Those functional
 disorders which may be imputed to the pancreas,
 although  with much doubt and  reservation ;
 2d. Inflammations of it, and the consequences
 they usually produce ; and, 3d. Those lesions of
structure not necessarily consequent upon in-
flammation.
I.  Functional Disorders which may  be impu-
   ted chiefly or partly to the Pancrkas.
    Classif —1. Class, I. Order (Author).
   Defin— Alterations of the quantity or quality
of the pancreatic fluid so as to disorder  the func-
tions of digestion or defacution.
   3. Although I have inferred  that  a  material
change  in  the quantity or quality of the  pan-
creatic secretion  will be productive of disorder
of the stomach or bowels, still the exact char-
acters  of such disorders, and the differences
subsisting  between them and  other disorders
of these viscera, cannot be fully shown, or  il-
lustrated by satisfactory proofs.—A. Deficiency
of the pancreatic secretion—Torpor Pancreatis—
cannot be  ascertained, although it very proba-
bly often occurs independently of organic lesion,
and owing to impaired vital action of this gland.
The extent of disorder, or the symptoms pro-
duced  by this condition, hardly admit of re-
mark;  but it is not improbable that indigestion,
costiveness, flatulence, and  many of the symp-
toms I have assigned to functional disorder of
the duodenum (see art. Duodenum, § 2,  et seq.),
may partly depend upon this state of  function
of the  pancreas.   Indeed, when the vascular
and nervous connexions of  this organ, the du-
odenum, the liver, and of the stomach are con-
sidered, it will be admitted that impaired ener-
gy of one or more of them  will readily extend
itself to the others.   Emaciation, anajmia, or
imperfect sanguification  and assimilation, in
any of their grades, may not improbably partly
depend upon this state of function.   In the ex-
periments by Brunner of extirpating the pan-
creas, the  alvine  evacuations  became scanty
and indurated ; and, although but little reliance
can be placed  upon the results of so violent an
operation as this, still they correspond with ra-
tional inferences.
  4. B.  Increased secretion of the pancreatic fluidf
with or without change of its  qualities or proper-
ties, may take place independently of structu-
ral lesion of, although hardly without  vascular
determination to, this organ.  Analogy supports
this inference, although demonstration of the
fact cannot be adduced ; and it may, upon the
same evidence, be admitted that some agents
will have the effect of increasing this fluid, al-
though the proofs of such an effect may be dis-
puted.   In some  cases of diarrhoea  the stools
present appearances so closely resembling those
of the salivary and pancreatic fluids, that it is
not unreasonable to infer that  they  consist,  at
least in part, of an increased flow of the latter
fluid.   But when diarrhoea follows the  suppres-
sion or disappearance of salivation, the stools
presenting these appearances, the inference as
to its nature and origin—as to its being actu-
ally a form of pancreatorrhaa—is still more con-
clusive.  In those cases, also, where watery
and ropy evacuations  have  followed the exhi-
bition of chologogue purgatives, with the view
of removing dropsical effusion,  it  is  not un-
reasonable to suppose that  a portion of  these
evacuations has consisted of an increased flow
of pancreatic fluid.
   5. Since I commenced lecturing  in 1825, I
have argued that the discharge from the stom-
ach in Pyrosis (see that article) chiefly consist-
ed of  an augmented, and  probably also of a 
PANCREAS—Inflammation of the.
5
 somewhat  altered pancreatic secretion ;  that
 this secretion, owing  to its properties or its
 quantity, or to both, had been regurgitated into
 the stomach, and that its accumulation there
 had occasioned pain and irritation, followed by
 its  rejection.  Thus I have  viewed pyrosis as
 being more correctly a form of pancreatorrhoza,
 and have considered that alteration of the qual-
 ity  of the fluid has caused its ejection upward,
 instead of its  passage through  the bowels.
 More recently, MM. Mondiere and Guersent
 have espoused nearly the same view of the or-
 igin of pyrosis, ascribing it to  the irritating
 quality of the  pancreatic fluid.  It  should not
 be overlooked, also, that Wedekind and  Por-
 tal ascribed chronic diarrhoea and  dysentery,
 with watery,  colourless, or  ropy discharges,
 chiefly to a morbidly increased secretion  from
 the pancreas.   But Dupuytren went still far-
 ther when  he  believed that the enormously
 abundant discharges in epidemic  cholera pro-
 ceeded from this viscus.
 II.  Inflammation on the Pancreas.—Synon.
   Pancreatitis, Inflammatio pancrealis.—Pancre-
   atite, Fr.  Gekrbsdrusenentzundung, Germ.
     Classif.—III. Class, I. Order (Author).
   Defin.—Deep-seated pain, somewhat below the
 pit  of the stomach, or between this part and the
 umbilicus, extending to the back and under the left
 shoulder-blade;  occasional vomiting of an  albu-
 minous and ropy fluid, great thirst, and sympto-
 matic fever.
   6. The pancreas may, like  other  organs, be
 inflamed either in an acute, sub-acute, or chronic
 form.   It is doubtful whether or not  the second
 and third of these states, owing to the compar-
 ative mildness of the disease, and the frequent
 association of  it with inflammation  of adjoin-
 ing  parts, can be certainly detected during life-
 most probably only in a small proportion of in-
 stances ; and it is not improbable that enlarge-
 ment and  induration of the organ  are conse-
 quences of one or other of these  states of in-
 flammation, more particularly of  the chronic.
 It has been doubted by  MM. Becour and Mon-
 diere whether acute, sub-acute, or chronic pan-
 creatitis is of most frequent occurrence, but
 the  point hardly admits of solution, nor is it of
 much practical importance.
   7. i. Symptoms.—a. The phenomena attending
 the  acute state of  pancreatitis are chiefly  dull,
 gravative, or even acute and deep-seated pain
 a little below the pit of  the stomach, extending
 to the back and below the left shoulder-blade,
 increased by bending the  body forward, and
 but  little affected by pressure ;  a sense of con-
 striction or of anxiety at the praecordia, and an
 unusual dryness of the  fauces and thirst, with
 more  or less symptomatic  fever.   There  are
 other symptoms which  are less constantly ob-
 served  than the above, and  there  are some
 which occur more frequently in the  course of
 the sub-acute and chronic states of the complaint
 than in that of the acute.  Occasionally, a pain-
 ful feeling of heat  is complained of at the epi-
 gastrium, and sometimes a sense of  tension in
 this  region.   There  is every reason to  infer
 that the pancreas  is greatly tumefied when it
 is  inflamed in either of the forms just mention-
 ed, and hence jaundice,  owing to the pressure
of the tumefied gland upon the common bile-
 duct, may be expected sometimes to occur.  In
some cases, also, more or less tuniour has been
 detected between the  scrohiculus cordis  and
 umbilicus, the tumour being hard, painful, deep-
 ly seated, and distinct from the liver and stom-
 ach.  Occasionally there  is a discharge of a
 ropy fluid from  the stomach without retching,
 or even without  nausea or anorexia ;  and in
 other cases both nausea and vomiting occur,
 a ropy mucous  fluid, of a whitish-gray colour,
 occasionally tinged with bile, being thrown up.
 Sometimes a more copious flow of saliva than
 usual takes place.   The state of the bowels va-
 ries.  When a ropy fluid is discharged upward,
 the bowels are generally  confined; but occa-
 sionally a  mucous diarrhoea,  or loose,  ropy
 stools are observed.
   8. b. The more chronic states of pancreatitis
 are recognised  with difficulty.   Many  of the
 symptoms above detailed are present in a slight-
 er or less manifest form ;  but several of them,
 particularly the pain, sense of tension, and heat,
 are either felt only after a meal, or are  aggra-
 vated by it.  In addition  to these, flatulence,
 acrid eructations, or pyrosis, various dyspeptic
 symptoms, and pain or  uneasiness in the back,
 are complained  of.  According to Heinecken,
 Eyting, Mondiere, Fallat, and  others, some
 degree of tumour, or fulness, may be detected
 in the epigastrium, and a  ropy mucus, resem-
 bling saliva, is generally vomited every morn-
 ing ; or, when this is not observed, regular at-
 tacks of pyrosis  occur, or evacuations from
 the  bowels of matters partly resembling those
 which have been brought up by the oesophagus.
 In a few instances salivation  has alternated
 with the above symptoms.
   9. One question suggests itself, viz. : wheth-
 er the augmented pancreatic secretion attends
 the  acute, sub-acute, or chronic states  of the
 disease?  An increased discharge of this fluid
 appears often in connexion with inflammation
 of the gland;  but  whether it is antecedent to,
 coetaneous with, or consequent upon the inflam-
 mation, has not been determined.   It is not un-
 likely that the most acute states of the disease,
 when the substance of the gland is the seat of
 the inflammation,  are not attended by an aug-
 mented, but  rather by a diminished secretion
 of the pancreatic fluid.
   10. c. The complications of pancreatitis gen-
 erally obscure, or altogether conceal, the dis-
 ease of this viscus.  Indeed, even when pan-
 creatitis is the primary complaint, the inflam-
 mation may soon extend to the duodenum, or
 to the stomach, or to the  liver, or to the root
 of the mesentery,  or even to any two of these
 viscera ; but probably the pancreas is more fre-
 quently affected  consecutively of inflammation
 of one or other of these organs than primarily.
 The symptoms attending  these complications
 have not been satisfactorily observed ;  but they
 may be inferred  to consist  of an association of
 many of the above symptoms ($ 7) with the
 phenomena characterizing  inflammation of ei-
 ther of those viscera complicated with pancre-
 atitis.
   11. d. The Terminations and Consequences of
 pancreatitis  are, 1st. Resolution ; 2d. The ef-
 fusion of coagulable lymph  upon the surface of
 the organ ; 3d. Suppuration ; 4th.  Gangrene ;
 and, 5th. Chronic enlargement and induration.
   12.  (a) Harles supposed that  a  copious
sweat  or diarrhoea is critical in pancreatitis,
especially if the  latter present a ropy or mu- 
6
PANCREAS—Inflammation of the—Causes
cous character ;  but facts are wanting to prove
these points.   It is, however, not unlikely that
the complaint is resolved in the milder cases
by a copious secretion, causing  more or less
diarrhoea, or even vomiting or pyrosis, without
the symptoms having been so prominent as to
lead to  the  detection of the antecedent pan-
creatitis.
  13. (b) The effusion  of coagulable lymph upon
the external surface of the pancreas gives rise
either to a false membrane, or to adhesion of it,
owing to the extension of inflammation  to the
external surface  of an adjoining viscus, as the
duodenum, pylorus, stomach, liver, spleen, me-
socolon.   These adhesions vary in thickness
and form with their situation, age, organiza-
tion, &c.
  14. (c) Suppuration has been noticed by Lieu-
taud, Harles, Baillie, Portal, Moulon, Be-
court, and others ; but it has been  most accu-
rately described by M. Gendrin, who states
that it generally commences with infiltration of
the interlobular tissue of the part of the organ
affected.  The glandular granules are soft, of
a reddish-gray colour, and diminished in size,
although the organ is enlarged.  The capsule
is much inflamed, and  sometimes thickened by
the formation of a false membrane.   At an ad-
vanced period of suppuration the matter is col-
lected in one cavity, generally of moderate size.
The pus is occasionally  intermixed with  the
pancreatic fluid, which exhibits a clear, yellow-
ish  appearance.  In some cases the abscess is
so large as to destroy the whole  substance  of
the organ.  In  these  cases M. Gendrin  de-
scribes the matter as  inodorous  and  creamy;
but Portal states that it is sometimes very of-
fensive.
  15. Pancreatic abscess may be discharged ei-
ther into the stomach  or into the  duodenum.
It may pass even into the duplicature  of  the
mesocolon,  where  it  may   be  retained,  or
whence  it may pass into the peritoneal  cavity.
It may even pass along the duct into  the in-
testines, and be  evacuated  by stool.  A case
communicated by Dr.  Haygarth to Dr. Perci-
val seems to have been of this kind.
  16. Secondary abscesses, or collections of mat-
ter  after phlebitis, or consequent upon the  ab-
sorption  of matter in  situations more or less
remote,  have been  found in the pancreas in
post-mortem examinations, but not so frequent-
ly in this viscus as in some others, as the liver,
lungs, &c.   They have been found chiefly af-
ter  puerperal  or uterine phlebitis,  and after
phlebitis consequent upon extirpation  of  the
testicle.  The occurrence of  abscess  in  the
pancreas, after extirpation of the  testis, was
first remarked by A. Petit  and  Portal ;  but
its  actual dependance upon inflammation  of
the veins after the operation was not  known
until more recently.
  17. The symptoms indicating suppuration  of
the pancreas have not been precisely observed ;
but they probably differ in few respects from
those attending  suppuration in other internal
parts, which is usually insidious and obscure.
If an abscess of considerable size should form,
so as to occasion a tumour, the situation of it
may assist in indicating its nature ; but if it
should cause jaundice by pressing on the com-
mon duct, it might be  mistaken  for tumour in
the liver, or for an over-distended gall-bladder,
from occlusion of the common bile-duct, which
latter generally attends enlargement or tumoui
of the pancreas of any kind.
  18.  (c) Gangrene has been  very rarely ob-
served in this organ.  Two cases of it have
been recorded by M. Becoubt, and one by M.
Portal.  In one of these the patient had been
suhject to occasional colicky pains, which were
deeply seated  above the umbilicus, and were
sometimes  preceded, at other times followed
by nausea or by diarrhoea.   He became emaci-
ated, the pains were more acute, and the pulse
rapid.  The heat of the  skin assumed an acrid
or morbid character ; the abdomen became ten-
der ; the urine scanty and red ; and death fol-
lowed  a few days afterward.  The pancreas
was found of a livid red hue, very much soft-
ened,  exuding from its whole surface a  black-
ish, foetid fluid, and gangrened almost through-
out its extent.  The stomach and  duodenum
were inflamed.
  19.  (d) Enlargement  and  Induration of the
pancreas are probably also consequences  of
chronic inflammatory action or  irritation, or
of prolonged excitement, followed by a change
of the nutrition of the organ ; but more partic-
ular notice will be taken of these lesions in the
sequel (§ 25).
  20. ii. The Causes of Pancreatitis are not fully
ascertained. Many foreign writers consider the
abuse of mercury to be the most frequent cause
of it; and, next to mercury, Hildenbrand views
the use of tobacco, particularly the smoking and
chewing of this noxious herb, as most influen-
tial.  The immoderate use of spirituous liquors;
a frequent recourse to purgatives ; falls, blows,
and other external injuries ; and the extension
of inflammation from adjoining organs, are prob-
ably also causes of this disease.  Pancreatitis
may even occur sympathetically of inflamma-
tion of the salivary glands.   M. Andral found
the pancreas greatly injected in a patient who
died of fever with enlargement of the parotids.
M Mondiere refers to  a case in which these
glands were remarkably enlarged.  The en-
largement disappeared rapidly, but was follow-
ed by symptoms of disease of the pancreas ;
and this disease, in its turn, was superseded
by inflammation of the testicle   The enlarge-
ment of the parotid again appeared, the affec-
tion of the testicle subsided, and the applica-
tion of a blister upon the parotid  fixed the  in-
flammation in  this latter part, suppuration be-
ing the result.  I  have met with several cases
in which inflammation, in a sub-acute or chron-
ic form, seemed to  exist in the pancreas, but
chiefly in pale and debilitated persons, who had
complained of prolonged disorder of the digest-
ive  organs.  Only one opportunity, however,
was afforded me of verifying the diagnosis by
an examination after death ; and  in that case
the pancreas was very much enlarged, and
somewhat indurated.  The following case, re-
corded by Dr. Schmackfeffer, will  illustrate
the history of acute pancreatitis:
  21. A female, twenty-nine years of age, con-
tracted syphilis, for which she was treated by
means of corrosive sublimate.  Violent ptya-
lism took place, four pounds of saliva being ex-
creted in the twenty-four hours.   As this se-
cretion diminished, diarrhoea appeared and  in-
creased.  Soon afterward the patient complain-
ed of anxiety  and heat, with  a fixed, obtuse, 
PANCREAS—Structural Lesions  of the.
7
 and deep-seated pain  at the epigastrium ; of
 loss of appetite, nausea, tension of the abdo-
 men ; of great thirst and dryness of the throat,
 and rapid pulse.  These symptoms were aggra-
 vated when the stomach was full.   During five
 days some amelioration was remarked, but bil-
 ious vomiting supervened, and the pain and di-
 arrhoea increased.   The frequency of the calls
 to stool became remarkably great, a  watery,
 yellowish fluid resembling saliva being voided.
 The deep seated pain above the umbilicus pre-
 vented the patient from lying on her back and
 left side, and was increased by a full  inspira-
 tion.   Some days of relief followed, after which
 a violent increase of fever appeared, with a re-
 turn of the diarrhoea, an acute pain at the epi-
 gastrium, and cough and orthopnoea.   Blood-
 letting was prescribed.  The following morn-
 ing the  parotids were hot and painful ; the
 mouth was burning, the pulse small, and the
 stools were suppressed.   Mercury, camphor,
 and opium were ordered, and leeches, blisters,
 &.c,  to  the  parotids.   Towards evening the
 breathing became stertorous, the anxiety ex-
 treme, the pulse thready and intermittent, the
 extremities  cold, and  the  face Hippocratic.
 She expired in  the night.   The pancreas was
 found red, swollen,  and somewhat more  con-
 sistent than natural.   It weighed eight ounces,
 and blood  ran freely from it upon dividing it.
 The duct was dilated.   The parotids were also
 inflamed.
   22. Hi. The Treatment of pancreatitis differs
 but little from that of other inflammations of
 an acute and sthenic  character.   General or
 local blood-letting, or  both, according  to the
 state of the pulse  and vascular system  gen-
 erally, and  to the condition of the patient;
 warm baths, fomentations, and diluents ; cool-
 ing diaphoretics and sedatives, are the most
 appropriate means.  If diarrhoea be present, it
 merely should be moderated, by absorbents and
 opiates, or small doses of Dover's powder, and
 the circulation  determined  to  the surface of
 the body by promoting a copious perspiration.
 A large blister, sinapisms, or warm turpentine
 embrocations, placed over the epigastrium, will
 generally alleviate  the deep-seated pains, as
 well as  the  vomiting,  when these symptoms
 are present.   If the disease appears to have
 passed into a chronic state,  these external de-
 rivatives may be rendered more permanent by
 repetition,  or by procuring a discharge from
 the blistered or  inflamed surface ; and, if indi-
 cations of suppuration of the gland occur, the
 constitutional powers should be supported, and
 absorption  promoted by prescribing the iodide
 of  potassium  and liquor potassae with  sarsa-
 parilla and tonic vegetable  infusions or decoc-
tions, a  discharge from the external  surface
 being also  procured.   The  pale and anaemial
state  of some patients in  whom I have had
 reason to suspect the  existence of inflamma-
tion of the pancreas, seems to contra-indicate
the propriety of general, and  even of local
blood-letting, and to suggest very different, if
not opposite means of cure ; and  in a very few
instances I have prescribed the sulphate of iron
with camphor and opium ; sulphate of quinine
with camphor and hyoscyamus, or conium, or
extract of hops -,  the trisnitrate of bismuth with
ipecacuanha and either of these narcotics, and
similar medieines, with marked  benefit ; but
 more or less doubt existed as to the exact seat
 and nature of the malady.
 III. Structural Lesions of the Pancreas not
   NECESSARILY DEPENDANT ON INFLAMMATION.
     Classif.—IV. Class, I. Order (Author).
   23. The organic lesions of the  pancreas, as
 those of other organs, have been chiefly refer-
 red to diseased nutrition when they appear to
 differ from the more obvious consequences of
 inflammation.   Still,  this diseased  nutrition,
 varying as it does in character, form, and re-
 sults, must itself depend upon some  pre-exist-
 ing morbid state or states, originating either in
 the organic  nerves of the part,  or in  the capil-
 lary vessels, or in the secreting apparatus of
 the part, or  in these collectively—in the vital-
 ity, in short, of the  organ.   Modern  pathol-
 ogists, in grappling with this and several other
 subjects which  have long been matters of dis-
 cussion, have had recourse to new names and
 terms, believing that they afford explanations,
 even if they do not actually constitute discov-
 eries.   But  the reader will soon be enabled to
 estimate the true value  of terms  or epithets
 when he reflects upon their meaning, and their
 applicability to visible phenomena and changes;
 to deviations from the healthy condition, which
 are never stationary or exactly identical with
 one another, but varied in form, character, ap-
 pearances, associations, morbid relations,  and
 results, to an extent that precludes the possi-
 bility of description ;  and he will readily detect
 what portion of sense and precise information
 may be concealed beneath the rubbish of phra-
 seology, and the affected use of novel  terms.
 Still, terms  and names of some kind are con-
 ventionalities that must be resorted to, in or-
 der to convey accurate  ideas of certain mor-
 bid conditions and their probable results ;  but
 these should not he multiplied beyond the ne-
 cessity of the occasion, nor be used when gen-
 erally-received  and well-understood words are
 altogether applicable.
   24. i. Atrophy or  wasting  of the  pancreas
 sometimes occurs, according to Siebold  and
 Lobstein, at an advanced age.   It is  occasion-
 ally, also,  the result of disease, either of itself
 or of adjoining  organs.  Dr.  Lobstein records
 an  instance of the pancreas being  atrophied
 and somewhat  indurated, independently of le-
 sion of any other organ.   Most  frequently,
 however, the wasting is connected with organ-
 ic disease  of the liver, duodenum, stomach, or
 of the mesenteric glands ; or consequent upon
 tumours developed in its vicinity, as scirrous
 enlargement of the pylorus, aneurisms of the
 aorta, &c.   Doctor Hull found the  pancreas
 wasted, owing to the pressure caused by a scir-
 rous tumour in the  mesentery.   M. Guerin
 observed  this  lesion  produced by a similar
 cause; Morgagni by a tumour in the  liver ; M.
 Berjaud by aneurism  in  the  aorta; and  M.
Mondiere by scirrous  pylorus.   In  this  last
case, it is supposed  that the  atrophy  of the
 pancreas is  the result rather of interrupted or
diminished function, owing to the small quan-
tity of chyme passed into the duodenum, than
of any pressure produced by the thickened py-
lorus.  M. Darcy has adduced a case of rabies
in which the pancreas was remarkably small.
In a case  recorded by Dr. Wolf, of  a  person
who had complained of nausea, vomitings of
bilious and mucous fluids, of a burning  sensa- 
8
PANCREAS—Structural Lesions of the.
 tion  along  the  oesophagus, of alternations of
 constipation and diarrhoea, and ultimately of
 excessive emaciation, the  pancreas was found
 very small, indurated, of a grayish colour ; its
 arteries being ossified, and its duct obstructed.
   25. ii. Hypertrophy or enlargement is the most
 frequent lesion  observed in the pancreas,  but
 it is  rarely seen without some change  in  the
 structure of the organ.  Chronic inflammatory
 action, and  the consequent deposition of albu-
 minous lymph in the areolar or cellular tissue,
 especially the interlobular tissue, this  lymph
 having become  more dense by the absorption
 of its more  fluid parts, and ultimately partially
 organized, are probably the changes constitu-
 ting a large proportion of the cases of enlarge-
 ment of this organ ; and these, in a  more  ad-
 vanced and  indurated state, have not unlikely
 been  mistaken for, and described as scirrus of
 the organ by several writers who have record-
 ed instances of scirrous tumour in this situa-
 tion.   It is  even not improbable that obstruc-
 tion of the  pancreatic duct may be followed
 by a form of enlargement which has not been
 accurately described.   An  out-patient of the
 South London Dispensary, under my care, in
 June, 1821,  had  complained of fever, pain be-
 low  the epigastrium,  of  nausea, vomitings,
 thirst, emaciation, &c.  She was  pale, debil-
 itated, and  ultimately deeply jaundiced.   A
 manifest tumour was  detected in the  lower
 part of the  epigastrium.  The body was  ex-
 amined after death by myself and Mr. Bryant,
 my colleague.  The gall-bladder was distended
 by thick black bile, the common and pancreatic
 ducts were  entirely obliterated by a  remark-
 ably enlarged and indurated pancreas.  Upon
 examining the  structure of this  organ more
 minutely, it  seemed as if the glandular struc-
 ture was more dense than natural;  the con-
 necting cellular  tissue was infiltrated with  al-
 buminous lymph, which had become condensed
 by the absorption of its more fluid parts, and
 the ramifications of the ducts were dilated and
 filled with the albuminous and more consistent
 constituents of  the pancreatic secretion, the
 more  watery portion  having apparently been
 absorbed.
  26.  It is not unlikely that these more simple
 changes, giving rise to enlargement of the or-
 gan, whether consequent upon  chronic inflam-
 mation or upon obstruction  to the discharge of
the pancreatic fluid, may be followed by other
important changes, several of those  about  to
be noticed actually originating in these.   The
infiltration of an  albuminous fluid or lymph into
the connecting cellular tissue ;  the subsequent
organization, partially or fully,  of this, and the
growth of it  afterward as the organization of it
becomes more perfect;  the changes  produced
by it from pressure or otherwise, upon the nat-
ural structure  and secreting  apparatus ; and
the alterations of organic nervous influence, of
vascular action and nutrition, of which the or-
gan is subsequently the seat, may reasonably
be viewed as not altogether an insufficient ex-
planation of several of the changes and trans-
formations observed in this and other glandu-
lar structures.   Several interesting cases and
notices  of enlargement  of the pancreas have
been  recorded by Sewall, Crampton, Greg-
 ory, Abercrombie, Becourt, Bedingfield, and
 others referred to in the Bibliography.
I   27. iii. Softening of the pancreas, as well as
 enlargement, may result from acute inflamma-
 tion ; but it has been observed chiefly in scor-
 butic and scrofulous persons. M. Portal found
 this organ remarkably softened, without being
 either reddened or enlarged, in  two children
 who  died in measles.  This change has been
 also remarked in fatal cases of confluent small-
 pox, and  of malignant scarlet fever.   I  have
 observed  it  in malignant remittent fever and in
 scurvy, but  only in common with  softening of
 several other organs, as the spleen, &c.   I am
 not aware of any instance having been record-
 ed of hemorrhage into the substance of the pan-
 creas, independently of wounds or rupture of the
 organ.
   28. iv.  Induration of the pancreas may exist
 independently of scirrosity, and it is extremely
doubtful whether or not simple induration is
the commencement of scirrus, as  supposed by
some writers.  Some degree of induration
sometimes  exists  with hypertrophy ;  but, in
simple induration of the glandular granules of
the organ, increased bulk is rarely observed,
the connecting  cellular  tissue being  neither
thickened nor indurated, as  in cases minutely
described  by MM. Mondiere and Becourt, in
which the granules only were remarkably in-
durated, the  connecting  cellular  tissue being
sound.  The subject of one of these cases died
of chronic duodenitis.   In incipient scirrus a
portion  only  of the organ is affected, and the
cellular tissue is either primarily  attacked or
early  implicated.  Although  simple induration
of the pancreas is thus independent of, yet it is
sometimes associated with hypertrophy, as in
a case already noticed, and  in  another which
was more  recently observed, in neitherof which,
nor in the two cases described by Dr. Sewall,
did the disease present a scirrous character.
  29.  v. Cartilaginous induration or transforma-
tion of the pancreas was met with by Morgag-
ni, Andry, and Liliknh.un, who have described
the organ as somewhat enlarged, its surface
irregular,  and its substance  of a cartilaginous
consistence.  This  change was found  in  per-
sons who  long experienced nausea, vomitings,
thirst, pain  at the epigastrium,  costiveness,
&c, and was probably the remote consequence
of chronic inflammation.
  30.  vi.  Concretions similar to those found in
the salivary glands  and ducts have  been  met
with in the pancreas in rare cases.   These are
either small  and numerous,  or  few and large.
In some instances  they are found apparently
in the substance of the organ, but probably
formed in  the ramifications of the  ducts; hut
more frequently they are  lodged in the excre-
tory duct.  Graeffe found seven of the size of
pease in the right portion of the gland. Galeali
found about  twenty contained in a cavity the
size of a hen's egg. in  the head of the  viscus.
Portal  met  with a dozen, some of which were
as large as a  nut.   The gland was greatly en-
larged, and the duct much dilated.  The con-
cretions were rounded, whitish, and when re-
duced to a powder  were dissolved by  boiling
water.  They had an insipid taste.  Merklin
found a concretion as large as an almond ;  and
Meckel states that  he has  seen the  organ
changed to an almost tophaceous mass  Those
commonly found in the excretory duct are oft
en large, about the size of a nut, and composed 
PANCREAS—Structural Lesions of the.                      9
 of the carbonate or phosphate of lime.   They
 are generally whitish, and their surfaces  irreg-
 ular.   By obstructing  the  duct, they occasion
 swelling and enlargement  of the gland.   The
 salivary secretion continuing  for a time after
 the obstruction, the ramifications of the  ob-
 structed duct are distended by this fluid, which
 becomes inspissated by absorption of the wa-
 tery parts of it, and thus  a form of enlarge-
 ment already noticed (§ 25) is  produced.
   31. vii. Tubercular formations have  been seen
 in the pancreas by several modern pathologists,
 and have been fully described by Nasse, Bou-
 illu'd,  Reynaud,  Mitivie, Harles, and Be-
 court.   They appear to have been attended by
 hectic fever, emaciation, occasional  salivation
 and diarrhoea, and by pain  at the epigastrium,
 or a little below it, and to have existed chiefly
 in the first and second stages of development.
   32. viii.  Transformation of the pancreas  into a
 fatty substance  has been observed  by MM. Du-
 puytren, Lobstein, and Becourt.  This lesion
 is different from, and should not be confounded
 with, an accumulation  of fat in the cellular tis-
 sue uniting the lobes and lobules.   The change
 may  affect  either a part or the whole of the
 organ, as in the cases  observed by the writers
 just cited.   The symptoms remarked in  those
 cases were, a sense of oppression at the epi-
 gastrium, pain  between the umbilicus and pit
 of the stomach, constant cardialgia, salivation,
 and jaundice.
   33. ix. Cysts have been  found in this organ
 by Morgagni, and M. Becourt has described a
 preparation in the museum of the medical school
 at Strasburg of a  cyst of a very large size in
 the body of the viscus.
   34. x. Scirrus and carcinoma of the pancreas
 have  been observed by most of the writers re-
 ferred to in  the Bibliography; but many of the
 cases adduced as scirrus have been more cor-
 rectly instances of enlargement, with indura-
 tion.  True scirrus generally  affects, or  com-
 mences in, a part  only of the organ ; but it may
 extend to the whole.   This malady appears to
 attack the pancreas primarily in a large propor-
 tion of cases, as it alone has been found affect-
 ed ; although in others it has  also been found
 in other parts.   In a few cases the  pancreas
 only is diseased ; but in the great majority, le-
 sions of some kind—non malignant or malig-
 nant—slight  or extensive—are also  observed
 in other, most frequently in adjoining organs,
 particularly  the  duodenum, the stomach, the
 pylorus, the liver, the  spleen,  the mesentery,
 the adjoining or connected ducts, blood-vessels,
 &o, or any two or more of these or other vis-
 cera.   Scirrus of the pancreas  may exist with-
 out any increase  of size.   Most  frequently,
 however, the bulk of the organ is more or less,
 or even very remarkably enlarged.  The  scir-
 rous pancreas sometimes  adheres to one or
 more adjoining organs or parts; most  frequent-
 ly, when the scirrus has gone  on to ulceration,
 a result not frequently remarked, probably ow-
 ing to the circumstance of  scirrus  and the le-
 sions associated with it in other organs usually
 terminating  fatally before ulceration  commen-
 ces.   Cases, however,  of open cancer of the
 pancreas have been recorded by Hasenoehrl,
 Bertheau, Mattheis, Mabille, Van Doeveren,
 Lerminier, Portal, and Vidal.  Scirrous en-
largement of the pancreas is generally attended
by very  obstinate vomiting, particularly when
the pylorus or duodenum is much pressed upon
or constricted  by it, and by acute  pain in the
back.   Instances not only of constriction of
these and of the common  bile-duct, causing
deep jaundice,  but also of compression of the
aorta by this lesion of the pancreas, have been
recorded  by  Rahn,  Portal,  Salmade,  and
Briere de Boismont.  The compression and
constriction of the aorta may  even occasion
aneurismal dilatation above the seat of con-
striction,  as seen by Portal and Salmade.
   [The following case  of scirrus  of the pan-
creas,  recently reported by  Dr. Battersby, is
too instructive  to be omitted.
   " The subject of the  case was a woman be-
tween  fifty-five and sixty years of age, who had
been remarkable for her embonpoint, and had al-
ways enjoyed good health until  two years pre-
viously,  when  she  became  subject to severe
pains in the back, which affected also the shoul-
ders and arms, and were supposed to be rheu-
matic.   After the lapse of a year, there was
discovered in the epigastric region a deep-seat-
ed pulsating tumour, about the size and shape
of an orange, having a regular diastolic enlarge-
ment synchronous with the pulse, and a  well-
marked bruit de soufflet.  Her disease was, in
consequence, considered to be aneurism of the
aorta.   She also suffered from fluid eructations,
and an obscure,  deep-seated pain.   Dr.  Bat-
tersby found her extremely emaciated.  There
was a marked fulness in the epigastric region,
in which  was to be felt a deep-seated, solid,
and fixed  induration, having a flattened surface
and defined outline inferiorly.  It was without
pulsation, but a bruit de soufflet was audible on
the application of the stethescope  over  it in
the course of the aorta.  She suffered much
from constipation, from symptoms of contrac-
tion of the  colon,  and from temporary  dys.
phagia.   There were occasional eructations of
a clear watery fluid, and her mouth seemed al-
ways full  of saliva.  The tongue was pale and
cle-an.   Before  death the limbs became highly
anasarcous, and there was some fluid  in the
abdomen.  On examination after death, the
colon and cardiac orifice of the stomach were
found narrowed.   The  pancreas was univer-
sally hard and enlarged, and had lost every
trace of its natural structure.  Near the centre
of this  gland, and at its lower edge, existed a
thin, translucent, horny cyst, which was slight-
ly prominent, about the size of a walnut, and
lay directly over the aorta.   Its base was sur-
rounded by a hard, cartilaginous, s,cirrous for-
mation, which in  part projected into it.   The
rest of the gland was composed  of a less solid,
but  unyielding, heavy  substance,  apparently
made of  dense, closely-interwoven  membra-
nous bands.   The lining membrane of the aorta
was diseased, and in some points was eroded.
The error committed of mistaking  the tumour
of the pancreas for aneurism of the aorta was
due, no doubt, to the early development of the
cyst, which, probably in the progress of the dis-
ease, had  its fluid contents lessened by the en-
croachment  of the scirrus, while  the  close
union of the latter to the spine having removed
the impulse of the aorta, towards the conclu-
sion no other symptom remained but the bruit
de soufflet, which was  not of itself likely to mis-
lead.  Ptyalism, as remarked by Dr. Battersby 
10                     PANCREAS—Structural Lesions of the.
 in this case, has not been observed, in connex-
 ion with diseases of the pancreas, by any wri-
 ter in our language, so far as he is aware, al-
 though it  has been frequently noticed  by our
 continental brethren.   Dr. B. thinks that this
 symptom may serve as a guide towards the di-
 agnosis of pancreatic diseases, of which the
 other symptoms are in general very obscure and
 ambiguous, and in  this he is confirmed by the
 facts of a  case communicated recently to him
 by  Mr. Robert  Macdonnell, in which the
 cleanness  and great moisture of the tongue and
 mouth attracted the attention of three German
 physicians in attendance on Dr. Graves's Clin-
 ique, who, from this circumstance principally,
 were led to pronounce the patient to labour un-
 der scirrus of the pancreas ;  and although the
 post-mortem examination showed that the dis-
 ease was not confined  to the pancreas, yet that
 gland was sufficiently engaged to  confirm the
 accuracy of their opinion, founded on the ex-
 treme moisture and the pale and macerated ap-
 pearance of the tongue."—Dublin Med. Press,
 April 17, 1844.]
   35. xi.  Fungo - Hcematoid disease has been
 found  in  the pancreas in  three cases by Dr.
 Abercrombie, and  in single  instances by Dr.
 Bright and others.  I found  this lesion in the
 pancreas of a boy about fourteen years of age.
 Several other organs were also the seat of this
 malady.
   36. xii.  Melanosis has been found in  a few
 cases ;  but this disease has not been accurate-
 ly observed and described as it affects the pan-
 creas.
   37. xiii.  The symptoms of organic lesions of
 the pancreas  are often very obscure;  and, al-
 though it may be inferred, from the grouping
 of morbid phenomena, that the pancreas is the
 seat of disease, the exact nature of that disease,
 or the extent of lesion of other organs  associ-
 ated with it, can rarely be recognised  during
 life.  The symptoms which are most frequent-
 ly observed, although not constantly, are car-
 dialgia, nausea, vomiting, and other disorders
 of the stomach ; pain at the lower part of the
 epigastrium ;  tumour in the  same situation ;
 salivation ; diarrhoea, or constipation;  emaci-
 ation ; and jaundice.
   [Apoplexy of the Pancreas has been observed
 by  Dr. Roberts : the particulars of the case
 are recorded in the fourth number of the  " Bul-
 letin de la Societe Anatomique.  The subject was
 a female who was affected with a haemorrhagic
 diathesis, and who died on the twelfth day of
 her illness, having laboured for some time under
 violent oppression of the chest, attended with
 copious expectoration of blood.  Deposites of '
 blood were found not only in the pancreas, but
 in nearly every organ in the body, even to the
 kidney, ovary, mammary gland, and omentum.
  Internal hemorrhage into the pancreas is re-
 corded by Storck in his Annus Medicus.  The
 pancreas weighed thirteen pounds, and was
 converted into a membranous sac full of blood,
 partly  grumous, and partly organized.   The
 appearances were doubtless owing to the rup-
 ture of a small blood-vessel in the interior of
 the diseased gland.   The subject, a female aged
 twenty-four years, had been subject to frequent
 fainting fits, with great anxiety and palpitation
 in the region of the  heart, and was finally car-
ried off, after a period of three  months and a i
I half, by an attack of bilious vomiting and diar-
 rhoea.  A large, heavy, and  irregular  tumour
 had been latterly observed in the epigastric re-
 gion ]
   38. (a) Cardialgia, and other symptoms of
 severe  indigestion, had been early remarked in
 all the  cases of organic lesion of the pancreas
 which I have had an opportunity of observing.
 The appetite at this early period was not usu-
 ally impaired ;  it was  even  increased in some
 cases.  Thirst was often complained of at an
 early stage, but not so much as in the acute
 state of disease.  To these symptoms general-
 ly  succeeded nausea or vomiting, either occa-
 sionally or at intervals. At first  only  eructa-
 tions of a ropy fluid occurred ; but subsequent-
 ly vomitings, two or three hours after a meal,
 supervened.  As the disease  proceeded to a fa-
 tal issue, the vomiting was more frequent  and
 obstinate.
   39. (6) Pain, deep-seated in the lower part of
 the epigastrium, w ith a sense of heat, was also
 an early symptom, and was most complained of
 when the stomach was empty. It was aggrava-
 ted at intervals, especially by flatulence, which
 frequently attended  it, and was relieved for a
 time by eructations, which sometimes were at-
 tended  by a discharge of a ropy  fluid, some-
 times insipid, at others acid.   The  pain usual-
 ly extended to the  spine, and to either hypo-
 chondrium.   It seems to have been most se-
 vere in  the cancerous cases, as in  that  descri-
 bed by M. Andral, in which it was  very acute,
 and seated chiefly in the back, whence it irra-
 diated to the chest and  abdomen. . In some in-
 stances, as observed by Dr. Sewall and oth-
 ers, it was increased by the vertical  position,
 the patient generally bending forward to obtain
 relief.  In order to ascertain the exact seat of
 pain, and to distinguish between disease of the
 pancreas and that of the pylorus, the epigastri-
 um should be examined or pressed upon at the
 same time that  the left hand presses firmly
 against  the back. When the pylorus is affected
 the pain is felt more  superficially, chiefly to the
 right of the epigastrium,  is  more  aggravated
 by  pressure than in disease of the pancreas,
 and is more relieved by vomiting ;  but disease
 of both  parts is often associated.
  40. (c)  Tumefaction between the pit  of  tne
 stomach and the umbilicus was found  deep-
 seated,  in the more  emaciated subjects, when
 there was considerable  enlargement of the or-
 gan.  The tumour was  generally, at first, very
 difficult to detect.  When this is the case  the
 examination should be made in the manner just
 now directed.  In some instances,  in addition
to a tumour, there was a feeling of weight in
 the hack, with a sense of pulsation,  which was
 perceived externally, or felt by the hand placed
on the epigastrium.
  41. (d) Salivation occurs  in both acute and
chronic  diseases  of the pancreas, and in both
the early and late stages of the latter.   J. P.
Frank saw a case in the last stage  of emacia-
tion from scirrus of this organ, in  which  six
pints of saliva were discharged daily.  Similar,
but not so remarkable instances, have been re^
corded  by others.  Salivation  is one of the
most frequent symptoms; it was sometimes fol-
lowed and relieved  by  vomitings ;  and it waa
also often superseded by diarrhoea  in the  ca-
ses which I have seen. 
         PANCREAS—Structural Lesions of

   42.  (e)  Constipation  and  diarrhoea are  gen-
 erally present at certain stages of organic  le-
 sion of this organ.   They often alternate ; but
 constipation is commonly observed at an early
 period, and  is obstinate.  Diarrhoea  presents
 unusual characters, the stools being frothy and
 ropy.   Dr. Bright has directed attention to a
 very remarkable state of the evacuations when
 scirrus or other disease of the pancreas is as-
 sociated  with ulceration, or  other lesions  of
 the duodenum.   In several cases of this com-
 plication, the stools contained much semifluid,
 fatty, or oily matter, which was of a foetid odour,
 and somewhat resembled adipocere.
   43.  (/) Emaciation and anamia, the former
 especially, always  attend the  advanced stages
 of chronic alterations of the pancreas.  Doctor
 Pemberton considered that emaciation is more
 extreme  in  these  than in  any other malady.
 The anaemia is also remarkable, and  is obvi-
 ously  owing to the impaired  chylification re-
 sulting from the disease of this  organ.
   44-  (g) Jaundice  is a frequent symptom, par-
 ticularly  where  the head or the whole of the
 organ is enlarged.   The  pressure on the ducts
 is often, also, attended by great distention above
 the seat  of pressure  and accumulation of bile
 in them and in the gall-bladder.   In these ca-
 ses, the tumour caused by the distended  gall-
 bladder may be distinguished from that caused
 by the diseased pancreas, by  the more super-
 ficial position of the former.
   45.  xiv. The treatment  of chronic maladies  of
 the  pancreas is  very generally inefficacious.
 Hoffmann placed more reliance  on  diet  than
 on medicine for these diseases. Pemberton en-
 tertained a similar opinion, and recommended a
 vegetable and milk diet for them.  Still, there
 is reason to believe that in an early stage, and
 when  not malignant,  they may be influenced by
 medical treatment;  more especially  by local
 blood-letting, by diaphoretics,  by cooling or sa-
 line purgatives when the bowels are costive,
 and by absorbents  and antacids, with ipecacu-
 anha  and opiates, or  with Dover's powder,
 when  the bowels are  relaxed.   Blood-letting
 can be ventured on  only at an early period of
 the  malady, and even  then it should be  local.
 The anaemia attending an advanced period of
 these  lesions forbid a recourse to it subsequent-
 ly.  Besides determining to the surface of the
 body by diaphoretics, by warm or vapour baths,
 and by ipecacuanha, with opium or other narcot-
 ics, blisters  may  be applied over the  epigastri-
 um, or in the vicinity, and a discharge procured
 from them for a considerable time, or an issue
may be formed.  If there  be  any evidence  of
deep-seated  tumour, the  iodide of potassium
may be prescribed with liquor  potassae  and co-
nium, or with other medicines, according to the
peculiarities of the case ;  an external drain  or
purulent  discharge being procured in any way
that may be  least unpleasant.
   46.  When the disease is attended by vomit-
ings,  opiates,  creasote, the hydrocyanic acid,
and small doses  of calcined magnesia, with a
few drops of laudanum in mint  water,  may  be
severally prescribed.  Dr. Carter  recommends
a  drachm of the tincture of  senna,  with five
minims of laudanum, in an aromatic fluid ;  or
small doses of caluinba, soda, rhubarb, and cap-
sicum, conjoined in the form of powder.  Mer-
curials ought not to be employed, and drastic j
 the—Bibliography and References.      11


 purgatives are generally injurious.  When the
 bowels are confined, enemata are preferable to
 purgatives, unless those of a mild kind, taken
 by the mouth.
   47.  If the disease be inferred to be of a scir-
 rous nature, the  remedies just  enumerated,
 with conium, the  iodide of potassium in small
 doses, and liquor potassae, or the liquor hydrio-
 datis hydrargyri et arsenici, with tinct. opii, may
 be tried ;  and unpleasant  symptoms  should be
 alleviated as they appear.   In the more chron-
 ic cases, the deobstruent  and alkaline mineral
 waters may be taken, and subsequently those
 which  contain  iron, along  with deobstruent
 salts.   The diet should be light, nutritious, and
 after short  intervals, but  in small  quantities.
 When an  external drain or discharge is con-
 tinued for a long time, the diet should be more
 nutritious than in other  circumstances; and
 wine in moderate  quantity may be allowed, ac-
 cording  to the state of the case.  Change of
 air, sea air, and gentle exercise in a dry atmo-
 sphere, are generally beneficial,especially when
 aided by the use of deobstruent and chalybeate
 mineral waters.

  Biblioo. and Refer.—De Groaf, Tract. Anat. Medr-
 cus de Succi  Pancreatici Natura  et Hsu., 8vo. Leid.,
 1664.—F.  Hoffmann, Dissert, de Paucreatis Morbis, 4u».
 H:ilie, 1713; et Opera, Suppl., ii.—J. C.  Brunntr, Experi-
 ments Nova circa Pancreas, 8vo.  Lugd. Bat.,  172.—Mor-
 gagni, De Sed et Caus. Morb., Epist. xxx., arts. 7, 10,110.
 — Lieutand, Hist. Anat. Med , t. i., p. 245.—/. R. Rahn,
 Diagnosis Scirroruin  Pancreatis Observationibus Anat.
 Patholog. illustrata.  Gott., 1796; et in  Brera's Syll. Se-
 lect. Opusc, t. xi., p. 99.—Portal,  Cours d'Anat. Medi-
 cate, t. v.,  p. 355. — G.  C. M. Hoffmann, De Pancrente
 ejusque Morbis, 8vo.   Nuremb., 1807.—Pemberton, Practi-
 cal Treatise on the various Dis. of the Abdominal Viscera,
 2d eu\, 8vo., p. 63.  Lon.l., 1807. - J. P. Frank, De Cu-
 ramlis Horn. Morbis Epitome, t. v., p. 87.—C. F. Hm-les,
 Ueber die Krankheiten des Pankreas, 4to.  Nuremb., 1812.
 —J. Bedingficld, a Compendium of Medical Practice, &c,
 &<:., 8vo., p. 197.  Lond., 1816.— T. Sewall, in New Eng-
 land Journ. of Med., <feo. Jan., 1813 ; and in London Med.
 and Phys. Journ , vol. xxxi.,  p.  194.—Dupuytrcn, in Bib-
 lioih. Med., t. xiii., p. 20.— Hasencerhl, Hist. Med. Morb.
 Epid., p. 60.—Mat/ieis, Ratio Instituti Clinici Romani, 8vo.
 Roma., 1816.—M. Gelcen, Journ.  Complem., &c, t. xi.,p.
 12.—£. Pcrcival, Inflani. and Enlargement of the Pancreas ;
 in Trans, of Fellows and Licentiates of College of Phys. of
 Ireland, vol. ii.,  p. 128.—J. Crampton, in ibid., vol. ii., p.
 134.—Schmackfeffer, Olwcrvationesde quibnsdam Pancrea-
 tis Morbis, 4to. Halle, 1817.—V. N. ab  Hildenbrand,  In-
 stitutions  Practico-.Medicae,  &c, t. iii., p. 366.— Darcy,
 M'-in.de Med. et Chirurg. Militaires, t. x., p. 87.— Ber-
 jaud, in ibid., t. xviii., p. 262.—Ltlienhain, in Revue M6d-
 icale, t. iii., p. 130, 1826.—Cruveilhier, Essai  sur l'Anat.
 Pathol., 8vq., t. i., p. 193 ; et Anat Pathol , ful., livr.  15,
 19.—Sandaith, in Edin. Med. and Surg. Journ., vol. xvi.,
 380.—Martland, in ibid., vol. xxiv., p. 493.—J. Abercrom-
 bie, in Edin. Med. and  Surg. Journ , t. xxi., p. 243 ; and on
 Dis. of the Abdominal Viscera, 8vo.  Edin.,1828.—Rennes,
 in Archives Gen6r. de Med., t. vii., p. 82.—Briere de Bois-
 mont, in ibid., t. xvi., p. 132.—Bouillaud, in ibid., t. ii., p.
 193.— Reynaud, in ibid., t. xxv., p. 165.— Lobstein, Anat.
 Pathol., t. i., p. 193.— Tacheron, Recherches Anat. Patho-
 log., t. i., p. 335, 345. —Gendrin. Hist. Anat. des Inflainmat.,
 t. i., p. 262.—Heyting, in Philadelphia Med. Journ., vol. viii„
 p. 198.— Duponchel, Lond. Med. Repos., vol. xxii., p. 162.
 —J. G. Becourt, Recherches  sur le  Pancreas, ses Func-
 tions, et ses Alterations Orgaiiiques,4to,, tig, Strasb., 1830,
 — Carter, Cyclop, of Pract. Med., vol. iii., p. 237.—Jolly,
 Diet, de Med. et Chirurg. Prat.,  t. xii.—II'. Lawrence, in
 Trans, of Medical and  Chirurg. Society of Lond., vol. xvi.,
 p. 367.—R- Bright, in  ibid., vol. xviii., p. 1.—J.J. Bigsby,
 in Edin. Med. and Surg. Journ., vol. xliv. p. 85.— Wolf, in
 Gazette Medicale, t. v., p. 42, 1837.— W. Thomson, in  Li-
 brary of Medicine, vol. iv.. p. 200.—/. T. Monthirt, Re-
 cherches pour servir a l'Histoire Pathol, du Pancreas, in
 Archives Gtn6r. de M6d., 2d ser., t. xi., p. 36, 265; t. xii.,
 p. 133.
  [Am.  Didliog. and  Refer. — IV. B. Ranney, Case of
 Pancreatic Sarcoma, in Boston Med. and Surg. Journ., vol.
 xiii., p. 42,—Charles Knowlton, in Boston  Med, and Surg,
Jour., vol. xxix., p. 379 ; a very interesting, but obscure casd
of scirrus of the pancreas.  The pancreas was covered ex-
ternally with closuly-adherent cellular aud adipose matter 
12                      PARALYSIS—Varieties and States  of.
and internally it had wholly lost its reddish, watery ap- I
pearance, being gristly, dense, and heavy.  It was firmly
adherent to the duodenum, and diseased throughout.  The
patieut, a man of 69. was extremely pallid, and subject to
bilious diarrhcea.—'. Bell and IV. Stokes, Lectures on the
Theory and Practice of Physic, 2 vols , hvo., 3d ed.  Phil.,
vol  i., p. 551-554. — Battersby, in Am. Journ.  Med. Sci.,
vol. viii., N. S., p. 206.—Ibid., vol. iv., N. S., p. 178. — R.
Dunglison, in Cvcloped. Prac. Med., vol. iii.,  p. 457 ; et
Practice of Medicine, 2d ed., vol. i., p. 5*1.  Phil., 1844.—
Archives General., 1336.—S. D. Gross, Elements of Patho-
log. Anat., &c, 2d ed.   Phil., 1845, p. 689.]

PARALYSIS.—Syn. Tlapalvvic (resolutio, dis-
  solutio), ndpeaic ;  Resolutio nervorum, Celsus.
  Paralysis,  Pliny, et Auct. Recent.    Carus
  paralysis, Good.  Paralysie,  Fr.   Lahmung,
  Germ.   Paralisia, Ital.   Palsy.
    Classif.—IV.  Class, III. Order  (Author
       in Preface).   See, also, Apoplexy.
  1. Nosological Defin.—A diminution or loss
of motion, or of sensibility, or of both motion and
sensibility,  in one or more parts of the body.
  2. Pathological Defin.—Disease generally
organic, either of the cerebro-spinal axis and ram-
ifications, or of adjoining parts implicating these,
so as to impair or altogether to  abolish motion  or
sensation, or both, in a part, or more extensively
throughout  the frame.
  3. Paralysis presents itself in several forms
and states, according as the sensibility or the
power of motion, or  both, may be  affected; and
according to the degree and the extent of the af-
fection.  It varies thus in grade, character, and
extent, from the numbness or weakness  of a
single joint or finger,  to a complete apoplexy,
in which the sensation and motion of the whole
body are abolished.  These circumstances have
led to the use of various terms, as respects the
form and extent of the disease, that may briefly
be  noticed.  As regards the form or character
of the malady, when either motion or sensation
is entirely  lost, the paralysis is complete as re-
spects that function ; if either be impaired only,
or  not altogether  lost, the disease  is incom-
plete.   If only one function is affected, the pa-
ralysis is imperfect: if both sensation  and mo-
tion are lost, the disease is perfect, as suggest-
ed  by  Dr.  Bennett.   Thus palsy may be not
only complete or incomplete, perfect or imper-
fect ;  or both complete and perfect, or incom-
plete and imperfect;  but it may even be com-
plete as respects either function, and yet imper-
fect, inasmuch as only one  is lost; or it may be
incomplete, and yet perfect as regards the af-
fection of both functions.
  4. Palsy has been divided, as respects its ex-
tent, into partial and general; the former has
been farther divided into hemiplegia, when one
side or lateral half of the body is affected ;  par-
aplegia, when  the inferior half is attacked ; and
local,  when a  smaller  portion of the frame  is
affected.   It has,  moreover, been called  idio-
pathic  and  symptomatic;  but  those who have
thus divided it have not pointed out in what  its
idiopathic nature consists.  Palsy is generally,
if not universally, a symptomatic malady, inas-
much as it depends upon  lesion of the central
nervous  masses, or of the principal nervous
trunks or chords, or of parts implicating them ;
as it is rarely owing to an affection of the parts
themselves which  betray  the disorder, unless
in a few instances  of  palsy from cold  or from
6ome agents directly influencing these parts.
  5. Paralysis has been termed continued or in-
termittent, fixed or  movable, according as it pre-
sents these characters.  It has  likewise been
called plethoric, serous, bilious, febrile, &c, ac-
cording to its presumed cause, or to these states
of concomitant disorder.  Its origin in certain
metallic  and vegetable poisons has also been
used, and with true practical advantage, to dis-
tinguish  those instances which  are thus pro-
duced.   To these forms and characters of the
malady attention will be directed in the sequel,
as well  as  to  the complications presented by
them in  practice.   In describing the several
states and forms of paralysis, loss of sensation
will be first considered, and afterward the sev-
eral forms of loss  of motion.
I. Varieties and States of Palsy.
  6.  i. Paralysis of Sensation.—Loss of Sen-
sibility.—A particular sense, or the feeling of a
limited, or even of the greater part of the body,
may be  impaired or altogether lost—the palsy
of sensation may be incomplete or complete in the
part  affected ; the affection being either limited
or so extended as to be almost general.  Under
the head of local,  limited, or partial loss of sen-
sation, may be comprised incomplete and com-
plete palsy of the several senses, although some
of these affections of sense  are treated of in
separate articles.
  7. A.  Loss of Smell—Anosmia—is commonly
a symptom of some disease,  as  a catarrh, &c.
It is rarely observed as  a simple affection, un-
less  it be caused by the abuse of stimulants or
of irritants, as of snuff, &c.   Dr. Todd and Dr.
Good mention instances of this  having been a
congenital affection.  It often attends coryza,
ozana,  nasal polypi, diseases of the spongy
bones, &c, and it is sometimes  caused by ex-
ternal injuries; by prolonged irritation or ul-
ceration  of the  Schneiderian  membrane ; and
by diseases of, or tumours pressing upon, the
olfactory nerves.  M  Serres states  that dis-
ease of the roots of these nerves, and more par-
ticularly of the external root, is not  an infre-
quent cause of defect or loss  of this sense.
  8.  B.  Loss of Taste—Ageustia—sometimes,
also,  attends other  diseases.   It occasionally
accompanies palsy of the tongue, or of the mus-
cles  of the face.  It is  frequently observed  in
continued  and exanthematous fevers;  and  is
in them, as well as in some  other acute dis-
eases, partially caused  by  the fur and viscid
mucus covering the tongue and adjoining parts,
that prevents the  sapid body from coming into
close contact with the nerves of taste.   It may
be produced also  by the use  of  tobacco, espe-
cially by chewing it, or by other acrid substan-
ces.   It.  has even arisen from want of exercise
of the nerves of taste, as in a case detailed by
Dr. Robbins  (Lond.  Med.  Gazette, vol. x.,  p.
175), in which, owing to an  unsound tooth, sub-
stances were usually taken and masticated  in
one  side of the mouth,  without being brought
in contact with the side on which the diseased
tooth was situated.  After the  tooth was re-
moved, it was found  that taste in that-side of
the mouth  was impaired.  A slight degree of
ageustia often is associated with loss of smell
in severe catarrhs and coryza ;  and it is then
owing chiefly to the state of the nerves of smell
and  taste.   Marked  impairment, however,  of
the former sense often, also, slightly impairs'the
latter.  Defect or  loss of sight and loss of hear-
ing are fully discussed in the  articles Amauro-
sis and Hearing. 
PARALYSIS—Varieties and  States op.
13
  9. C. Defect or Loss of Feeling.—Absence of
the  Sense  of Touch.—Anasthesia.—Insensibility
of a part, or of the general Surface of the Body.
—Incomplete or complete loss of the sensibility
of a part  sometimes occurs alone or independ-
ently of any other form  of palsy, but it  more
frequently precedes or  attends  loss of motion,
generally of the same  part; in rare cases, of
another or opposite part.   It very rarely follows
paralysis of motion.  It  more commonly pre-
cedes loss of motion of the  lower than of the
upper extremities ; but paralysis  of motion is
often unattended by loss  of sensibility.
  10.  a. The access of anaesthesia is often sud-
den, and without any premonition.   Sometimes
it is characterized by a perversion, rather than
by an absence of feeling;  the sensation of fine
sand, or of some  intermediate substance  be-
tween the skin and the object touching it, being
for  some  time present, before feeling is lost.
In other cases, formications,  slight  tinglings,
and incorrect reports furnished by the sense of
touch,  precede for a short time more or less
complete numbness.
  11. The loss of  sensibility may be very par-
tial in any part of the surface.  It may exist in
one or more  fingers only; and in this partial
state may have been congenital, or have occur-
red soon after birth.   Partial anaesthesia is ob-
served most frequently in one limb,  or in one
half of the body, or in one side of  the face.  In
this latter situation, when any  substance is put
between the lips, the sensation of its being bro-
ken is occasioned.   Anaesthesia of the surface
has been observed by M.  Andral  in a number
of round spots, the surrounding skin being quite
sensitive.  When loss  of sensibility  of any of
the extremities is  considerable, muscular mo-
tion of the same extremity is generally more or
less impaired.  , In many cases, however,  the
defect  of the  muscular  power of the part is
caused by the want of report  between sensa-
tion and voluntary action ;  for in holding an
object in a hand which is deprived of sensibil-
ity, it  is readily dropped if the  eyes are  not
fixed on it: the sensation of its presence  not
being conveyed by the nerves of feeling in the
part, the  act  of volition is  either imperfectly
excited, or is not excited at all.   In some such
cases,  also, it is probable that volition  is  not
transmitted in sufficient  force to the muscles
to produce prolonged or  energetic action.  In
the familiar instance of numbness from  press-
ure on one of the lower  extremities, it will be
found that the limb will not support the weight
of the body unless  volition be strongly exerted.
  12.  b. It is  rare to find the sensibility of a
part completely lost, so  that  it  is  insensible to
the severest  kinds of injury,  as  to fractures,
burns,  &c.  Cases, however, of this kind have
been adduced  by Yellowley, Good, Earle,
Broughton, and others.   It is also rarely ob-
served to be universal; although it sometimes
commences partially, and extends gradually and
generally, until nearly all the surface of  the
body is implicated.  The more extended forms
of partial  anaesthesia generally appear in one
half of the body, hcmiplegic  ancesthcsia, and is
limited with precision by the median line, or in
the lower or upper extremities.  In these forms
it is most  frequently followed by, or associated
with, loss of motion of the same part.  Cases,
however, sometimes occur of  complete  anaes-
thesia of one side existing without palsy of mo-
tion, or with very slight local palsy.  In some
cases of this kind recorded by Mr. Broughton,
there was slight impediment only  of  speech.
In the cases of hemiplegic anaesthesia which I
have seen, the temperature of the surface was
below that of the sound side, while in hemiple-
gia, with loss of motion only, the temperature
was  somewhat higher than that of the opposite
side.
  13. c. The duration of anaesthesia is very in-
determinate, and depends much upon  the  re-
mote causes, upon the pathological conditions
producing the affection, and upon the treatment.
The  affection  may continue but a short time,
as in cases of concussion, or of temporary press-
ure on a nerve.  It may be very protracted,
and terminate only with life.  The sensibility
may  be restored unexpectedly, and sometimes
even suddenly.  When the anaesthesia is asso-
ciated with loss of motion, it is generally pro-
tracted, although it is often removed, while the
palsy of motion continues, or is but little re-
lieved.
  14. d. The pathological changes producing an-
aesthesia are not always obvious :  they have
even been incorrectly assigned ; and it is doubt-
ful whether certain of the localities, which are
at the present day supposed to be especially
and solely concerned in the propagation of sen-
sation, are really thus exclusively  employed.
The  alteration producing anaesthesia may exist
in the brain, in the spinal chord, or in the nerves
themselves ; but, although the posterior roots
of the spinal nerves appear to be more espe-
cially concerned in the function of sensation, it
has not been fully shown that the posterior col-
umns of the spinal chord are the appropriated
channels for the transmission  of  sensation.
Numerous cases are recorded in which the pos-
terior columns have been disorganized, or even
the whole chord pressed upon, softened, or oth-
erwise disorganized, and yet the sensibility has
either  been unimpaired,  or even  increased.
Some of these cases have been referred to by M.
Ollivier, and others have been lately published
in recent transactions of societies and periodi-
cal works. To these a more particular reference
will be made in the sequel.  I may here, howev-
er, briefly remark, that anaesthesia has followed
causes affecting chiefly the surface of the body,
as the prolonged influence or excessive degree
of cold. It has likewise been produced by torpid
or interrupted circulation of blood in the part.
It is sometimes a symptom in hysteria and hyp-
ochondriasis, in all which  cases  it is  usually
partial or limited as to extent; and it has oc-
curred in the puerperal states.  It has also ap-
peared in connexion with  certain epidemics
affecting the system generally, and  the  cuta-
neous  surface  and  extremities more particu-
larly, as that which prevailed during the sum-
mer  and  autumn of 1828 in Paris: a circum-
stance calculated to support  the view  of the
pathology of anaesthesia which I shall have to
state hereafter.
  15. ii.  Paralysis of Motion.—A.  The more
local  and partial stales of PaUy.—Under this
head are comprised those varieties of the dis-
ease which affect  a part  only of the body.
They are divided, as already noticed, into, 1st.
Local  paralysis;  2d.  Hemiplegia; and, 3d.
Paraplegia. 
14                      PARALYSIS—Varieties and States of.
   16.  A.  Local paralysis implies loss of motion,
 or of sensibility, or of both, in some part only
 Of the body, and to a small extent.  Although
 sometimes'a permanent state of the disease, it
 is more frequently the commencement of a more
 extended  malady.
   17. a. Paralysis of motion of particular mus-
 cles and parts is not infrequent, occasioning af-
 fections to which certain names have been ap-
 plied  according to their seats.  Strabismus is
 often caused by palsy of one or more muscles
 of the eyeball, although not by this in all cases.
 Ptosis, or falling of the  upper eyelid, often ari-
 ses from an atonic or paralytic state of the le-
 vator palpebral superioris, owing to some altera-
 tion  implicating the nerve which supplies it;
 although  it  may arise also from  a spasmodic
 action of the orbicularis palpebrarum.  A slight
 examination, or the degree of resistance op-
 posed to  raising the  eyelid,  will  immediately
 show the  nature of the affection.   Ptosis from
 local palsy is often associated with  squinting,
 showing that the third pair of nerves is palsied.
 It is  always a  serious  affection,  particularly
 when thus associated ;  and is often  indicative
 of cerebral disease, being frequently a precur-
 sor of hemiplegia, or even of apoplexy.  It is a
 common and most unfavourable  symptom of
 the advanced stages of diseases of the brain in
 children.  It is, however, sometimes caused by
 a tumour pressing upon  the  nerves in some
 part of their course.
  18. b. Lagophthalmia, or gaping of the eyelid,
 the eye being  generally open or  imperfectly
 closed, sometimes proceeds from paralysis of
 the orbicularis palpebrarum, owing to disease of,
 or implicating  the portio dura. When this  is
 the case,  the affection  is associated with a
 state of partial  palsy about to be noticed.
  19. c. Palsy  of the muscles of the face is not
 infrequent, and  is generally caused by pressure,
 injury or  disease of the portio dura, and  fifth
 pair of nerves.   If loss  of motion is complete,
 the portio dura and motor branches of the fifth
 pair are affected ; if sensibility also be abolish-
 ed, then the sensitive part of this nerve is im-
 plicated.  Where the portio dura only is  para-
 lyzed, there is little evidence of palsy until the
 muscles supplied by this nerve are called  into
 action.  As long as the patient neither speaks
 nor smiles, the countenance  presents nothing
 remarkable, and the sensibility of the face  is
 unimpaired ;  but when  laughing,  coughing, J
 sneezing,  crying, or any of the actions of ex-
 cited  respiration are  produced, the  deformity
 of the countenance is apparent.  The mouth is
 drawn to  the sound side, the derangement of
 the features being remarkable in proportion to
 the intensity of the respiratory act.  The af-
 fected cheek remains motionless, while the oth-
 er is thrown into unusual action,  is flaccid, or
 swells out at the moment of expiration, or when
 the patient attempts to pronounce a word with
 emphasis, and appears broader and more prom-
 inent  than the  sound  one, which  is more con-
 tracted or wrinkled.   The muscles moving the
jaws, and used  in mastication, which are  sup-
 plied by the motor portion of the fifth, still per-
 form their functions.   Owing to  the palsy of
 the lips on the affected  side, the  labial conso-
 nants are imperfectly articulated, and saliva,
 or even aliments, sometimes escape from the
 palsied side of  the mouth.  The patient is un-
 able to spit out his saliva, or to blow fully.
 or to snuff up with  the nostril of the attectea
 side.  Lagophthalmia generally accompanies
 this state  of the disease,  the  eye appearing
 more prominent, and, being exposed to con-
 stant irritation,  generally becomes  inflamed.
 In  protracted cases the muscles are wasted,
 and hence the face acquires a peculiar expres-
 sion.
  20. Palsy  of the portio  dura may be occa-
 sioned by severe  or protracted cold, or currents
 of air, giving rise to what was usually termed
 a blight;  but it is  probably  more frequently
 caused by an inflamed or enlarged state  of the
 parotid  gland, or a tumour in the vicinity of
 the stylo-mastoid foramen, or inflammation or
 abscess of the internal ear, or by disease of
 the petrous  portion of the temporal bone, or by
 a tumour or abscess  compressing the nerve at
 its entrance into the internal auditory foramen;
 by disease  of the brain  at the origin  of the
 nerve, or by ulceration implicating the  nerve
 in some part of its course ;  or,  lastly, by a
 wound or injury of the nerve.
  21. When the motor portion of the fifth pair oj
 nerves only is palsied, there is generally  slight
 loss of sensibility of the parts supplied by this
 nerve ; but the motions of the jaw on the af-
 fected  side  are impaired.   Mastication is im-
 peded, and is not performed on that side, owing
 to the palsy of the muscles which  convey the
 morsel to the operation of the teeth, and  to the
 lost action of the masseter and temporal mus-
 cles.  There are  still, however, command over
 the countenance, little or no distortion of the
 features, and no loss of expression.   The jaw
 is in some cases a little depressed, but this dis-
 appears when the patient  smiles or laughs, a
 circumstance distinguishing this variety of pal-
 sy from that  caused by disease Implicating the
 portio dura.  This state of disease may exist
 alone, but it is commonly associated with loss
 of sensibility ($ 10, et seq.), and is usually far-
 ther complicated with hemiplegia.  The disease
 of the motor portion of the fifth pair may be
 seated in the course  of the nerve, or in or near
 the origin of it in the brain
  22. As Dr. Bennett has very justly remark-
 ed,  it is rare that the lesions are confined to
 the fifth or to the seventh  pair of nerves.  In
 general, the  symptoms of  disease of the one
 and the other are conjoined, although they sel-
 dom indicate an equal affection of both nerves.
 Commonly the disease appears first in the one,
 and then in  the  other, and, when the muscles
 on which the nerves first  affected ramify are
 completely paralyzed, the muscles supplied by
 the second are partially affected.   In  some of
 these cases, also, the paralysis is accompanied
 with neuralgia of a very acute  description.
 Palsy of either of these  nerves is very rarely
 met with in  both  sides in the same case.  Dr.
 Abercrombie met with an instance of palsy of
 the fifth pair  on one side of the face, and of'the
 portio dura  on the other,  occasioned by a tu-
 bercle in the brain.
  23. d. Palsy of particular muscles, or of a sin-
gle  limb, is not uncommon. Temporary palsy
 is not infrequently produced in these by casual
 pressure of the nerves supplying them   It may
 arise, also, from overstraining the nerves, or the
 muscles  themselves, by  over-exertion,  as hv
 lifting  very  heavy weights.   Dr.  Healy  has 
PARALYSIS—Varieties and States of.                       15
described instances of palsy of the hand  and
forearm, owing to pressure caused by the head
resting  on the  arm when asleep, which could
be removed only by electricity ; and Dr. Dar-
well has ascribed the palsy consequent  upon
over-exertion to the  injury done to, or over-
straining of, the nerves supplying the affected
muscle.
  24. Palsy of  a single limb is not infrequent
in children. It is often congenital, and the up-
per are  more liable to it than the  lower limbs.
It is sometimes owing to congenital disease or
deficiency of the brain ; but, when it takes place
subsequently to birth, it has been  imputed to a
loaded state of the bowels, or to disorder of
the stomach ; but disease of the brain or spinal
chord is probably more immediately than those
connected with its occurrence.  Some of these
cases grow up, and present the limb of a child
joined to the  body of an adult.  I have  met
with several instances of this occurrence, one
in a physician, another in  a medical student,
both being characterized by remarkable irrita-
bility of temper.  An upper extremity, which
contrasted remarkably in size with the sound
limb, was affected in both these cases.
   25. Palsy of a  part, or of the whole of one
limb, is very generally the commencement of
a more extended malady ;  and instances are
sometimes met with  where only a  few of the
muscles of an extremity are affected, these be-
ing, according  to Sir C. Bell, muscles  natu-
rally combined in action, although supplied with
different  nerves  and different blood-vessels.
Sometimes all the extensor  muscles lose their
power,  while the flexors preserve it.   In  rare
instances, also, as in  the case of a  lady lately
under my care, the  motions  necessary for wri-
ting,  or for  any fine work, were  completely
lost, while the  arm could be moved as strong-
ly as ever.  It has  been  supposed that the
nerve in these cases is  incapable of perform-
ing  its functions, owing to pressure or dis-
ease ; and this is probably the case in some in-
stances, as in  those recorded by  Drs. Aber-
crombie and Storer, and more especially when
partial  paralysis follows acute or chronic neuri-
tis.   It  is even possible that, in other cases,
the palsy is caused by imperfect or  interrupted
circulation through the blood-vessels of the
limb, owing to disease  of  them, as supposed
by Graves, Stokes, and others.  But  in some
instances there are no indications of disease of
the nerve itself, and  the circulation is perfect
in the affected  extremity.  In the case of the
lady just alluded to,  who is about  sixty years
of age, and of  a full  habit of body, there was
no sign of disease in either the nerves or the
blood-vessels of the limb itself.  I prescribed
for her blood-letting, which  was performed un-
der  my own eye,  twenty-four ounces  being
quickly taken away without any  faintness be-
ing caused.  After the depletion and purging,
the partial state of palsy gradually disappeared.
   26. e. Paralysis of the tongue and muscles of
articulation, although  occurring frequently  in
connexion with hemiplegia and  apoplexy,  is
very rarely met with alone.   I have, however,
been consulted in  several  cases, in which it
was either the  chief part of the disease, or was
associated with difficult  or impossible degluti-
tion.   In a case from the country, which  I re-
cently attended, complete loss of the power of
articulation was associated with partial palsy
of the extremities, the patient being deficient
chiefly in the power of contracting the muscles
of the hands  and forearms.  Both lower ex-
tremities were also weak.  He returned with-
out benefit from treatment, and died soon af-
ter.   I have  not  learned the particulars con-
nected with his death.  In this case loss of ar-
ticulation  was the first and chief symptom, yet
the tongue could be protruded  without being
drawn to either side.
  27. Some years ago, Mr. Winstone consult-
ed me in the case of a professional gentleman,
aged  about fifty, who had, for many  months,
lost all power of  uttering the most simple ar-
ticulate sound, and who swallowed substances
with the utmost difficulty, or not at all, unless
they were conveyed over the base of the tongue.
The tongue could not be protruded, and, indeed,
was incapable of motion.  The mouth, also,
could be opened only imperfectly, but the sense
of taste was not affected.  He had neither head-
ache nor any other ailment, and  no  other part
was paralyzed.  He  attended regularly to his
profession during the usual hours of business,
but was obliged to write down all he wished to
say.  The disease was ascribed to pressure or
structural  change at the origin, or in  the course
of the lingual and glosso-pharyngeal  nerves;
and  the prognosis of suddenly fatal apoplexy
or general paralysis  was hazarded, which oc-
curred, some months  after my attendance ceas-
ed.  Various means  were prescribed without
any effect on the disease.
  28. Most frequently, however, paralysis of
the muscles engaged in articulation, or in deg-
lutition, or in  both functions, follows upon se-
vere  or renewed  attacks of apoplexy,  or of
hemiplegia complicated with apoplexy.  I have
seen  it occur after inflammation of the brain,
and  after  cerebral convulsions in children, as
in the case  of a fine boy, respecting whom I
was consulted by my friend Mr. Worthington
of Lowestoft.  The  disease may continue for
many months unmitigated by treatment; it  is
generally  ultimately  fatal, death taking  place
after or during a convulsive attack.
   29. /. Aphonia, in the true sense of the word,
can occur only when the larynx is affected, ei-
ther its muscles being paralyzed, or its struc-
ture changed by serous  or other effusion be-
tween its ligaments, tendons,  or  cartilages.
Loss of the power of articulation depends upon
paralysis  of the tongue, cheeks, and lips; and
this loss may be so complete as  to  prevent, all
articulate sounds from being produced ; still the
power of uttering sound remains, but in its sim-
plest form only.   When articulation is entirely
gone, the motions of the muscles of the pharynx
and base  of  the tongue are also lost.  Simple
aphonia is often caused by temporary inaction
or torpor  of the nerves of the larynx, in hyster-
ical or nervous persons. Loss of the power
of articulation is a much more serious and per-
manent malady than aphonia, and is either at-
tendant upon, or followed by, the most general
or fatal states of palsy, unless in hysterical ca-
ses ;  and  in  these the motions of  the tongue
are  also sometimes temporarily lost.  In cat-
alepsy, voice and articulation  are  quite lost,
with all voluntary motion, but they return  as
soon as it is  restored.  In incomplete palsy  of
the  tongue, protrusion of it may generally  be 
16
PARALYSIS—Varieties and States of.
effected ; but it is generally drawn to one side,
particularly if hemiplegia also exist.  In other
cases it  is usually protruded in a  straight di-
rection.  The tongue, even in cases of hemi-
plegia, is not always drawn towards the sound
side.   Sometimes it is drawn to the paralyzed
side.   Lallemand imputes its direction to this
side to the action of the genio-glossus  muscle
of the unaffected side drawing the base of the
tongue forward, and turning  the  apex to the
opposite  side.  Cruveilhier attributes the di-
rection of this organ, when protruded, to feebler
resistance on one side than on the other.
  30.  g.  Paralysis of any of the muscles of or-
ganic  life rarely takes place to any extent, and
is, indeed, incompatible with the continuance of
life, unless in those viscera which are particu-
larly influenced by volition, as the urinary blad-
der, the sphincters,  &c.   A temporary state of
relaxation, or loss of the contractile power, of
portions of the alimentary canal not infrequent-
ly occurs in the course of various diseases, and
constitutes a part of the pathological conditions
obtaining in  inflammations of this canal, in col-
ic and ileus, in lead  colic, in hysteria, &c.; but
it rarely continues for any considerable period,
at least in a  complete form, and  in the same
portion of the tube, without being followed by
a fatal result.
  31.  h.  Palsy of the urinary bladder, owing to
over-distention, is a frequent occurrence ; it is
likewise connected with paraplegia, and in both
circumstances of the complaint retention of the
urine  is the  prominent phenomenon.  Hyster-
ical paralysis of the bladder is  often met with.
Dr. Todd says that  there is  much truth in Sir
B. Brodie's remark  that, in these cases of hys-
terical paralysis, " it is not that  the  muscles
are incapable of obeying the act of volition, but
that the function of volition is suspended."  Of
course the muscles possess their capability of
motion ;  no  one could have suspected the con-
trary  ; that the function of volition is suspend-
ed in  these cases is, however, a more doubtful
proposition.   The  truth is, that a careful in-
quiry  into the phenomena of hysterical paral-
ysis,  in some cases which have  come before
me, has  shown that, owing  to a weakened or
exhausted stale of the spinal chord and motor
nerves, volition is not transmitted in sufficient
force  to produce muscular action ;  and that vo-
lition  i§  not suspended, although it may be
weakened ; but that it must be made with more
than  usual energy to act upon, or even  to be
transmitted to the muscles.
  32.  i. Palsy,  more or less complete, of the
rectum, is not infrequent in aged  persons, and
in hysterical females.  In these cases faecal ac-
cumulations often form in the rectum  and co-
lon, owing to their  inaction  or want of power
to overcome the resistance of the sphincter.
  33.  k.  Palsy  of the sphincters of the  rectum
and bladder attends  most maladies in which ei-
ther the brain or the spinal chord is oppressed,
or has lost its power.  The inability to retain
the faeces, or the incontinence of urine which
results, becomes one of the most troublesome
and unfavourable phenomena  of  the  disease.
As, however, this form of local paralysis very
rarely occurs unconnected with a more exten-
sive malady, it  will  be more fully noticed here-
after.
  34.  B. Hemiplegia (from  ijfitav,  the half, and
note paralysis of one side, exieiiuu.„
the upper and the lower extremities.  JYhen
the upper limb of one side and the lower ot
the opposite side are affected, the palsy is usual-
ly called transverse or crossed palsy; put tins
form is comparatively rare.  Hemiplegia is the
most common form of the malady ; and it oc-
curs more  frequently on the left than on  the
right side, the proportion being as three to two,
according to the observations of Sir G. Blane.
Generally the paralysis  extends to the side of
the face,"the  angle of the mouth being drawn
to the sound side, and  a little upward ;  the
tongue, also, is often more or less affected, and
on the same side, as shown either by its imper-
fect protrusion, or by its being drawn to one
side—usually to  the same side as the mouth.
The pharyngeal muscles are sometimes also
affected.  " Hemiplegia is limited exactly to one
half of the body, the median  line being  the
boundary, owing to the distribution of the spi-
nal nerves.
  35.  The attack  of hemiplegia occurs various-
ly.  1st.  It may  appear  gradually ; local palsy,
affecting first the fingers or toes, leg or hand,
taking place, and extending slowly and gradual-
ly until the lateral half of the body is implica-
ted.  In some cases of this form of the disease,
convulsive movements  of a limb, or even of
both limbs, are  remarked, and continue until
the loss of motion is complete.
  36.  2d. After various chronic cerebral symp-
toms, and affection of one or more of the senses,
the speech becomes affected, the  tongue more
or less palsied, or protruded with difficulty, and
the face distorted ;  upon these complete hemi-
plegia supervenes in a short period. This form
is not infrequent  in aged persons.   In this and
the preceding variety, several organic lesions,
as tumours, tubercles of the brain, or its mem-
branes, are often  present.
  37.  3d. After cerebral symptoms of a more
acute and painful character ; after severe head-
ache, febrile  commotion,  sometimes  delirium
or intellectual disorder,  spasm ortwitchings of
the muscles, pain  in the limbs, occasionally
spastic rigidity of some of the flexor muscles,
or even convulsions, complete hemiplegia takes
place.  In  this variety inflammatory softening
of a portion of the brain is often present, and
pain is complained of in the paralyzed limbs.
  38. 4th. After injury of the head, at a more
or less remote period,  or after chronic cere-
bral symptoms, and various affections of some
one or more of the senses, convulsions or ep-
ileptic seizures occur, which, after a more or
less frequent recurrence, are followed by palsy
of a limb, most frequently the arm, extending
to the whole side ; or at once  by complete
hemiplegia.  In three cases of this variety I
found one or more abscesses in the brain.   In
these several states of hemiplegia the sensi-
bility  is generally unimpaired, or  but partially
affected.
  39. 5th. Hemiplegia  may occur suddenly,
without any  previous indication.   In some of
these cases I have ascertained the existence
of inflammatory attacks of the brain at a re-
mote  period, recovery having taken place long
previously to the hemiplegic seizure.  This va-
riety  is often followed  by apoplexy, but  at no
precise period. 
PARALYSIS—Varieties and States of.                      17
  40. 6th. Hemiplegia frequently immediately
follows an apoplectic seizure,  or  attends it, or
appears in its course.  In this  variety more
especially, and very often  in that immediately
preceding, haemorrhage within the cranium has
occurred.   Generally the hemiplegia is observ-
ed only when the stupor subsides ; but in many
instances it  may be detected at first by a care-
ful examination of the state of the extremities
an J features. According to my experience, the
sensibility is most frequently  implicated in the
fifth and sixth of these varieties of the seizure.
  41. Although some reference  has just now
been made to the cerebral lesions upon which
those varieties of hemiplegia individually ap-
pear most frequently to depend, still  no pre-
cise  or constant  connexion between  the one
and the other has been ascertained, and most
probably it does not exist.  Nevertheless, the
relation is too frequent and too  obvious to be
entirely overlooked.  Of hemiplegia it may be
remarked, in general terms,  that it may pro-
ceed from any one or more of the  numerous
organic lesions which are  described in the ar-
ticles on the morbid anatomy  of the Brain and
its Membranes, and of the Cranium.  (See these
articles.)
  42. One fact may be relied on, viz.,  that the
lesion  exists, with very few exceptions, and
these  not very precisely  determined, in  the
side  of the brain opposite to the  seat of palsy.
Dr. R. B. Todd remarks that,  according to the
views  of Foville and others, we should  ex-
pect to find the optic thalami and corpora stria-
ta, or some of the  fibrous radiations which pass
through these bodies, the seat  of disease in
hemiplegia;  and,  in fact, in the generality of
cases,  those bodies, or some portion of the cer-
ebral hemisphere, present alteration of struc-
ture, variable in  extent as well  as in  degree.
It must be admitted, however, that cases  oc-
cur in which one only of these  bodies is  the
seat  of disease, or in which no appreciable le-
sion  can be detected in the hemisphere.  Such
occurrences, however, as  Dr. Todd justly ob-
serves, can hardly be deemed to militate against
the theory of Foville, inasmuch as our igno-
rance  of the mechanism  of cerebral action,
whether healthy or morbid, is alone sufficient
to make them appear anomalous to us.
  43. Hemiplegia is very rarely produced by
disease of the  upper part of the spinal mar-
row.   In several  cases of lesion of this part,
in which I have been consulted, the paralysis
has been at  first  local or partial, generally af-
fecting one arm, but it has soon  become more
general.  In  some instances, however,  one side
has been affected  more than the other, or one
or two limbs more  than the rest.  Instances,
however, have been observed of loss of mo-
tion on one side, and anaesthesia of the other ;
but these are remarkably rare.   One has been
adduced by Portal, and another by Mr. Dun-
das.   This  latter case was consequent upon
concussion  of the  spine produced  by a fall.
The temperature  of the side and limbs, depriv-
ed of sensation, but possessing muscular pow-
er, was lj3  Reaumur, below the side which
retained sensation without motion, the heat on
this side being rather beyond  natural,  and the
sense of feeling morbidly increased.
  44.  Hemiplegia may be congenital,  or may
occur soon  after  birth.  M. Cazauvieilii has
       III            2
shown that congenital hemiplegia usually de-
pends upon an arrester defect of development
or growth in a portion of the brain.   The limbs
of the affected side, particularly the  arm, were
stunted in growth, and flexed and contracted.
The opposite hemisphere of the brain was gen-
erally  smaller, the convolutions imperfectly
developed, the  capacity of the ventricle  less,
and the corpus  striatum and optic thalamus of
smaller size.  Cases  of this kind may attain
an advanced age.  Most of the instances I have
had an opportunity of observing were idiotic,
as well as incompletely paralyzed on the de-
formed  side.   Cases  of hemiplegia  have oc-
curred in which the opposite side has become
similarly affected,  either soon after the  first
attack, or during  convalescence from it.   In
these the sensibility has sometimes either been
only partially, or not at all  affected.
  45. The paralyzed side  may be the subject
of pain, the result of morbid action in the brain,
or of spasm; hence designated spasmodic hem-
iplegia by Sauvages and others.  In these, in-
flammatory irritation in the brain or its mem-
branes, in the vicinity of the primary seat of
lesion, often exists.  Deep-seated pain or spasm
may occur in a limb, the superficial sensibility
of which is either impaired or altogether lost;
and either or both phenomena may  affect the
opposite or sound limb, although less frequent-
ly than the paralyzed side.  I have never seen
an instance  of hemiplegia with spasm of the
paralyzed side, to which the term of hysterical,
imposed by some  nosologists, was strictly ap-
plicable.  Hysteria very rarely occasions  true
or complete hemiplegia, but I  have  met with
several cases of paraplegia caused by hysteria.
  46. Intermittent hemiplegia has been noticed
by Sauvages, Morgagni, Cullen, Elliotson,
and Todd ; but examples of it have been rare-
ly and  imperfectly observed.   It would seem
that the congestion  of, or vascular determina-
tion to, the brain, during the febrile paroxysm,
occasioned a condition of one of the hemi-
spheres, or of a portion of it, so as to interrupt
the action of volition ; but that the change
was  only temporary,  and  depended upon  the
state of circulation attending the febrile parox-
ysm ; that it consisted neither of softening nor
of haemorrhage.
  47. Much variety in  the symptoms are ob-
served in the course of hemiplegia, depending
upon circumstances that  will be alluded  to
hereafter, and upon a partial or more complete
return  of sensibility when this has  been also
lost, and upon a slight recovery of some of the
motions of the limbs, particularly of the lower
limb ; but generally when the patient is  able
to walk  a little, or with the aid of a stick, the
lower extremity is usually thrown forward by
the inclination of the trunk to the sound side.
The foot is pointed outward when the limb is
raised, and falls from its  own gravity.   The
affected arm  is applied to the trunk, and the
forearm is slightly flexed on the arm, the wrist
and fingers being also slightly bent inward, and
occasionally  somewhat cedematous.
  48.  C. Paraplegia  (from nupu, vitiose, and
nlriaau, percvtio)  has in modern times been
applied to that form of palsy in which the  low-
er half  of the body is deprived of motion or
sensation, or of both.  Hippocrates denomi-
nated all paralytic affections paraplegia which 
18
PARALYSIS—Vari
eties and States op.
were consequent  upon apoplexy;  and Are-
tjevs employed the  word  to  designate  any
form of palsy.  Boerhaave  and Van Swieten
defined paraplegia  to be a palsy of all parts be-
low  the neck, or viewed it  as  a general palsy
($65, et seq.); and in this  sense it has  been
used by Ollivier  and several modern  pathol-
ogists.  I shall, however, apply the term para-
plegia to that  form of palsy which affects the
lower half of  the body on both sides.  When
palsy extends  to the upper and lower extrem-
ities of both sides, it may be denominated, al-
though it is not strictly, general palsy.
  49. The  symptoms  most  characteristic of
paraplegia are, loss of the power of motion in the
lower limbs, with inaction of the  urinary bladder
and rectum, with loss of power over the sphincters,
and often with  impairment or entire loss  of sen-
sation.
  50. The  accession of the symptoms of para-
plegia, as well as the  character,  range,  and
grouping of the symptoms themselves, varies
with the pathological changes or physical caus-
es of the malady,  as it proceeds from  injury,
from inflammation and its consequences in the
spinal chord or its  membranes, or from organ-
ic lesions of these parts, or  of the bones  and
cartilages of the spine.  When the  disease is
consequent upon injury, the symptoms are gen-
erally sudden  in their accession and fully de-
veloped, although this is not always the case,
especially if the accident be slight, and  serious
only as regards its consequences.   When it
proceeds from disease of the chord or of its
envelopes,  some disorder of sensation or of
motion, or  even  of both, is  first experienced,
which becomes more or less rapidly increased
to numbness,  or diminished  power of motion,
of the lower  extremities.   The patient  trips
when walking, is unable to stand for any time,
and complains of a  sense of weight in the limbs,
and  of pains extending to the legs and feet.
He cannot  walk without the aid of one or two
sticks, Or of another person.  The urinary blad-
der, reetum, and sphincters soon afterward be-
come more or less affected,  and various other
phenomena supervene,  according to the seat
and extent of  the organic change occasioning
the affection.  In some cases sensibility in the
lower extremities  is but slightly, or even not
at all impaired, particularly when the lesion is
seated high in the  spine ; and when this is the
case, even  the patient's power over  the excre-
tions and the sphincters may not be materially
impaired.   It is comparatively rare that sensi-
bility is impaired or altogether lost in the low-
er limbs without the power of motion being also
diminished or  abolished.
  51. a. The symptoms, progress, and consequen-
ces or terminations  of paraplegia vary with the
lesion producing it ; and it is  difficult, if not
impossible, to  connect the symptoms, in  their
full extent and course, with the particular le-
sion upon which they depend.   The exact seat
of lesion, in respect not only to the portion of
the chord which it affects, but also to the roots
of the nerves connected with the part implica-
ted ; the nature of the lesion, particularly as
regards the degree of pressure, or of irritation,
it produces ; and the suddenness or slow prog-
ress of the change, all influence very remark-
ably the phenomena and course of the malady.
  52. There are few diseases which have been
 more lucidly illustrated than paraplegia conse-
 quent upon injury has been in the admirable
 paper upon the subject published by Sir  a. o.
 Brodie ; and as injury often causes inflamma-
 tion and its usual consequences of the spinal
 chord and  its membranes, the subject has both
 a medical  and surgical bearing.  Many,  how-
 ever, of the changes consequent upon injury-
 even haemorrhage upon or into, and softening
 of, the spinal chord—and various organic lesions
 of these parts or in  their vicinity, may occur
 independently of external  injury, and cause par-
 aplegia.  It will be proper to enumerate these.
   53°.  ia.  Concussion of the spinal chord affect-
 ing the intimate structure of some part of the
 chord, although not evidently to the unassisted
 eye ; *b. Manifest laceration or division of its
 substance  ; 3c.  The pressure or irritation caused
 by extravasated blood; *d.  The pressure  or irri-
 tation produced by displaced bone; 5e. Sanguin-
 eous congestion, particularly of the spinal veins
 or sinuses;  6/. The  usual consequences of in-
flammation of the  chord or of its membranes,
 especially effusion of coagulable lymph, indura-
 tion of the substance of the chord, &c.; ig.
 Softening of the chord, whether it be consequent
 upon inflammation, or upon impaired nutrition
 or lost vitality  ; 8A. Inflammation and its conse-
 quences of  the vertebra, or  of the intervertebral
 substance, as caries,  exostosis, anchylosis, 6rc.t
 of the vertebra; H. Scrofulous disease and tuber-
 cles  in these parts;  10k.  Tubercles or tumours
 in the chord or its  membranes ; ul. Hydatids in
 either of these situations ; nm.  And fungoid or
 malignant tumours implicating the chord or the
 roots of the spinal nerves, are  severally patho-
 logical causes of paraplegia ; but the symptoms
 of individual cases, as well as the issue, depend
 upon the part of the chord affected ; upon the
 extent of the particular lesion ; upon the slow-
 ness or rapidity of its development; and  upon
 the manner in  which  the chord or roots of the
 spinal nerves is implicated, whether by press-
 ure, loss of substance, softening,  irritation, in-
 terrupted  circulation, &o, or by two or  more
 of these conjoined.
   54.  It would be inconsistent with a proper
 consideration of this subject were I to overlook
 the physical condition of  the spinal chord, es-
 pecially in relation to the fluid surrounding it,
 to the membranes enveloping it, and the  bony
 case protecting it.  The physiological view here
 suggested  materially  aids the pathological con-
 sideration  of  the subject.  This interesting
 physical condition also obviously concerns the
 roots of the spinal nerves, and serves to explain
 several circumstances connected with them, as
 well  as  with the spinal  chord itself.  These
 parts, being  thus  surrounded by a limpid  fluid,
 and being  protected by membranous coverings,
 and by a bony case and  muscles, are thereby
 rendered much less liable to disease and injury
 than if they were otherwise circumstanced, as
 first insisted upon by Cotugno, more recently
 by Magendie,  and most  satisfactorily  by Dr.
 Todd.  Before pursuing farther this part of the
 pathological bearing of the subject, I will notice
 more fully the  chief phenomena of paraplegia.
   55. b. Paralysis of motion is the chief  char-
 acteristic symptom of paraplegia,  and it affects
 more or less all the muscles supplied with nerves
 from the seat of,  and below, the injury or dis-
[ ease in the chord.   If the disease be slight, 
PARALYSIS—Varieties and  States or.                     19
only one limb, or a set of muscles, may be af-
fected, as above adverted to, especially if the
roots of a nerve or nerves on one side only be
implicated ;  or one limb may be more severely
affected than the other ; or a slight affection
may soon become  severe, or  the converse.
Complete  paraplegia may thus be gradual and
slow, or it may be sudden.  It rarely happens
that the palsy extends to parts  supplied with
nerves proceeding from a portion of the chord
above the seat of injury.  Instances, however,
of this occurrence are  recorded by Mr. Staf-
ford and Sir B. Brodie.   In these cases, it may
be presumed that the consequences of  the  in-
jury, as softening of the chord, effusion of blood
or of lymph,  had extended  upward from the
part primarily injured.
  56. Although voluntary motion is completely
abolished in the lower  limbs, involuntary mo-
tions and  spasms of their muscles are  not  in-
frequent.  When the lesion  is seated high in
the  chord,  spasmodic contractions, either of
more or less permanency, or of a momentary
or short continuance, may affect  the abdominal
muscles, as well as  the  muscles of the lower
limbs, and these may be attended by much or
by  little pain,  either in some  portion of the
spine or in the limbs.  Occasionally the invol-
untary  motions are of a tremulous kind, and
often the flexor muscles are those more per-
manently contracted.  The pains, involuntary
motions, and spasms are manifestly caused by
inflammation or irritation of the  chord or of its
membranes, or of the roots of the nerves at the
seat of lesion, especially by extravasated blood;
by  pressure or irritation of tumours, displaced
bone, effused  pus;  by caries of the vertebrae,
by  malignant or other formations.
  57. c. The affection of the urinary organs con-
sequent upon  paraplegia from injury or disease
of the spinal chord varies in different cases.   It
may be considered with reference  to the  func-
tions of the kidneys  and the states of the blad-
der.  Paraplegia from severe external injury is
very frequently followed by diminished secre-
tion of urine, or even by complete cessation of
the function ; but this is often only temporary,
and the urine is secreted in variable quantity
and altered quality.  In some  cases,  it is at
first acid, very offensive, of a yellowish colour,
and deposites a yellow, amorphous  sediment.
More commonly, however, especially after two
or  three days, the urine is ammoniacal and tur-
bid  when voided,  and deposites on cooling  a
quantity of adhesive mucus.  At a later period
a white substance, phosphate of lime, may be
detected in the mucus,  which is  often tinged
with blood ; and subsequently blood and bloody
coagula are blended in  tire urine and mucus.
These changes generally take  place between
the third and ninth days from the paraplegic at-
tack, when  it is sudden and complete, especial-
ly  if caused by injury, and when the bladder
becomes distended from loss of its contractile
power.   At the same time that  this distention
exists, a dribbling of urine often takes  place, if
the fluid is not drawn off.  In other cases, es-
pecially in those caused by disease seated in,
or implicating, the chord, the voluntary power
over the sphincter of the bladder only  is para-
lyzed,  there being incontinence, hut no reten-
tion of urine.  In the most  severe cases, the
urinary affection continues and hastens a fatal
issue ;  but in others, the power of evacuating
the bladder,  or of retaining the urine, is resto-
red ; and the urine assumes a more acid  and
healthier character.  This amelioration of the
urinary disturbance is one of the chief indica-
tions  of restoration of the functions  of the
chord ; but the state of the urine often varies
from time to time, before it becomes  perma-
nently healthy, or before the muscles of the ex-
tremities obey the will.
  58.  In these cases, where the urinary blad-
der is paralyzed, and the urine retained, a state
of septic or asthenic inflammation is  rapidly
produced in  the mucous membrane of the blad-
der, ureters, and  pelves of the kidneys, occa-
sioning the chief changes observed in the urine,
particularly the ammoniacal state, the presence
of mucus and coagula of blood, &c.   Sir B.
Brodie has put the question, whether the inju-
ry of the chord operates directly on the  mu-
cous membrane, or whether its first effect is to
alter the quality of the urine, the mucous mem-
brane  becoming affected afterward, owing to
the unhealthy and  irritating secretion 1  Instead,
however, of imputing the effect on the urinary
organs to one of these causes only, I believe
that it may be justly imputed to both of them :
that the unhealthy and irritating secretion  rap-
idly induces inflammation of the surfaces with
which it remains  for a time in contact, owing
to the marked disposition of these surfaces to
become inflamed  when deprived of that portion
of nervous  influence which they derive  from
the spinal chord ; and that they partake in this
disposition to be  inflamed and ulcerated with
other parts below the seat of spinal lesion.  In
some instances, particularly when the lesion is
seated high in the chord, or when the paraple-
gia is incomplete, or the power of'motion prin-
cipally affected, the urinary disturbance is not
considerable, and the powers of expulsion and
retention but little impaired.
   59.  d. The bowels are generally not only tor-
pid in paraplegia, but the evacuations are very
dark and morbid.   This latter state is the more
remarkable, the higher in the chord is the seat
of lesion.  In a case lately under my care, the
evacuations, which were procured with diffi-
culty, were nearly black, or of a deep greenish
black, and of a treacle or tar-like appearance
and consistence.   This colour is probably ow-
ing to impaired decarbonization of the blood by
respiration, the liver and digestive mucous sur-
 face  performing  a  vicariously increased  func-
tion in respect of sanguineous depuration, or
of removing the superabundant carbon from the
blood.  This explanation of the  phenomenon
 was published by me as early as 1815, and sub-
sequent observations induce me to reassert it
now.
   60.  One of the  earliest phenomena associated
with  paraplegia is  palsy or inaction of the rec-
tum and colon, the  latter viscus especially be-
ing unable to propel its contents.  At the same
time, the sphincter ani is not relaxed, but sub-
sequently, or as soon as the faecal matters ac-
cumulate in the lower bowels, they pass invol-
 untarily, owing to reaction of  these bowels on
their contents, and the loss of voluntary power
over the sphincter.  Incontinence of the faeces
generally accompanies retention  or  inconti-
nence of the urine ; while,  on the other hand,
it is not remarked in  the same states of the 
20                      PARALYSIS—Varieties and .States op.
disease that are unattended by the urinary dis-
turbance (y 57).   Still, although the patient has
power over the faecal  evacuations, particularly
when the upper portion  of the chord is affect-
ed, or when paraplegia is consequent upon dis-
ease  slowly developed  and implicating  the
chord, the stools are not the less black and of-
fensive.  They are often also very abundant,
and the intestines are usually distended by gas-
es, and are tympanitic.
   61. e. The sensibility in paraplegia varies re-
markably.  When the palsy is caused by con-
cussion or other  severe injury of the chord,
both sensation  and motion  are abolished.   In
slighter cases, and in  diseases or spontaneous
lesions implicating the  chord,  and occurring
gradually and slowly, the sensibility may be un-
affected, while  motion is altogether lost.   In
other cases, sensation may be only blunted, or
it  may be impaired in one part, and perfect in
another, or entirely lost. Very frequently sen-
sibility of the surface  only is impaired or abol-
ished, while deep-seated parts retain their sen-
sibility ; and often pains, more or less acute, or
feelings of heat, burning, or constriction, are
felt in the back, abdomen, or loins ; or even in
limbs or parts which are altogether insensible
to touch, and even to external punctures or in-
juries.  Sensation is sometimes gradually, oc-
casionally suddenly, lost; but, as in hemiplegia,
so in  paraplegia, it is restored before the pow-
er of motion.
   62. /. Priapism attends paraplegia from con-
cussion or injury of the upper portions of the
chord ; but it sometimes occurs in those cases
which are caused  by  disease.   Sir B. Brodie
has not met with this symptom where the seat
of lesion was below the sixth dorsal  vertebra.
It  is observed even where the sensibility is al-
together aboli.shed.  It seems to be occasioned,
in  some cases, by the irritation consequent upon
the introduction of the catheter.
   63. g. The temperature of the paralyzed parts
is  generally above the healthy standard.   This
is  most manifest  in complete paraplegia from
external injury ; but I have observed it also in-
creased in cases produced by disease, although
not so  generally  and remarkably, and where
the sensibility of the surface was unimpaired.
This  increase  of  temperature  appears  to be
chiefly owing to the dry and  unperspiring state
of the surface of the paralyzed parts, in con-
nexion with  the  state of the  circulation and
blood.
   64. h. The occurrence of gangrenous sores,
upon  the least injury or pressure of any of the
paralyzed parts, is generally observed, and is
often remarkable.   It seems to  be attributable
to an  impaired vital cohesion of the tissues,
caused by a loss of that portion of nervous en-
ergy  bestowed  on them by the spinal chord
It  is most manifest in cases of severe injury of
the chord, and when sensibility is altogether
lost.  When the  lesion is seated high in the
chord, and  is more or less chronic,  a  scurfy,
dry, or furfuraceous slate of the surface is oft-
en observed.
  65. D. General Paralysis.—When palsy ex-
tends to both sides of the whole body—when
all the limbs and trunk of the body are deprived
of motion—the disease has usually been viewed
as general palsy.   In  this very extended form
of the malady voluntary motion may alone be
lost, sensibility still remaining.  But the gen-
eral sensibility is sometimes also more or less
impaired, as in cases of paraplegia, much more
rarely  altogether abolished.   Indeed, general
palsy may be viewed as a more extended state
of paraplegia, as it has been by some of the
older as well as of more modern writers.   In
some rare instances the senses, or one or more
of them, have been impaired, or even lost, as
well as the power of motion and sensation.  In-
stances of this kind have been published by M.
Defermon and Mr. Davies Gilbert.  In  the
more common states of general palsy the af-
fection extends  no higher  than the  upper  ex-
tremities, and depends  upon  some lesion im-
plicating the spinal chord or its membranes be-
low the origin of the pneumogastric nerves.   In
the rare instances, where the  senses are also
implicated, the lesion is generally seated with-
in the cranium, or in one or more  of the parts
composing the base of the  brain.  In the case
described  by  Mr. D.  Gilbert,  it was  found,
upon dissection,  that " the dura mater lining
the basis cranii was deficient, and  its place oc-
cupied by a thin  and  transparent membrane,
loosely and singularly arranged ; the tentorium
cerebelli was likewise deficient, so that the pos-
terior lobe of the brain rested immediately upon
the upper surface of the cerebellum.  All the
nerves were regular."
   66. a.  Concussion of the brain and the more
severe stales of apoplexy are attended by gener-
al palsy, concussion of the  brain especially im-
plicating also the senses.  These, however, oc-
cur differently, and are attended  by phenom-
ena which remove them from the category of
paralytic diseases. The relation between them,
however, is  intimate.   Motion, sensation, and
consciousness are all  lost in these maladies,
respiration and  circulation alone continuing.
As soon as the respiratory nerves are affected
by direct or counter-pressure in apoplexy,  or
by the change produced in the intimate struc-
ture of the brain, or medulla oblongata in con-
cussion, life is soon terminated.  When, on the
other hand, the mischief is less extensive, and
the patient regains consciousness, a more or
less general state of palsy may remain, at least
for a time, and either  recovery take place, or
hemiplegia, or more partial palsy, only remain.
The apoplectic )r cerebral form of general palsy
may be viewed as an indication merely of the
nature and extent of  the  cerebral lesion.  A
person may be seized .with hemiplegia conse-
quent upon softening of a portion of one of the
hemispheres, or upon haemorrhage in the brain,
or upon any other organic lesion.   A greater
amount of the same lesion, or others concur-
ring with it, may so completely  subvert  the
powers of motion, and even of sensation, as to
give rise  to  a general palsy,  circulation and
respiration alone remaining.   These occurren-
ces are not rare.  Thus, inflammation, limited
to a portion of the brain, may first occur, and
be manifested by symptoms which the close ob-
server will detect.  At an indefinite period sub-
sequent to this attack, the  patient may be sud-
denly seized with hemiplegia,  and  may contin-
ue in  this state for weeks, months, or even
years,  when a profound apoplectic seizure oc-
curs, occasioning general palsy, extending ul-
timately to the  muscles  of  respiration, and
causing death by asphyxia.   But in rare in- 
                        PARALYSIS—Vari

stances, instead of an apoplectic seizure, the
other side may become palsied, as respects the
power either of motion or sensation, or of both,
and either before or after the side first affected
has recovered any, or much of its powers.  In
this  case there is general palsy,  incomplete,
probably, as regards one or other function in ei-
ther side, with certain of the senses and many of
the faculties of the brain but little affected, un-
til apoplectic coma or paralysis of the muscles
of respiration  terminates life.   An instance of
this  kind recently occurred in the practice of
my friend Dr.  Babington, and upon dissection
lesions  were found in both  hemispheres of the
brain.
  67. b. The  forms of general palsy to which
I am most desirous of directing attention are
altogether spinal.  They may occur suddenly,
as in cerebral general palsy, or gradually, and
even  slowly.   Severe injuries, as dislocation
of the cervical vertebrae, laceration of the chord,
violent  concussion of the  spine, haemorrhage
upon  the cervical portion  of the  chord, &c,
usually  occasion general palsy instantly; but
disease seated in the spinal chord or its mem-
branes,  or implicating these consecutively, pro-
duces  the   paralytic  phenomena much  more
slowly.   Even severe injuries may not  be fol-
lowed by palsy for a considerable period ; still
it may be stated that the accession of  general
palsy from  injury, as well  as the  phenomena
characterizing it, will vary  with the immediate
or more remote effects of the injury upon the
chord or its  membranes, it  being either instan-
taneous or remote, according to the extent and
nature  of the lesion produced.  A  muscular
man, aged  about sixty years, the  father of a
late  medical friend,  when  turning in bed, his
head being forcibly pressed  on the pillow, so as
to partially raise the  trunk,  felt something snap
in his neck.    He was afterward unable to bend
or to rotate the head without causing much
pain in  the  neck.  I inferred that rupture or
laceration of some of the small muscles or lig-
aments  had  occurred, and advised quietude and
various means which palliate the more painful
symptoms.  Still the least mevement  of the
head  caused  distress.  Notwithstanding this,
he travelled outside a coach, during the sum-
mer, to  Cornwall, and returned to  town, and
not till  sixteen months after  the accident he
complained  of numbness and want of power in
the left arm.   In  a  day or two the palsy ex-
tended to both the upper extremities, but was
incomplete in  the right; it  soon .became more
general, and in a short time difficulty of breath-
ing, rapidly  terminating in  asphyxia, superve-
ned.   The body was  examined by Professor R.
Quain and myself, and the second cervical ver-
tebra was found fractured completely across on
both sides, the fracture on one side  passing
close  to the  base of the  odontoid process.
Chronic inflammation had  extended from the
fracture to  the  theca and  membranes  of the
medulla oblongata ; lymph was thrown out upon
the arachnoid surfaces ; the  membranes, partic-
ularly the dura mater, were much  thickened,
and ultimately the chord at  this part was press-
ed upon.
  68.  Next to  injury or concussion of the spi-
nal chord, caries of one or more of the cervical
vertebrae may  be considered as a cause of gen-
eral palsy;  but the  palsy  rarely occurs until
ties and States of.                      21

 the disease of the vertebrae has induced chron-
 ic inflammation of the membranes of the chord,
 with thickening and effusion of lymph, or such
 a degree of angular curvature as to affect the
 physical condition of  the  chord  itself.   I was
 lately consulted in the case of a child, twelve
 years of age, who presented unequivocal indi-
 cations of caries of one or two  of the cervical
 vertebrae consequent upon malignant scarlatina.
 To these supervened  incomplete palsy of mo-
 tion in  one arm and hand, which gradually  in-
 creased and extended to the other arm and low-
 er extremities, until general and complete pal-
 sy  of motion  existed ;  sensibility was unim-
 paired.   The bowels were  obstinately constipa-
 ted, and the evacuations black and  tar-like.
 The sphincters were not paralyzed. Respiration
 was performed by the  diaphragm, and all parts
 below the face were deprived of motion.  The
 head could neither be  rotated nor bent without
 great pain.  The body and limbs were much
 emaciated.  The skin was cool and dry, and
 covered with a furfuraceous scurf, particularly
 the scalp.  The pulse was  very frequent, weak,
 and soft; the  tongue  furred and loaded.   Af-
 ter persisting for many months  in a treatment
 hereafter to be described, this young lady re-
 covered the use of her limbs, the neck, how-
 ever, remaining stiff,  shortened, and turned a
 little  to one  side.  In this case, the  change
 produced  in  the  membranes enveloping  the
 chord, or in the theca, was most probably lim-
 ited to the diseased vertebrae  and their imme-
 diate vicinity.   It is not unlikely owing to this
 limitation of the disease, and to the gradual
 accession and increase of it, that the sphincters
 continued unaffected.
  69. c. General palsy may be only an extension
 of paraplegia, or, in other words, the disease
 may commence and  continue for a time as par-
 aplegia,  either complete  or  incomplete, and
 gradually extend higher and higher until the
 trunk and upper extremities  are deprived  of
 motion, sensibility being generally  either not
 at all or but little impaired.  In some of these
 cases, the  palsy of the lower extremities,  as
 well as  that consecutively affecting the upper
 parts of the body, continues incomplete for a
 long time, the motions consequent  upon  voli-
 tion being imperfect, weak, and vacillating, and
 executed slowly, tremulously, and with difficul-
 ty.   In these  the patient  often  complains  of
 spasmodic or severe pains in the limbs, with a
 sense of constriction ; of  spasm and flatulent
 distention, with  occasional attacks  of painful
 constriction in the abdomen ;  of want of pow-
 er over the sphincters, and  involuntary dis-
 charges.  This last symptom often varies much
 in different cases  and different times in  the
 same case, according to the treatment, &c.
  70. In other cases, the  paralytic  symptoms
 either appear nearly cotemporaneously in sev-
 eral parts or limbs,  soon becoming  general or
 more complete, or extend much more rapidly
 from the lower to the upper extremities, than
 in the immediately preceding class of cases.
 Still the same symptoms are generally present,
 only varying in some  subordinate phenomena,
.sometimes continuing  nearly  stationary for
 months or even for years, and ultimately ter-
 minating in a similar  manner.   I occasionally
 attended, during nine or ten years, a  gentle-
 man somewhat above  the middle age, who was 
22
affected with this particular form of general pal-
sy.   It was long incomplete, sensibility being
but little impaired, even  when  the power of
motion was altogether lost.  Power over the
sphincters was only partially retained for some
years, but was very considerably increased by
opiates, conjoined with stimulants and aromat-
ics ;  at last it was altogether lost.  The intel-
lectual powers were unimpaired.  Ultimately
cerebral symptoms, followed by coma and death,
supervened.   Permission to  examine the body
was  allowed  by  his accomplished  and highly
intelligent relatives.   The membranes at the
base of the brain were more  vascular than usu-
al, and a considerable quantity  of serum was
effused.   All the spinal  arachnoid presented
appearances of previous chronic inflammation.
It was thickened, covered in parts with false
membrane, or adherent to the opposite surfaces
by means of cellular bands.   The whole dura
mater, or sheath of the chord, was more or less
thickened throughout, and the arachnoid of the
chord, where it was not adherent, was opaque
and thickened.  The venous  sinuses, placed be-
tween the bodies of the vertebrae and the sheath
of the chord, were remarkably dilated and con-
gested, so as manifestly to encroach  upon the
spinal canal and diminish its calibre, especially
at the lowest part of the chord.   The chord it-
self was firmer than  usual, particularly in this
situation, was somewhat atrophied, and its gray
substance was wasted and less apparent.  Its
vascularity also  was diminished, although the
spinal veins and sinuses external to the sheath
were remarkably diluted, and congested with
coagulated blood.
   71. While I was treating  the above case, a
respectable tradesman, aged about fifty, came
under my care, and was  seen by me occasion-
 ally until his death, which took place three or
four years  afterward.   The  symptoms, pro-
tracted course, and termination of the disease,
were altogether the  same  as  those just de-
scribed.   On examination  after death, the  le-
sions found in the spinal chord  were  also sim-
 ilar  to those observed in the preceding case.
 The chief difference was the less remarkable
 congestion of the spinal veins or sinuses,  al-
 though this  was  considerable.  The conse-
 quences of the chronic inflammation of the
 membranes, and the state  of the chord itself,
 were nearly the same as those already descri-
 bed. There was, however, a  more  abundant
 effusion of serum between  the membranes  of
 the  chord than in the former case ; and much
 fluid was found  in the ventricles of the brain.
 The upper  portion of the  medulla oblongata,
 and the membranes at the base of the brain,
 presented appearances of recent acute inflam-
 matory action, especially increased vascularity
 and congestion, with a turbid serous effusion :
 these corresponded with the  cerebral symp-
 toms preceding death.
   72. I have occasionally seen, during the last
 few years, with Mr. Pettigrew, a gentleman
 between thirty and  forty years of age, whose
 complaint^  are nearly the same as those char-
 acterizing the above cases, and are most prob-
 ably owing to similar changes existing in  the
 spinal chord and its membranes.  In this case
 the loss of power over the sphincters is more re-
 markable than in the preceding cases, or, rath-
 er,  appeared earlier in the course of the disease.
PARALYSIS—Varieties and States or.

                      73.  The above cases of general palsy from
  to  1 lie auuw i^aa*-^ "•  e>--     - c ,    i  ■
chronic inflammation of the numbrane,^of the >rhord
and its consequences came before me, whej.the
paralytic symptoms were more or less fully de-
veloped.   I had  an  opportunity, many  years
ago, of observing the  disease  from is com-
mencement.  In  1820, a  boy,  aged thirteen,
was brought to  my  house with  chorea.  He
had rheumatism of the arms and  wrists, asso-
ciated with rheumatic  pericarditis.   After  a
few days the rheumatic affection subsided, and
the chorea returned, with  pain in the course
of the spine.  Leeches, &c, were applied along
the spine ;  but the disease passed into a state
of general palsy, which was complete  in re-
spect only of motion, from the head downward.
All power over the sphincters was lost; sen-
sibility of the surface was at first acute, and,
although it became somewhat impaired as the
general palsy was developed, still it was not
materially  diminished.  After death, coagula-
ted lymph and turbid serum were found effused
between the opposite surfaces of the arachnoid
of the chord in  a very  remarkable quantity,
and  so as to press upon the chord itself.  (See
Lond. Med. Repos., vol. xv.)
   74. d.  It has  been stated  above (y 52, 53)
that softening of the spinal chord, whether it be
the consequence of concussion  of the spine, ol
inflammatory action, or of some  other morbid
condition of the vessels, or constituent tissues
of the chord, is not an infrequent cause of para-
plegia when seated in any portion of the chord
below the  fourth or fifth cervical  vertebra.
When the disease is seated at or above this
part, the palsy is nearly general.  In a very re-
markable case  recorded by Dr. Webster, the
spinal chord was soft  and pulpy  in this situa-
tion, particularly the  posterior columns; the
membranes were adherent to the chord ; close
to the softened part the medulla was of a dusky
red  tinge, but above  and below  this part it was
healthy.  The subject  of  this  case " was for
many months totally unable to move, even  in
the slightest degree, any muscle situated low-
 er than  the neck, but still retained the capa-
 bility of feeling quite perfect  throughout the
surface  of the  body ;  while the other  senses
 and  intellectual  faculties were  unimpaired  to
 the last  moment of his existence.  Indeed, the
 patient's cuticular sensibility even appeared, in
 the latter stages of the case, to be more acute
 than natural."   The evacuations took place in-
 voluntarily, and violent spasmodic twitchings
 frequently affected the lower extremities.
   75. e. Although general palsy as well as para-
 plegia is most generally caused by some mani-
 fest lesion seated in, or implicating the spinal
 chord or its membranes, when the functions ol
 the brain  are unimpaired, still it is not to  be
 inferred that the lesion is always of a nature
 which may be deteoted.  Cases sometimes oc-
 cur that present no  appreciable lesion, at least
 to the unaided eye, upon  dissection ; and oth-
 ers  recover after a treatment  not obviously
 calculated to remove  any serious lesion of the
 chord or its membranes.  Sir B. Brodie refers
 to a case (Lancet, No. 1060, p. 380) which com-
 menced as paraplegia  and terminated  in gen-
 eral paralysis.  The  spinal  chord and  solai
 plexus  were examined  with the greatest care
 after death;  but they presented no  change
 from the  natural state.   Sir B. Brodie justly 
PARALYSIS—Varieties and States of.
23
remarks, that it is not, however, to be supposed
that this is a mere functional disease because
we see no lesion after death.   The minute or-
ganization  of the brain and  spinal marrow  is
not visible to the naked  eye, and even with
the microscope we can trace it only a little
way.  Some defect in  the minute organization,
some change of structure not perceptible to
our senses, may exist in the part and interrupt
its functions.
  76. Some years  ago I  attended,  with my
friend Dr.  Roscoe, a  gentleman who had re-
sided many years in  an intertropical  country.
On his voyage across  the Atlantic to this coun-
try, in the winter season, he was seized with
general palsy of the powers  of voluntary mo-
tion  immediately after prolonged exposure to
cold and wet.  The functions  of the brain were
unaffected ; and neither pain nor uneasiness
was felt in the  neck or in any part of the spi-
nal column under any circumstances of posi-
tion, flexure, rotation, or  pressure.   No evi-
dence of inflammatory action or of congestion
in the  spine could be detected.  Cutaneous
transpiration was suppressed, and the bowels
were costive and torpid;  but he retained the
Bensibility of the surface, and command over
the sphincters.   He was treated, at first, upon
the  supposition of either serous  effusion or
vascular congestion having taken place in the
spinal canal, but without receiving any benefit.
He  ultimately, however,  quite  recovered  by
having a frequent recourse to warm baths con-
taining  stimulating substances.
  77. That form or state  of general palsy  in
which structural lesion may  be  inferred to be
most decidedly absent, and which consists en-
tirely of functional disorder, is the cataleptic
seizure.  In this affection, as  shown elsewhere
(see art. Catalepsy), voluntary motion is alto-
gether suspended ; but in  two very remarkable
cases, which I had an opportunity of observing
attentively, consciousness and  sensibility re-
mained, with the senses of seeing and hearing.
Yet no  part—neither the muscles of the tongue
or jaw, nor the eyelids—could be moved during
the  attacks, which often  continued for many
hours ;  nor did the least muscular contraction
take place on tickling  the soles  of the feet,  or
on pinching any part, although the sensibility
was affected by  these acts.  Recovery from
these seizures was generally sudden and com-
plete, little disturbance beyond slight hysterical
disorder on some occasions being observed.
  78./. The symptoms of general palsy vary much
with the lesion occasioning it.—a. The accession
of the attack also varies.   In the cerebral form
of the  malady, particularly  when it depends
upon apoplectic or epileptic seizures, and when it
assumes the cataleptic form, the accession  is
sudden  or rapid.  In the spinal form the symp-
toms appear gradually, and  generally slowly,
when it is the result of disease,  but often sud-
denly and  completely when  it proceeds from
severe injury.  In the cerebral state, the sensi-
bility, and even consciousness, are abolished or
nearly lost;  but in the spinal states  (y 67,  et
teq.) of the malady, sensibility, the  functions
of sense, and the intellectual  powers are either
unimpaired or but little affected.  In a few ca-
ses only is the sensibility of the general sur-
face  remarkably diminished, and in still fewer
is it altogether lost.
  79. (3. The loss of voluntary motion  is  most
sudden and complete in the cerebral states of
the disease,  and in  cases of injury of the cer-
vical portion of the chord, or of concussion of
the spine.   When the palsy proceeds from dis-
ease of the spinal medulla or of its membranes,
the loss of motion  is rarely complete at first,
and often does not become complete until after
several  years, and  until the organic lesions
have advanced so far as evidently to interrupt
the functions of the chord.  Still, there are ex-
ceptions to this,  as  the case noticed by Sir B.
Brodie.  During the protracted progress of the
malady the patient often experiences spasmod-
ic actions, or more  permanent contractions of
the muscles, particularly of the flexors ; fre-
quently a sense of painful constriction around
the abdomen and the thighs; and sometimes,
especially when  the upper part of the cervical
medulla is implicated,  even  convulsions  or
complete  epileptic  attacks.  These are evi-
dently the consequence of inflammatory action
or irritation in or near the portion of the  chord
or its membranes which is the seat of lesion.
  80. A compositor, who was engaged in print-
ing a work which I was  editing many  years
ago, came to me with caries of one or two of
the upper dorsal vertebrae.  Matter had evi-
dently formed, and  was making its way exter-
nally.  He became paraplegic, and subsequent-
ly  generally paralytic ;  but at a very early pe-
riod of the paraplegic state fully-developed ep-
ileptic seizures occurred.  These became more
frequent, and ultimately  terminated in  coma
and  death.  On  examination, a  sanious pus
was found collected around the second  and
third  dorsal vertebrae, extending between the
muscles, and between the theca vertebralis and
bodies of the vertebrae.  The membranes at,
and to a considerable extent above, this part
were inflamed, the arachnoid surfaces  being
partially covered with lymph or adherent. In-
jection of the vessels and effused serum were
traced thence along the membranes to the brain.
The chord itself was not, however, materially
changed.
  81. y. Pain, even  of a most severe character,
is  often remarked,  particularly in  the inflam-
matory states of the spinal disease, and when
the roots  of the nerves,  or when the nerves,
as they pass  through the spinal foramina, are
implicated in the lesion.  The pains are  usual-
ly deep-seated in one or more limbs, and are
often not the less acute  where the cutaneous
sensibility is much impaired.  In some instan-
ces of spinal general palsy the sensibility of the
surface, particularly at first,  is painfully in-
creased, and sometimes even perverted.   Pain
is  often felt in the  part of the spine affected,
either primarily or consecutively.   In some in-
stances,  particularly when  the  disease  com-
mences in the lower portion of the spine and
extends upward, it  may be confounded with
lumbago ; or it may be viewed as originating in
lumbago, the pain in the loins being caused ei-
ther by inflammatory action or softening, or by
congestion of the  spinal veins and  sinuses.
When the disease is consequent upon mastur-
bation or venereal excesses, it is often prece-
ded and attended by pain in the loins, extend-
ing upward with the local lesion and the  para-
lytic symptoms.
  82. 6. The bowels  are remarkably torpid, and 
24              PARALYSIS—in new-born Infants and young  Children.
the evacuations in the more complete states of
the disease, dark, and like tar or treacle (v 59).
The urinary organs are affected in the more
complete and  advanced forms, in the manner
already noticed (v 57, 58); but, in the less com-
plete  states, and  when the spinal chord itself
is not materially  changed, the patient still re-
tains more or less power  over the evacuations
and actions of the sphincters.  In the more se-
vere and sudden cases, particularly those con-
sequent upon injury of any kind, and attended
by marked disturbance of the urinary functions,
priapism is a frequent symptom.
  83.  e.  The  external surface is always dry,
often  scurfy, sometimes discoloured in the ex-
tremities, or presenting livid  spots resembling
vibices.  It is  generally emaciated, and colder
than natural, even when the patient complains
of a sensation  of heat.  The disposition of the
surface to ulcerate or slough on pressure, so
remarkable in  paraplegia, is less so  in general
palsy, unless at the last stage or more severe
and complete  state of this latter form of the
disease.
  84.  C The cerebral functions—sensation and
intellectual power—are unaffected in general
palsy as well as in paraplegia, and continue un-
impaired until  the malady terminates either in
fatal congestion of the lungs, or asphyxia, or in
congestion of the brain with serous effusion.
   85. II. Of Paralysis in  new-born Infants
and young Children.—Paralysis is sometimes
met with in new-born infants.  It may be the
effect of injury to the  nerve either in the part
paralyzed or in its course  after its transmission
through the cranial or spinal aperture.  Dr. E.
Kennedy remarks that we have examples of
this fact in injury to the portio dura, as in face
presentations ; or where the head has  been
long pressed in the pelvis against the project-
ing ischiatic spines ; and he adds, that several
cases of this kind  had occurred to him in which
the disease was quite local, the paralysis being
removed on the subsidence of the swelling pro-
duced  by the  protracted  pressure.—a.  I  have
already mentioned (§44) that the paralysis may
be the result, not  merely of spontaneous lesion
of some part of the nervous centres during foe-
tal life, but also of arrested development or in-
sufficient growth during the early  periods of
this epoch.  In this latter case the palsy is oft-
en associated  with idiocy.   The cerebral or
spinal  lesion may, however, occur shortly be-
fore, as well as during the period of parturition
In the following case, recorded by Dr. E. Ken-
nedy, the lesion must have existed  some time
before birth ;  and probably,  from the speedy
recovery, consisted merely of congestion of one
side of the brain.
  86.  Immediately after birth a large, soft tu-
mour was observed on the right side of the
head, principally  on  the  vertex, with two or
three small excoriations on the left side.  The
left eye was closed ; the mouth  drawn to the
left side ; and when the child  cried, the ala nasi
and angle of the mouth  were drawn up; the
right  eye was open, and  the right side of the
face unaffected during crying.  The left  side
of the body was completely paralyzed.  The ex-
tremities of this  side were of less bulk than
those of the right, and were rough to the touch ;
the muscles were flabby.   Both pupils were in-
sensible  to light.  The  child was unable to
suck ; but deglutition did not seem to be affect-
ed.  On the third day it had several slight con-
vulsions, confined to the upper half of the  body.
A leech was  applied to the vertex, followed by
the warm  bath : stimulating liniments  were
rubbed over the spine, and the child recovered.
In this interesting case the portia dura of the
right side, and  the levator palpehrae  of the left
side, supplied by the third nerve, were para-
lyzed, in connexion with hemiplegia of the left
side.
  87. It is often difficult to  ascertain the ex-
tent of  paralysis in new-born infants and very
young children, as the paralyzed limbs are gen-
erally either so  much convulsed, or so spasmod-
ically contracted, as to be removed from under
the influence of volition.  When the  spasms
cease, the paralyzed  state of the limb some-
times becomes  more evident in the more unfa-
vourable cases.  The lesions which most fre-
quently  occasion paralysis in this class of sub-
jects are, congestions of the brain and spinal
column, serous effusion either  between  the
membranes or in the ventricles, and extravasa-
tion of blood.  This last is much less frequent
in children and  infants than in adults, and  very
rarely occurs in the cerebral  structure.  When
haemorrhage  takes place within the cranium or
spinal canal of  infants, it is generally found to
proceed from the surface  of the membranes,
and seldom  causes  permanent  paralysis, but
usually  apoplectic attacks, or eclampsia, tris-
mus, or convulsions,  terminating generally in
death.   In these cases the effused  blood pro-
duces either  coma,  spasm, or convulsions, ac-
cording to the  quantity effused ; and ultimate-
ly, if the child  live  a  short time, inflammatory
action  in the parts  into which it is extravasa-
ted, owing to the irritation it occasions.
  88. b. Paralysis, sometimes partial, at other
times more  or  less  general, accompanies the
advanced progress of the disease usually called
acute hydrocephalus, and  of true  or  chronic
dropsy of the  brain.   In the former of these
maladies (see Dropsy, acute, of the Brain), I have
shown that the palsy is the consequence of the
softening of the more central parts of the brain,
rather than of  the effusion into the ventricles
which either attends  or supervenes on the soft-
ening.   The  tubercles sometimes found in the
brain, or its membranes, of children, either as-
sociated with, or independent of, softening and
serous effusion, are rarely a cause of paralysis,
unless at an advanced stage of these lesions,
or as a termination of convulsions or spasms,
with which, however, some degree of paralysis
is occasionally  associated.
   89. c. But  palsy is  sometimes met with un-
der different circumstances, especially during
suckling and teething ;  and, although  not so
frequently as immediately  after birth, still suf-
ficiently often to have procured for it, as occur-
ring at this  period,  more  attention than has
been paid to  it. From the first dentition to the
period  of puberty, paralysis is generally the
consequence of scrofulous  caries or disease of
the vertebrae, or of softening of a  portion of
the brain, or of tubercles  within the  cranium
or spine.  In cases of softening or tubercles in
the brain or  its membranes, convulsions, more
or less  of an epileptic character, almost always
precede the  paralysis, which commences gen-
erally iu one arm,  and sometimes  passes into 
PARALYSIS—Shaking Palsy.
25
hemiplegia.  When  these  lesions are seated
within the spinal canal of young children, con-
vulsions of  a  more  limited character,  often
spasms or contraction of a limb, are more fre-
quently remarked  either before  the  develop-
ment of palsy, or in connexion with it; although,
even in these cases, the convulsions may as-
sume an epileptic  character,  particularly  when
the upper part of the chord is implicated.
  90. d. Infantile paralysis  may, therefore, be
divided as follows:   1st. The congenital, and
then it is commonly  a consequence of arrested
development or  congestion of a portion of  the
cerebro-spinal centres ; 2d. That caused by the
accidents attending parturition, as shown above
(v 85);  3d. That  consequent upon lesions or
spontaneous disease, of a demonstrable nature,
implicating the  brain or some portion of  the
cerebro-spinal axis ;  and, 4th. That which pre-
sents no obvious lesion in the brain and spinal
chord beyond slight congestion, and from which
recovery often  takes place without sufficient
evidence of organic lesion having been afforded.
This last class of infantile palsies generally oc-
curs in  infants at the breast or during the first
dentition.  It is often sudden in its accession,
and  is preceded by no very apparent state of
disease, beyond  the  usual  irritation often  at-
tending dentition, or  disorder of the alimentary
canal or biliary  functions.  The arm is  com-
monly  the part affected ;  but  the  leg of  the
same side  is sometimes  either also paralyzed,
or contracted and drawn up, or both palsied
and contracted.   Sensibility  has  not been, as
far as I have observed, impaired in the affected
limb, but, on the contrary, sometimes morbidly
increased.   A  large  proportion of the cases
which  I have seen of this description has  re-
covered after the means  that will be noticed in
the sequel  have  been  employed.
  91. My very  learned friend,  Dr. M'Cormac,
of Belfast, has  noticed cases of paraplegia in
infants, which he  considered to proceed from
concussion of the  spinal  chord : a cause by no
means unlikely to  produce the disease in both
infants and children, and to be followed by ei-
ther haemorrhage, inflammation, softening,  se-
rous effusion, or  other  change of  the  parts
lodged in the spinal  canal.   He believes, also,
that injury to the sciatic nerve  may produce
paralysis  of the limb in infants ; but this is
manifestly a rare occurrence.
III. Shaking Palsy.—Syn.  Scelotyrbe festinans,
  Sauvages.   Paralysis  Agitans, Parkinson.
  Synclonus ballismus, Good.  Tremor, J. Frank.
  Tromos  (Tpo/ioc),  Swediaur.    Tremblement,
  Fr.  Zittern, Germ.  Trembling Palsy.
  92. This disease is characterized by a tremu-
lous agitation, a  continued shaking, and by great
weakness of one or  more parts or members of the
body.  Although  it was described by Harscher,
Diemsrbroeck, Schelhammer, Hamberuer,and
others, and more recently by Parkinson and J.
Frank, it has not received the attention which
the  frequency of its occurrence and the obscu-
rity of  its nature should  have obtained for it.
Even its symptoms, its relations to other ner-
vous affections,  its  course  and terminations,
have been imperfectly observed and described ;
and no accounts have been furnished of the  ap-
pearances observed in fatal cases.
  93 Shaking palsy  may affect either a single
part or limb,  or many parts, or even the great.
er part of the body.  It may continue limited to
its original seat for many years, and even nev-
er extend  beyond it; or it  may not only in-
crease gradually in the part first affected, but
extend to two, or to  all the limbs of the body.
Generally the power  of motion only is affected,
and usually is only  partially  impaired; and it
continues long in  this state ; so that the com-
plaint may be viewed as imperfect palsy of the
power of motion, with  shaking of the part.
  94. The affection usually commences imper-
ceptibly, and proceeds slowly.   It often begins
in the head, or in one or both arms, and it fre-
quently is confined to these parts for a long pe-
riod, or even for years.  It is generally attend-
ed by a feeling of weakness of the part.   In
two  instances I have seen the complaint  lim-
ited to the lower jaw, which was moved by a
rotatory or lateral action in one case, and by
a vertical action in the other.   When the head
is affected, it is commonly  moved upward  and
downward;  but  it is in some instances  in a
constant state of rotation.  In these  situations,
as well as when it affects the hands and arms,
the motion often does not exceed that-of  tre-
mour, or a gentle but quick shaking ;  but in oth-
ers the  agitation is more remarkable and  vio-
lent ; and even the slighter cases may be more
severe when the patient is influenced by any ex-
citement or marked emotion of mind.
  95. The affection commences usually with a
slight sense of  weakness  and  proneness to
trembling, especially on any emotion or after
physical exertion,  and commonly in the hands
or arms, but sometimes in  the head, or in the
tongue or lower jaw.  These symptoms grad-
ually and  slowly increase; and usually after
one, two, or three years, but in some cases not
until after a longer period,  they extend to the
lower extremities ; and the patient finds great
difficulty in walking ; bends his body forward,
and is obliged to assume a hasty or rapid pace,
from the fear  of falling forward.  The tremu-
lous  agitation  has now extended to his legs,
and the limbs have become less and less capa-
ble of obeying volition.  Suspension  of the  agi-
tation is seldom experienced, unless in some
cases when  the  limbs are  held or supported ;
and when  it ceases from this circumstance in
one limb or side, it continues  in  the other.
Thus it sometimes ceases in the arm  or side
on which the  patient lies  or reclines, but as
soon as he changes  to the  opposite side it be-
gins  in the former.  Occasionally, attempts to
restrain the agitation only increase it; and it
is often exasperated  at the sight of strangers.
When the patient walks, he is often  thrown on
the fore part of the feet, and impelled to adopt
a quick or running pace, from fear of falling at
every step on  his face.  At an early stage, or
in less severe  cases,  the affection ceases for a
short time, or is ameliorated after a  refreshing
sleep;  and it is often  then controlled by the
will or by earnest attention to the part, but it
soon afterward recommences.
  96.  At a far-advanced stage, the  tremulous
motions of the limbs occur during sleep, and,
particularly when  the patient dreams, waken
him,  often in agitation.  The power to convey
food  to  the mouth ultimately becomes so  im-
peded as to oblige him  to be  fed  by  others.
Mastication and deglutition are impeded, or dif-
ficult, and the saliva dribbles from the  mouth 
26
PARALYSIS—from Poisons.
The trunk is permanently bowed, from the gen-
eral want of power in the muscles.  The bow-
els  are costive ; are acted upon with difficulty ;
and sometimes require mechanical means to
remove them from the rectum.  Ultimately, the
agitation becomes more vehement and  con-
sent ;  and when exhaustion passes into sleep,
it sometimes becomes  so violent  as  to shake
the room.  The head falls  down, so that the
relaxed or shaking jaw meets the  sternum.
The power of articulation fails or is lost, and
the urine  and faeces  are passed involuntarily.
Slight, low delirium, passing into coma, usually
terminates life.
  97.  I have met with  this affection both  as
the chief and primary malady, and in connex-
ion with disease in some distant organ, of which
it appeared either as a consecutive change, or
as a concomitant disorder.  I have seen it more
frequently in males than females, and  chiefly
in persons about fifty years  of age  and upward.
I observed it to a very remarkable extent in a
man aged  about  sixty, who had valvular dis-
ease of the heart, upon which pulmonary con-
gestion and dropsy supervened ;  but I could
not obtain permission to examine  the body.  I
observed it also in a lady in a similar form of
complication, but I ceased  to  attend her long
before her death.   I  was recently consulted by
a gentleman from Lancashire, affected by this
complaint in the arms, and in every other  re-
spect he professed himself to have been in good
health.  I  have seen it both in plethoric and in
thin and spare habits,  but  more frequently in
the fair and sanguine  than in any other tem-
perament.  I have never had an opportunity of
observing the changes that existed after a fatal
termination of the complaint, and I do not rec-
ollect  of any case being recorded where such
an opportunity had  been  enjoyed.   It is fre-
quent  in very aged persons  in its slighter forms.
   98.  In  rare instances hysteria assumes a
form  very nearly allied to, or closely resem-
bling,  this affection.   In 1842  I attended, with
Dr. N. Grant, a girl  aged about sixteen, on ac-
count  of various anomalous nervous affections
consequent upon obstructed catamenia.  After
passing through various phases, in which  the
tongue, larynx, and diaphragm seemed spasmod-
ically  affected, violent  tremulous agitation of
the head and arms supervened. The head was
rotated from side to side without intermission
for several days.  She  received benefit from
treatment, and ultimately recovered.
   99.  In the absence of post-mortem examina-
 tions, opinions as to the origin and seat of this
 complaint must be viewed as suppositions mere-
 ly  ; but it is not unreasonable to infer that the
 medulla oblongata and  upper part of the spinal
 chord  are the chief seat of the  affection.  J.
 Frank adduces the case of a widow, aged  for-
 ty, who had experienced an interruption of the
 catamenia, had complained of pain in the spine,
 and had recourse to a vapour bath ; after com-
 ing out of the bath she was  exposed  to cold,
 and suddenly was attacked by this affeetion
 Her head was in a constant state of rotation,
 and the  arms, hands,  legs, and  feet  were in
 continual  motion.   Blood  was taken from the
 spine  by  cupping,  and  she  recovered sooner
 than was expected.   It is  not improbably con-
 nected with congestion of  the venous plexuses,
 or sinuses, placed between  the sheath of the
chord and bodies of the vertebrae, particularly
in persons of a plethoric habit, and when it is
consequent upon  suppressed evacuations.  In
other cases it appears to depend more upon the
states of the chord and nerves, or to be more
strictly nervous.
  100.  IV.  Paralysis from Poisons.—Paraly-
sis venenata, Cullen.—Paralysis e vcncnis.—
Palsy, varying as to seat and character, is not
infrequently observed consequent upon the op-
eration of several poisonous substances of ei-
ther  a  mineral  or vegetable nature, especially
the former.  The poisons most liable to cause
palsy are lead,  mercury, arsenic, ergot of rye,
monkshood, thorn-apple ; and in rare instances
palsy occurs as a contingent remote effect of
most of the acro-narcotic poisons.
  101.  A. Palsy from Lead.—Lead palsy gener-
ally occurs after one or more  attacks of colic
(see  Colic from Lead); but it occasionally ap-
pears without any severe disorder of the digest-
ive organs.  When the palsy is connected with
colic it usually  becomes manifest as the colic
subsides ; but both affections may be associated
or cotemporaneous.   When the  palsy occurs
independently of colic, costiveness  and indi-
gestion, with or without slight pains  in the ab-
domen, are generally  present,  both before and
concomitantly with it.   The palsy usually pre-
sents peculiar characters.  It  is seated chiefly
in the upper extremities, and affects the ex-
tensor more than the flexor muscles.  It is at-
tended by great emaciation of the affected mus-
cles, and the loss of power is most remarkable
in the muscles  which move the thumb and fin-
gers.  The  palsy is seldom complete, even  in
these, except in the extensors.  The hands and
fingers  are constantly bent, unless when they
hang down by the sides.  The patient, in the
most severe cases, is unable to raise them, and,
when one arm is more affected than another,
he raises the one by the aid of the other.  Se-
vere pains are  also felt in the lower limbs and
arms.   Attacks of colic, severe fits of indiges-
tion, and obstinate constipation are  apt to oc-
cur, especially after irregularities of diet  or
exposure, and  generally carry off the patient.
The palsy of the arms is sometimes associated
with deafness, owing to palsy of the auditory
 nerves.
   102.  In fatal  cases the  paralyzed muscles
have been found pale, bloodless, and flaccid;
 and in cases of long standing they have become
 still more pale and fibrous.   The  nerves have
 also appeared  atrophied  and firmer than natu-
 ral.   It is not improbable  that  the lead, in a
 state of oxide, has in some measure combined
 with these tissues.   In  this case, however, it
 ought to be detected by chemical analysis ; but,
 while some chemists avow that they have de-
 tected  it, others assert that they were unable
 to do so.  Dr.  Christison's able researches
 into this subject do not  countenance the opin-
 ion  that a combination takes place between the
 lead and tissues affected in these cases.   That
 the metal affects the states of these tissues
 cannot be doubted;  but whether by its actual
 presence, or by its indirect  operation on the
 nerves and nutrition  of the muscles, independ
 ently of its presence, has not been demonstra-
 ted.  Most probably its operation is direct in
 the state either of an oxide or of a salt, in ei-
 ther of which states it may pass into the cir- 
PARALYSIS—General History of Palsy.
27
 culation, and act immediately upon the nerves
 and muscles.
   103. B. Mercury, when carried into the sys-
 tem in the form of an oxide, or of a salt, some-
 times causes palsy, but generally in the form
 described as shaking palsy (v 92), or incomplete
 valsy of motion with tremour—the tremblement me-
 lallique of French writers.   It usually occurs
 in miners, in gilders, and in other workmen ex-
 posed to the operation of mercurial substances.
 It usually commences with unsteadiness of the
 arms, and afterward with tremours, which ex-
 tend more or less with the continuance of the
 malady,  and often  becomes  associated with
 convulsions.  For a fuller account of this af-
 fection I  may refer to the article Arts and Em-
 ployments (v 24).
   104. C. A rsenic sometimes occasions limited
 or partial palsy, when  it has failed of causing
 fatal effects in a short time, or in  the advanced
 stage of the more prolonged cases of poisoning
 by it.   In some cases an incomplete form of
 paralysis, resembling palsy from lead, and af-
 fecting one  or more of the extremities, is caus-
 ed by this  poison.  Occasionally the palsy is
 preceded by cramps, tenderness, and weakness
 of the extremities, the  palsy being sometimes
 attended  by contractions of the joints.  The
 affection  is not confined to the power of mo-
 tion, but generally also extends to that of sen-
 sation. Dr. Falconer observed a case in which
 the palsy was limited to the hands, and anoth-
 er in which it gradually extended to the should-
 ers.
   105.  D. Paralysis from narcotic or acro-nar-
 colic poisons is sometimes observed contingent-
 ly upon their more remote effects.  I was con-
 sulted many years ago  respecting  a case of
 hemiplegia caused by eating the root of monks-
 hood by mistake.   The more immediate effects
 had  been numbness and palsy of the tongue,
 followed by  apoplexy, and a state of the cuta-
 neous and mucous surfaces closely resembling
 that existing in fully-developed purpura haemor-
 rhagica.  The apoplexy had been either asso-
 ciated with  hemiplegia  from  the commence-
 ment, or  the  latter  rapidly  followed  it.  The
 patient, aged about  twenty, ultimately recov-
 ered, and I lately sawT him without any remains
 of the paralytic affection, which,  however, had
 continued during two or three years.  Paralysis
 from this class of  poisons generally affects the
 powers of sensation  more or less  remarkably.
   106. E. Ergot, or spurred rye, sometimes oc-
 casions palsy, especially of sensation ; but the
 effects of this substance are fully treated of in
 the article Ergotism.
   107. V. General  History of Palsy.—i.  Of
 the various Disorders  preceding and attend-
 ing Palsy.—From the description of the sev-
 eral varieties of palsy, it will be seen that the
 power of motion  is much more frequently im-
 paired than that of sensation ;  that either may
 be singly, or  both jointly affected in various
 grades, but that, when  motion  is totally lost,
 sensation  is  frequently more or less impaired ;
that sensibility is very rarely entirely lost in a
paralyzed  part, and still more rarely over the
surface of the body; and that palsy is both
preceded and accompanied by considerable de-
rangement of the general health as well as of
the nervous system, to which especial attention
should be  directed.
   108.  A. It is impossible to notice all the pre-
 monitory symptoms of palsy, as the varieties and
 relations  of the malady are so numerous as to
 render  them  both  diversified and inconstant,
 and as  they depend very much upon the nature
 of the pre-existing disorder and of the remote
 causes.   Hemiplegic palsy is often preceded  by
 the same premonitory symptoms as have been
 mentioned in connexion with the accession  of
 Apoplexy (§ 4), especially by various affections
 or disorders of one or more of the senses, par-
 ticularly of hearing, sight, and touch ;  by neu-
 ralgic pains about the face or head ; by twitch-
 ings, spasms, or convulsions ; by weakness  of
 muscles, or of a limb ;  by headaches, restless-
 ness, sopor, lethargy, or watchfulness;  vertigo,
 faintness, and unsteady gait; irritability of tem-
 per, loss of memory ; imperfect or difficult ut-
 terance ;  flatulence, costiveness, and  various
 dyspeptic symptoms ; more or less manifest in-
 dications  of irritation or inflammatory action
 in some part of the brain ; epileptic seizures,
 and most frequently apoplectic attacks.   (See
 aboie, Y 40, and art. Apoplexy, y 4.)
   109.  The paraplegic and general states of pal-
 sy are often preceded by pain in the course of
 the spine, sometimes resembling, and frequent-
 ly mistaken for, lumbago ; by spasms or cramps
 of particular muscles ; by pain in the neck,  or
 wry-neck; by neuralgia or neuralgic pains ; by
 numbness of the toes or fingers ;  by attacks  of
 nephritis ; by increased sensibility of the  sur^
 face of  one or more limbs, or of the body gen-
 erally ;  by costiveness and colicky  pains, or
 obstinate  constipation ;  by retention of, or dif-
 ficulty of voiding, the urine ; by chorea, partial
 convulsions, or various anomalous nervous dis-
 orders ; and by the  more limited forms  of  par-
 tial palsy.
   110. B.  The disorders of the nervous system,
 and of the general health, accompanying palsy, are
 various  in different cases, according to the seat
 of the malady.—a.  In hemiplegia and palsy of
 any of the organs of sense, the memory, and,
 in severe or prolonged cases, even the intel-
 lectual powers, are  more or less impaired, the
 palsy extending even to the mental powers.
 This state, however, is the most  remarkable  in
 the complication of general palsy with insani-
 ty, hereafter to be  noticed.  The temper and
 disposition are often changed from their usual
 characteristics, persons of a mild disposition
 becoming  peevish and irritable, and those who
 have been irascible  becoming placid ; in some
 cases the memory, chiefly of words or of names,
 is impaired or perverted, so that the  patient
 substitutes those which either are inappropri-
 ate, or have an opposite meaning to that which
 he wished to convey.  The powers of attention,
 and application, and mental energy generally,
 are usually impaired.
  111. The action of the heart and lungs is sel-
 dom much excited  in  hemiplegia or cerebral
 palsy, unless when  inflammation  of a  portion
 of the brain supervenes upon or attends the
 lesion causing the  hemiplegic state.   Nor  is
the action  of these organs oppressed or  impair-
ed, unless effusion, so as  to cause direct or
counter  pressure, takes place, or the medulla
oblongata  becomes  in  any  way  implicated.
 Hence the temperature of the surface of para-
lyzed  parts is seldom  lower than  natural, and
frequently, owing to diminished transpiration 
28                     PARALYSIS—General History of Palsy.
from the  surface of these parts, it  is higher
than in other situations.
   112. Digestion and assimilation are often but
little  disturbed or impaired.  In some cases
vomiting or nausea, with or without flatulence,
attends the accession of hemiplegia, but sub-
sequently acidity, heartburn, or flatulence, is
complained of.  The  appetite is but little im-
paired ; it  is even frequently keen or craving,
and  is generally too great  for the amount of
exercise taken, and of air consumed by respi-
ration, and consequently for complete digestion
and  assimilation.  This keenness or craving
appetite I have often remarked as an indication
of latent irritation in the substance of the brain.
The bowels and liver  are  usually torpid, and
often require powerful chologogues and purga-
tives to act on them.
   113. The nutrition of a paralyzed part is oft-
en not materially affected when the disease
occurs after the growth of the body has been
matured.   Occasionally, however, some degree
of shrinking, or atrophy, exists, especially in
prolonged cases, owing chiefly to disuse of the
muscles.   The nerves are also somewhat atro-
phied.   Very  frequently an cedematous  state
of a paralyzed limb is  observed, increasing  its
bulk,  although the  muscular and other soft
parts may be more or less wasted or atrophied.
The urinary functions  are seldom  much affect-
ed in hemiplegia and  other cerebral forms of
palsy.
   114. b. In paraplegia  and general palsy the
attendant phenomena have been  already fully
noticed (t)  48, et seq), and consist  chiefly  of
lesion  of those functions which  depend upon,
or are influenced by, the part of the chord which
is the seat of disease.   As the brain continues
unaffected until the fatal termination of the dis-
ease draws near, so the mental powers contin-
ue unimpaired till that period arrives.
   115. When  the medulla oblongata, or upper
part  of the chord, is affected, the action of the
heart and lungs is often much disordered ; and
if these parts, especially the former, are press-
ed on, or much disorganized, death by asphyx-
ia is more or less speedily produced.   In slight-
er lesions of these parts, remarkable slowness
of the pulse in some cases, and great rapidity
of it in others, are often observed
   116. Respiration is usually performed chiefly
by the diaphragm, and the quantity  of oxygen
consumed during the process is very small, con-
sequently the  heat of the surface is low, and
transpiration from it  much diminished.  The
skin is dry, becomes covered with a branny or
furfuraceous substance, owing to rapid exfoli-
ation of the cuticle.  When the lesion is seated
lower in the chord, or so as not to impede the
motion of the chest, and, consequently, not to
diminish  the action  of the air on  the blood, the
parts below the seat of injury experience  di-
minished or interrupted cutaneous transpira-
tion, and, instead  of  any diminution of tem-
perature, they  present an actual rise of tem-
perature, owing to  the interrupted transpira-
tion, the  functions of respiration not being im-
paired.
   117. The heat of the surface of paralyzed parts
depends upon  the state  of  respiration and the
consumption of oxygen, in connexion with the
amount of transpiration from that surface ; for,
while  the  oxygenation  of  the blood proceeds
without diminution, suppression of the cutane-
ous transpiration will raise the temperature of
the surface on which transpiration is suppress-
ed ; but when the  oxygenation of the blood is
impaired, suppressed transpiration cannot have
this effect, or only to a small amount.   If the
change produced by respiration on the blood be
much impeded, the temperature will generally
continue much  below  the  natural  standard.
This appears to  me to be the true cause of the
different states  of temperature  of  paralyzed
limbs in different cases ; and it is preferable to
account for the phenomenon  conformably with
established principles, upon which a sound and
safe practice may be based, than to mould it so
as to suit a preconceived hypothesis, and to
make it subserve a doubtful or hazardous treat-
ment.
  118. It may be objected, however, that  the
rise or fall of temperature in  a paralyzed or in
an inflamed part may be independent, in some
degree, of states of respiration ; and this is  ac-
tually the case ; for, although  the passage of
oxygen into the  circulation takes place in  the
lungs, the oxygenation  of the  blood, or,  rath-
er,  of certain elements of the blood, occurs
chiefly in the systemic capillaries, under the in-
fluence of the organic nervous power, the  ox-
ygen combining  partly with these elements for
the nutrition of the tissues, and partly with  the
carbon of the blood.  The change in the capa-
city for  latent heat consequent upon the  com-
bination of oxygen with these elements in  the
several parts of the body is great in proportion
to the extent of combination ; and, as this com-
bination is  strictly a vital process, or at  least
brought about by vitality, although conformably
with chemical laws, so it takes place  independ-
ently of the cerebro-spinal  nervous system
Notwithstanding that this  combination and  the
change of capacity for caloric consequent upon
it are independent of this system, and are ef-
fected chiefly by vital or ganglial nervous  pow-
er, still they may be influenced by the cerebro-
spinal system.  The passions  and  emotions
show this;  but  they also prove the predom-
inant influence of the organic nervous system,
their  physical action—their  operation on  the
circulation and the tissues—being through  the
medium of this  latter system.   Fear blanches
the cheek and lowers the temperature of  the
surface ; sexual passion produces turgescence
of the erectile tissues and heightens the tem-
perature ; but these, as well as  other mental
emotions, change the state  of the circulation
and temperature by depressing or exciting,  ac-
cording to  the nature of the emotion, the  or-
ganic nervous or vital  power  in  the first  in-
stance, the effect upon the circulation and tem-
perature being consecutive.  The independence
of the organic  or vital  nervous system of  the
cerebro-spinal is shown, even in those vital or-
gans which  are most influenced by the mental
emotions and the spinal chord, in the course of
paralytic cases.  Thus  palsy, even when gen-
eral, does not extend to the  organs of genera-
tion.  Erections take place  in  almost all  the
varieties of the disease,  if no other concom-
itant  complaint  exist to  prevent them ; they
are even morbidly frequent or constant when
the upper part of the spinal chord is congested,
inflamed, or otherwise implicated   Pregnancy
proceeds  in its usual course, and parturition 
PARALYSIS—Associations and Complications of Palsy.
29
takes place in the natural way, in cases of par-
aplegia or general palsy in females.
  119. When the  upper part of the chord is
the seat of lesion, the stomach is sometimes so
much disordered as to reject its contents.  The
bowels are obstinately confined, as above no-
ticed (y 59);  the tongue  is furred and loaded ;
the urinary organs remarkably affected (v 57),
and the vital cohesion of the  superficial and
other tissues below the diseased  portion of
the chord is  more or less impaired, disposing
them  readily to undergo asthenic inflamma-
tion, sloughing, &c. (Y 64.)
  120. ii. The Associations and Complica-
tions of Palsy.—As palsy is generally a symp-
tom or consequence of some lesion sustained
in a part of the cerebro-spinal nervous system
and nerves, it will readily be admitted that it
will frequently present itself in practice as an
accident or result of an immediately  antece-
dent and intimately related disease, and often
be  associated with  such disease—with  apo-
plexy ; with  inflammation and softening of the
brain ; with similar lesions of the spinal chord;
with  structural changes  of the membranes of
the brain, and of the spinal medulla ; with dis-
ease of the cranial and spinal bones ; with ep-
ilepsy, convulsions, hysteria, and  catalepsy ;
with  insanity, imbecility,  and  idiocy ;  with
rheumatism,  lumbago, and congestions of the
spinal sinuses; with neuralgic affections;  with
inflammation of the kidneys, or other parts of
the urinary apparatus.  In the progress  of all
these maladies, some form or other of palsy
may appear whenever lesions of structure, or
even  congestions, take place in, or extend to,
any portion of the cerebro-spinal axis, or nerves
proceeding from it during their course ; or, in
other words, when palsy is  complicated  with
any of these maladies, it is a consequence of
the vascular  and organic  lesions characterizing
or supervening in the  progress of such malady.
The importance and danger of these complica-
tions require that a brief notice should be taken
of them.
   121. A. Of all diseases, apoplexy is the most
frequently associated with, and  the most inti-
mately related to, palsy,  especially to hemiple-
gia, and to some states  of general and partial
palsy.  The  complication of apoplexy with pal-
sy is fully described  in  the  article Apoplexy
(v 31-49).  I have there  shown that it general-
ly presents itself as follows : 1st. The apoplexy
occurs as the  primary malady, and is either asso-
ciated with,  or followed by, paralysis.   2d.  The
paralysis, in some one or other of its partial states,
often  in  that  of hemiplegia, first appears, and is
followed, after a very indefinite period, by an ap-
oplectic attack more or  less profound.
   122. a. In  the first of these complications the
paralytic affection  may disappear in  a short
time  after the apoplectic seizure, or not  until
after several days or weeks.   It may be per-
manent,  or continue for  years, or until another
apoplectic seizure carries off the patient; or it
may be rendered more complete or general, or
it may affect  additional or different parts, those
first affected being either partially restored or
unchanged, by renewed seizures of apoplexy, or
by coma, attended by sinking or exhaustion.  In
these cases death is usually produced by the ap-
oplectic state, or by a comatose sinking, attend-
ed  by a  general palsy, in which, owing, prob-
ably, either to nervous exhaustion, or to coun-
ter pressure on the base of the brain, or on the
medulla oblongata, or to lesions extending to
these parts, the respiratory organs participate.
I have described fully, in the article just re-
ferred to (v 34, et seq.), the lesions usually ob-
served in these circumstances; and I need not,
therefore, allude to them farther than to  state
that, in the slighter and less prolonged instan-
ces, they consist chiefly of congestion and se-
rous effusion ; and, in the more severe and per-
manent cases, of extravasations of blood, soft-
ening of portions of the brain, and of extrava-
sation and softening conjoined.   In  some ca-
ses little or no lesion  is seen, or at least lesions
insufficient to  account for the phenomena and
for death ; and in other cases, in connexion
with one or more of these lesions, effusion ot
serum in the ventricles, or between the mem-
branes ; inflammation of a portion of the brain,
or of the  membranes,  and other  concomitant
or contingent lesions, are observed.  (See art.
Apoplexy, y 36,  et seq.)
   123. b. In the  second of these forms of  com-
plication (v 121)  the palsy in some one or oth-
er of its more partial forms, frequently in that
of hemiplegia, is the primary seizure, and is
generally then caused by alterations in  some
part of the  substance of the brain, especially
by softening, haemorrhage, cysts,  tumours, tu-
bercles, and by  almost  any of the diversified
lesions described in  the article Brain and its
Membranes, particularly when they have ar-
rived at  an advanced state  of development.
Many of these lesions are followed by inflam-
mation, softening, congestion, or effusion of
serum or of blood in the brain  or  its  mem-
branes, causing  either a more complete or a
more extensive  palsy, or spasms or contrac-
tions of one or  more limbs,  or superinducing
apoplexy, which may either terminate  life, or
be removed, leaving the pre-existing palsy more
complete or extended than before.  (See arts.
Apoplexy, v 46,  et seq.,  and Brain.)
   124. B. Palsy  may become  associated with
epilepsy; but  it  is generally a  consequence,
even when thus associated, of repeated returns
of the epileptic  paroxysms.  Even in the ear-
lier attacks of epilepsy, occurring in young per-
sons, the  epileptic fit may be followed  by  in-
complete palsy of the limb, or of certain mus-
cles, especially of an arm, or of the muscles of
articulation, &c.  In  these cases the palsy may
soon disappear,  and  follow the next or subse-
quent attacks ; and may continue without  much
variation, or become more complete until  ei-
ther hemiplegia, or even more general palsy,
supervenes.   In some  instances the epileptic
seizure may present a mixed character, or a
state intermediate between apoplexy and ep-
ilepsy ; or it  may be viewed as  apoplexy at-
tended by convulsions, a form of seizure which
had  been  overlooked until  it  was described in
the  early parts  of this work.  These mixed
forms of seizure are not infrequently followed
by palsy.  It  has been stated in  the articles
Brain and  Epilepsy, that any organic lesion
of the brain or  of its membranes may be fol-
lowed by epileptic attacks ; and these lesions,
in a more advanced stage of development, may
occasion either  palsy or apoplexy ; often both
in succession, at very indefinite intervals. The
slighter states of palsy consequent upon the ep- 
30
PARALYSIS—Associations
and Complications of Palsy.
ileptic fit may be viewed as the result of con-
gestion, more particularly  affecting  that por-
tion of the brain that has most intimate rela-
tions to the paralyzed part.  Where, however,
the palsy is more complete or extensive and
permanent,  it may be  viewed  as  depending
upon similar changes to those which have been
alluded to as causing palsy in connexion with
apoplexy (y 121);  and if the palsy be attended
by contractions  or spasms either of the para-
lyzed or of the sound limbs, inflammatory  ac-
tion or irritation may be inferred to exist ei-
ther in the vicinity of  the cerebral  lesion, or
in another part  of the brain, according to  the
seat and character of the spasms, &c.  In rare
instances, the same lesion of the  brain that
causes the epileptic or convulsive seizure may
induce at the  same  time a  paralytic state.
These cases usually soon terminate fatally.
  125. C. Inflammation  of the brain may be
complicated with  palsy; but in this state of
disease the inflammation is generally limited
to a portion of the brain. Either affection may
be primary, and thereby give rise to two states
in which this complication presents itself in
practice.  1. The  changes consequent upon  the
inflammation  may  induce those farther  changes
upon which the palsy depends; thus, inflamma-
tory  softening favours  cerebral haemorrhage,
and this latter  usually causes the paralytic
state.  2. The lesion primarily causing the palsy
may induce inflammation  of the adjoining parts of
' the brain, and the phenomena usually consequent
upon this state;  thus, blood extravasated, or a
tumour formed in the brain, will occasion pal-
sy, and inflammatory action will often follow
in the surrounding cerebral structure, or in the
adjoining membranes,  or  in both structures,
and give rise to the association of the chief
phenomena of inflammation of the brain, or of
its membranes, with the paralytic state.  Both
these states of association may present them-
selves even in the same case ; thus, a gentle-
man, attended by Dr. Paris and the  author,
had inflammation of the brain, and after  the
more acute attack had been removed, hemiple-
gia supervened.   The haemorrhage, consequent
upon the inflammatory softening, and  produc-
tive of the palsy, after a short time reproduced
the  inflammation, which was  again  subdued ;
but  after some  months an apoplectic  seizure
took place, and carried  off the patient.  In ca-
ses of this complication, the membranes may
or may not be implicated, according to the seat
of primary lesion, or to the nature of that lesion.
  126. D. The complication of insanity with pal-
sy has been very fully discussed in  the article
on  Insanity  (see  y 33-36, and 167-172);  and
I, therefore, need not farther allude to the sub-
ject at this place  than  to state that the palsy
generally does not appear  until  after the men-
tal disorder ; often not until the latter has con-
tinued for a considerable time, and assumed a
chronic and  general  form.  In  some cases,
however, insanity and palsy occur  almost si-
multaneously ; and in a few the paralytic af-
fection precedes the mental derangement.  Pal-
sy thus associated is commonly general, or soon
becomes such.  It is usually incomplete, espe-
cially in its early stages, and affects chiefly the
muscular system.  The sphincters, and, conse-
quently, the  evacuations, are  uncontrolled by
volition.   This form or association of palsy is
usually a result of chronic inflammation of the
brain, and is distinct from palsy caused by cer-
ebral  haemorrhage,  softening,  tumours,  &c,
which, however, may also occasion the more
partial, or  a hemiplegic form of palsy in the
course of insanity ; but these latter are not so
frequent  as the  general  palsy just  alluded to,
and fully described in  its more   appropriate
place  (Insanity, y 167, et seq.).  The paralysis
of the insane may be farther associated  with
epileptic, convulsive, apoplectic, or comatose
states, either of which may terminate  life, or
the patient may sink from vital  exhaustion.
The appearances  observed  after  death  from
these  complications are  minutely described in
the art. Insanity (y 235,  et seq.).
  127  Palsy is not infrequently, also, associa-
ted with  idiocy, and with puerile imbecility (see
art. Insanity, y 522, et seq.).  In these compli-
cations the palsy may be either general or par-
tial ; but when  it  is  general, some parts are
usually more affected-than  others,  and imper-
fect development of portions of the cerebro-
spinal  axis is often seen on examinations of
them  after death.
  128. E. Although both paraplegia and general
palsy are often  produced by the more common
consequences of inflammation of the  spinal chord
and of its membranes, still the inflammation, as
well as those consequences, may still continue
after the paralytic state has been produced, and
thus  become associated  or  complicated with it.
The history  of cases of this description, and
some  of those above noticed, suggests this po-
sition ; and the appearances I have  observed
during the  examination after death  sufficiently
confirm  it.   The importance of attending  to
this circumstance cannot be over-estimated in
a practical point of view, as being suggestive
of a rational treatment  of these cases.  The
persistence of inflammatory action in the spinal
chord and  its membranes, particularly the lat-
ter, during the paralytic  states depending  upon
lesions of these parts, is often evinced by pain
in the spine, by spasms or contractions of the
muscles, by pains in the limbs, and by the va-
rious  phenomena usually attending inflamma-
tions.  In  some instances, the inflammation
occasions  not  merely spasm, contraction,  or
pain of the muscles supplied with nerves  from
the part of the spinal chord which it affects,
but also  more  general convulsions;  or, when
the upper parts of the chord are implicated, epi-
leptic seizures, or coma  and asphyxia.
   129. F. Disease  of the cranial and vertebral
bones, or of the periosteum, sometimes  compli-
cates as well as causes palsy, particularly in the
scrofulous  diathesis.   In these cases the dis-
ease  of the bones  extends to the  membranes
enveloping the  brain or  chord ;  and inflamma-
tion, with its usual consequences, when affect-
ing these  membranes,  supervenes and inter-
rupts  the functions of, or extends to, the en-
closed portion of the cerebral or spinal struc-
ture.   Thus, I  have repeatedly met with in-
stances of caries of the  petrous portion of the
temporal bone, consequent  upon neglected oN
torhcea,  that were  followed  by inflammation
and abscess  of the adjoining membranes and
cerebral  structure,  and by palsy, with various
concomitant and consecutive phenomena.  Ca-
ses of this description not infrequently occurred
to me in dispensary practice, and  in children 
PARALYSIS—Associations and Complications of Palsy.
31
at the  institution for their diseases.  Lesions
of the cranial bones associated with, as well as
causing palsy, may be the result of disease or
of injury.   Thus, a portion of the parietal bone
was remarkably and permanently depressed in
a boy by accident, and coma, with hemiplegia,
was the result.  The coma soon passed off, but
the hemiplegia continued for a time.  Ultimate-
ly, the palsy also was altogether removed ; and,
long before he reached the period of puberty,
the paralyzed  side had become as strong as the
other.   The depression, however, continued as
remarkable as before ;  yet,  notwithstanding
this, the subject of this accident became, and
still is, a most powerful  and talented man, with
whom  I have been acquainted for more than
thirty years.
   130. Disease, particularly scrofulous caries of
the vertebra, is a frequent cause and concomi-
tant of paraplegia, and even of general palsy, as
in the case above noticed (y 68);  and not only
may the palsy be associated with disease of the
vertebrae, but  also be farther accompanied with
epileptic seizures.  A young man several years
ago consulted me respecting epileptic attacks,
each of which was preceded by the aura cpilep-
tica, which proceeded from the palm of the left
hand to the lower cervical vertebrae.  On ex-
amining the hand, the  palm of it was  found
swollen, and obscure fluctuation was detected
in it.  The part was opened, and matter was
discharged from beneath  the palmar fascia.
The fits disappeared for a considerable time;
but pain and stiffness in the lower cervical and
upper dorsal vertebrae were complained of, and
were attended by a diffused swelling.  The ep-
ileptic attacks returned, and paraplegia, nearly
amounting to general palsy, supervened.  An
abscess pointed between the scapula and spine,
which was opened ; and the patient soon after-
ward was carried off by an epileptic seizure.
In this case caries of the vertebrae, purulent in-
filtration of the adjoining muscles, and inflam-
mation of the membranes of the chord, with
effusions of coagulated lymph, adhesions, &c,
were found after death ; and the inflammation
of the  spinal arachnoid, with serous effusion
above the seat of adhesions, had extended to
the arachnoid of the medulla oblongata and the
base of the brain.
   131.  G.  Neuralgic affections of the face, head,
or limbs, not only precede, but also occasionally
accompany palsy.  The  pain sometimes ceases
when  the palsy takes  place, especially if the
muscles supplied or connected with  the pained
nerves are those paralyzed ; but it is sometimes
only alleviated.  The  neuralgic  pain  is occa-
sionally complicated with the palsy, particular-
ly when they occur on  different  sides of the
body.   Neuralgic  pains may thus accompany
hemiplegia, paraplegia, and  any  of the more
partial  states of palsy, the latter affection su-
pervening after the former has been of long du-
ration (see art. Neuralgic Affections, y 72).
It is only in rare  instances that neuralgia ap-
pears in the course of  palsy, or that the latter
is the primary affection.
   132. H.  Palsy is sometimes associated with
rheumatism, but not so  frequently as might ap-
pear on a superficial view of the matter.  The
pains,  whether  dull,  gravative, gnawing, &c.,
sometimes complained  of both before and du-
ring paralytic affections, are often  mistaken for
rheumatism, or for neuralgia, although they are
the not infrequent attendants of that change of
structure at the origins of the nerves supplying
the pained parts that ultimately produces palsy.
The  pains  may be even  felt in different  parts
from those which are paralyzed;  and they are
then to be viewed as the extension of inflam-
mation, or  of other  organic lesions, to  parts
differently related.  The  pains in the loins or
back, so often viewed as lumbago, and felt more
or less by persons  addicted  to venereal ex-
cesses or to manustrupation, are occasioned
either by congestion of the spinal sinuses, or
by inflammatory action of  the membranes of
the chord ;  and although  they are  most fre-
quently the precursors of palsy, particularly of
paraplegia, still they not infrequently accom-
pany it, and extend either  to  the sound  or to
the affected limb, or even to both.
  133. /.  Palsy, or palsy associated  with  apo-
plexy, is  not  infrequently consequent upon or-
ganic disease  of the heart,  particularly hypertro-
phy  of the left ventricle,  and lesions of the
valves or  auriculo-ventricular orifices.   The
remarks which I  offered  in the art.  Apoplexy
(v 96) on  the  connexion  subsisting between
that disease and structural changes in the heart
are quite applicable to the complication of those
changes with palsy, especially with hemiplegia.
rn this complication the disease of the heart is
generally the primary malady, and more or less
aids  in the production of the paralytic affection,
although some lesion of the  vessels or sub-
stance of the brain may have pre-existed, or
have been cotemporaneous with  the cardiac
disease.
  134. K. The association of palsy with disease
of the kidneys and urinary organs  generally has
already been  noticed, with reference only, how-
ever, to the supervention of disease  of the lat-
ter upon paraplegia and general palsy (y 57).
But the complication now to be noticed is of  a
different  kind.  When the kidneys, either from
intense inflammation or from a primary state
of inaction or palsy,  cease to  perform  their
functions,  and retention  of  urine  from this
cause results, a state of excrementitious  pleth-
ora  is produced, not infrequently terminating
in fatal coma or apoplexy.  These may assume
the form of general palsy ; and, in rare cases,
hemiplegia may take place.  In these the pro-
cession of morbid phenomena is sufficiently
manifest;  but in others it  is much less so, es-
pecially in those which present the occurrence
of paraplegia consequent  upon the nephritic
disease.  Mr. Stanley, in an interesting memoir
(Trans, of Med. and Chirurg. Soc., vol. xviii, p.
260), has adduced several  cases, in which in-
flammation of the kidneys existed in  connexion
with paraplegia,  and appeared as the primary
malady, and yet no change  was observed  in the
spinal chord  or its membranes.  Some of the
cases deserve a brief notice.
   135. A man  complained  of retention of urine
conjoined with paraplegia, motion and sensa-
tion being lost.  Tenderness  on  pressure was
felt at the third lumbar vertebra.  After death
no lesion could  be  detected  in the vertebrae,
spinal chord, or its membranes.  The kidneys
presented  inflammatory changes, with  small
abscesses dispersed through their substance.
   136. A man had  retention  of urine  conse-
quent  upon the suppression of gonorrhoea  by 
32                              PARALYSIS—Diagnosis.
injections.  He complained of pain in the back,
paralysis of the lower limbs, and of the sphinc-
ters.  He distinctly  traced  the course of the
pain from the bladder upward to the kidneys
and across the loins.  On dissection, the kid-
nevs were inflamed, with minute purulent dep-
ositions throughout their substance.  The blad-
der was inflamed, and its  inner surface partly
covered by coagulable lymph.   The brain and
spinal chord presented no disease.
  137.  A man, aged thirty, stated that he had
been suffering for a day or  two from pain in
the loins, when he was seized with  paraplegia
extending to the umbilicus.   The loss of mo-
tion was complete, and the loss of sensation
nearly so.  The functions of the brain were
unaffected.  The urine flowed  involuntarily,
and three pints were drawn off by the catheter.
In sixteen hours from the attack of  paraplegia
the man  suddenly died.  The kidneys were
found gorged with blood and  nearly black.  The
mucous membrane of the urinary passages was
congested.   The substance and membranes of
the spinal chord and brain were sound, vascu-
lar turgescence of these parts being but slightly
greater than natural.
  138.  I believe that, if cases of the kind now
adduced were carefully observed at an early
stage of their course, sufficient evidence would
be found of congestion of the veins or sinuses
placed between the sheath of the chord and the
bodies of the vertebrae. This congestion would
of itself be sufficient to cause disorder of the
urinary functions and inflammation of the kid-
neys and urinary passages, which would react
upon, and aggravate the spinal lesion.  In the
examinations of these  cases no mention is
made of the state of the venous sinuses of the
spine.
  139.  L  Palsy is  sometimes associated with
hysteria, and the association has been noticed
in the article Hysteria (y 35).   A remarkable
case of this complication was lately attended
by Mr. Flockton and myself.  A young lady
had experienced hysterical symptoms, with ir-
regularity of the catamenia, to which had su-
pervened suppression of this discharge, attacks
of vomiting, sometimes alternating with  diar-
rhoea, and complete paraplegia, as respected
the power of motion   The sensibility was only
slightly affected.  The urine required  to  be
regularly drawn off.  There was no tenderness
in the course of the spine ; and all the cerebral
functions, the organs of sense, the intellectual
powers, and the moral feelings seemed to be in
unimpaired  vigour  and duly regulated.   She
had been long ill, and had been under the care
of various eminent men both in London and in
fashionable  watering-places.   The treatment,
which will be noticed hereafter, restored her in
the course of a few weeks,  and after three or
four months she was quite recovered.
   140. It  is very difficult to explain  the con-
nexion between hysteria,  or disordered states
of the female organs, and palsy.  But it is not
improbable that many of the symptoms,  and
particularly those of a paralytic character, arise
not merely from irritation propagated  from the
uterine system to the roots of the spinal nerves,
or to the spinal chord itself, but rather from
superinduced congestion of the spinal veins and
sinuses, the congestion being attended  either'
by interruption to the circulation in the chord,
 or by compression, or even  by both.   This
 change will account for the frequent connexion
 also  of palsy of the urinary bladder with hys-
 teria, even  when paraplegia  is  not present.
 Yet  even in these cases, pains in the limbs,
 with weakness and partial loss of power, are
 often complained of.  When the remote causes
 of hysteria are considered, particularly in con-
 nexion with the effects they produce upon the
 spinal chord and roots of its  nerves, the fre-
 quent supervention of congestion of the spinal
 veins and sinuses may be viewed as altogether
 conformable with the laws of the animal econ-
 omy.
    141. VI. Diagnosis.—Palsy, in a simple and
 primary form, cannot be mistaken for any oth-
 er malady.  It is only when it appears second-
 arily, or associated  with any  one  of the dis-
 eases just mentioned, that the diagnosis re-
 quires attention ; and even then the object is
 chiefly to ascertain which is the primary affec-
 tion, to  trace the nature  of the connexion be-
 tween them, and to form some idea as to the
 structural changes upon which the paralytic
 symptoms, which are usually sufficiently man-
 ifest, depend.   It is to this last that our chief
 attention should be directed ; this is the great
 object of diagnosis, and one which is not only
 very difficult to determine on many occasions,
 but almost impossible on some.
    142. a. When palsy presents any of its more
 partial slates, the question of its origin will sug-
 gest  itself; and the chief point to determine is,
 whether the affection depends upon lesion at
 the origin of the affected nerve in the cerebro-
 spinal centre, or whether it proceeds from dis-
 ease in  the course of, or in the nerve itself.  If
 there be no symptoms of disorder referable to
 the brain  or spine ; if neither  pain, disordered
 function, nor sensation can  be observed; and
 more especially, if disease implicating the nerve
 can  be  detected, the source of the palsy be-
 comes manifest.  In palsy of the face, disease
 of the portio dura, and tumours or matter press-
 ing upon the nerve, are readily detected.  When
 the ganglionic portion of the fifth pair is impli-
 cated, the affection of the eye, and the symp-
 toms mentioned above (y 19-22), in connexion
 with  the states of the other senses, and of the
 functions of the brain generally, will readily
 indicate the seat of the disease.  The various
 circumstances of the case will also aid the di-
 agnosis.  Previous injury, the presence of tu-
 mours,  or of periostitis,  the scrofulous diath-
 esis,  or manifest scrofulous disease, the occu-
 pation of the patient, and the operation of lead
 or arsenical poisons, &c, severally aid the di-
 agnosis.
    143. b. Hemiplegia is generally caused by dis-
 ease  in one side of the brain ; but it may be
 produced  by lesion in one side of the spinal
 chord,  although  very rarely.   When it pro-
 ceeds,  as  it usually does, from  the former
 source, it is oiten preceded by cerebral symp-
 toms, or  attended  by an  apoplectic seizure.
 The chief difficulty is to  determine the nature
 of the  lesion producing  it;  for  the  several
 changes, upon either of which hemiplegia may
 depend, are not attended by determinate  phe-
 nomena.  When  it proceeds from haemorrhage
 it is  usually, as above noticed  (y 39, 40), both
1 sudden  and complete in its accession, is often
 not  preceded  by pain, and is frequently asso- 
PARALYSIS—Consequences, Terminations, and Prognosis.
33
 ciated with apoplexy.  If it proceed from soft-
 ening, or from tumours or morbid growths of
 any kind (see art. Brain, y 111, et seq.), it is
 generally preceded  by cerebral symptoms, by
 various  nervous disorders, by pain, &o, and
 attended by spasms, convulsions, contractions,
 or pains ;  its accession is usually slower, and
 it  is at  first  less complete than  in other cir-
 cumstances.  Tubercles in the brain or in its
 membranes are not infrequently causes of pal-
 sy in children from  one or two years of age to
 twelve or fourteen,  as stated in the art. Brain
 (v  19,115), and more recently by Dr. H.  Green.
    144. I may here  remark,  that  considerable
 lesions, or morbid growths, may exist in or near
 the periphery of the brain, or implicate chiefly
 the cineritious  substance of the convolutions
 without  causing palsy, although coma, convul-
 sions, or epilepsy generally result.   I have re-
 marked  this  circumstance in  several  cases ;
 but I have never seen any marked lesion of the
 central parts  of the brain without  palsy being
 present.
    145. c. Paraplegia has been assigned above
 (y  53) chiefly  to disease of, or implicating, the
 spinal chord  or  its membranes.   But  it was
 supposed by Dr. Baillie, Dr. Goon, and oth-
 ers to arise  much  more frequently from dis-
 ease within the cranium.  Many  years ago I
 controverted  this doctrine (see Lond. Medical
 Repository, vol.  xviii.,  p. 522, 1822).   I  then
 took occasion to state "that, although I admit
 that paraplegia will  sometimes result from le-
 sions seated at the base, or in both sides tif the
 central parts of the brain, still I contend that it
 most commonly arises from diseases  of the
 spinal chord."  "The chief reason of the prev-
 alence of the cerebral  pathology of paraplegia
 appears  to  be the  old physiological opinions
 respecting the nervous  system still entertained
 by many ; and the  circumstance of the brams
 of  paraplegic subjects being, in conformity with
 preconceived notions, the only parts of the ner-
 vous masses which, until lately, had attention
 paid to them.   It is by no means unlikely—and
 many pathologists have recorded the fact—that
 a patient, who has been for some time paraple-
 gic from lesion in the spinal chord or its mem-
 branes, shall  die  apoplectic,  or  shall  expire
 from lesions  subsequently developed  in the
 brain.  This latter morbid structure, instead of
 being consecutive,  may be even co-existent;
 but, at the present day, I should not expect to
 hear a pathologist, conclude, because he found
 lesions in the  brain, that the paraplegia there-
 fore arose  from the cerebral disease only.  I
 would  be still more surprised were I to hear
 the same inference  drawn without any  exam-
 ination of the  spinal canal or medulla oblonga-
 ta having been made.   Now I do contend  that
 such conclusions have been actually drawn from
 such inconclusive data as the above by those
 who suppose—for the inferences of those in-
 vestigators are but suppositions at the  best—
 that paraplegia is generally seated in the brain."
 Thus I wrote in  1822, in opposition to the then
 received doctrine ; and now the justice  of my
views, which even then were  based upon tol-
erably extensive observation, are  almost  uni-
versally acknowledged.
  146.  Admitting, as I  have  done, that para-
plegia may occur, in  rare instances, from  dis-
ease in both sides of the more central parts of
     HI             3
 the brain, or near its  base, it will be asked,
 How is paraplegia from this cause to be dis-
 tinguished  from spinal paraplegia 1  In many
 cases, the evidence of the former is negative
 only.   There are no circumstances nor symp-
 toms indicating disease in  the spinal chord,
 membranes, or containing  parts, and  then we
 are constrained to look to the brain for it.  But
 where, in addition to this evidence, there are
 indications, antecedently  or concomitantly, of
 cerebral affection—if  any of the functions of
 sense or manifestations of mind be impaired,
 or otherwise affected, or if headache or vertigo
 be present—the source of disorder may thus be
 conceded to the brain.
   147.  Where it is manifest that the  paraple-
 gia  proceeds from disease implicating  the spi-
 nal  chord or its membranes, the question as to
 the  nature of that disease is often solved with
 great difficulty.  When paraplegia is caused by
 accidents, injuries, wounds, &c,  the  nature,
 and seat, and direction of these often assist the
 diagnosis.   The suddenness or slowness of the
 accession of the malady, viewed in connexion
 with the presence or absence of pain and ten-
 derness  in  the  spine, will often suggest  cor-
 rect views.  Thus antecedent pain,  tenderness
 on pressure, &c, and the continued presence
 of these, constrictive pains  in the limbs or in
 the  abdomen, spasms  or  contractions  of the
 muscles, &c, will  indicate congestion or in-
 flammation  in some one or more of the con-
 stituent tissues of the  part, particularly if the
 palsy supervene gradually,  and if the  remote
 or exciting causes are such  as are likely to oc-
 casion these lesions.   If pain in the back oc-
 cur  suddenly,  and  is attended almost immedi-
 ately by paraplegia, extravasation of blood may
 be dreaded ; or the displacement of  a previous-
 ly-diseased vertebrae, or sudden effusion produ-
 ced  by disease of the spinal bones,  may be in-
 ferred.   (-See  Spinal Chord and Membranes,
 Inflammation of.)
   148.  Debility of the  muscles of the spine
 causing curvatures of the column is rarely at-
 tended by any considerable degree of paraple-
 gia.   When this palsy  is associated with  dis-
 ease of the  spinal bones, the curvature is an-
 gular, owing to caries and absorption of one or
 more of the  bodies of these bones.   In the for-
 mer case attempts to straighten the spine are
 not  attended by pain or risk, and the  patient
 can  lie on the back or  abdomen without pain.
 In the latter, such attempts are dangerous, or
 even fatal;  as in a case of caries of one or two
 of the cervical vertebrae, for which  a surgeon
 was consulted, and an attempt which was made
 to straighten the part was soon afterward fol-
 lowed by general paralysis.   I was afterward
 called to the  patient, who  recovered  after  a
 most protracted confinement.  When palsy is
 associated with angular curvature, as in a case
 now attended  by Mr. Chilcote, which  I occa-
 sionally see, any attempt to  lie on the back, or
 to straighten  the  spine, is  followed by pain ;
 and  in another case just seen by me, such at-
 tempts produce convulsions.   These attempts
 always  interfere with  those  processes from
 which alone recovery is to be expected.  (See
art. Spinal Column.)
  149.  vi. Consequences, Terminations, and
 Prognosis.—A. Several of the consequences of
palsy have  been already  alluded to (y 56, et 
34              v               PARALYSIS—Causes op.
seq ), but  as  the  affection is chiefly a conse-
quence itself of pre-existing disease, it seldom
induces farther change unless  what becomes
speedily fatal; and that change  is seated chief-
ly around, or in the immediate  vicinity of the
lesion causing the palsy. Owing to such change,
the mental powers are often weakened, or al-
together lost in hemiplegia, or attacks  of apo-
plexy or coma supervene ; a partial jalsy may
become more extended ; and even imperfect
paraplegia may gradually increase and be more
complete or be general, ultimately terminating
in coma or apoplexy,  or  in asphyxia from in-
jury to, or  counter-pressure on, the medulla
oblongata.  The principal consequences of pal-
sy, especially when the spinal chord is impli-
cated, are manifested in the urinary organs, the
digestive canal, and respiratory functions, and
in the weakened state of vital cohesion of the
tissues of the paralyzed parts ; and these have
been severally noticed at length (y 57-64).
   150. B.  The terminations of palsy are chiefly
apoplexy, coma, sinking of the vital powers, as-
phyxia, convulsions or epileptic seizures termina-
ting fatally, and more or less complete recovery.
Apoplexy frequently supervenes  on  hemiplegia
or partial palsy,  and  either aggravates it or
terminates life.  A state of gradually ingraves-
cent coma may also terminate these states of
palsy, and even general palsy, although this last
variety frequently causes asphyxia, death oc-
curring sometimes  gradually, at other times
suddenly; gradually, from defective oxygena-
tion of the blood and diminished production of
carbonic acid, coma usually intervening ; sud-
denly, owing to the arrest of the actions of the
respiratory muscles and  functions, and of the
heart, consequent upon lesion  at the origins,
and complete  paralysis  of the  respiratory
nerves.  In both  these latter classes of cases
the blood after death is fluid and of a dark ve-
nous colour.
   151. Paraplegia either passes into general
palsy and  terminates as  stated  above  (y 150),
or becomes fatal, owing to consecutive changes
produced in the  urinary organs, or  to  slough-
ing of the parts  upon which the  body rests,
sinking of the powers of life, and  contamina-
tion of the circulating fluids arising from these
alterations.   When the upper portions of the
chord or the medulla oblongata  become affect-
ed, epileptic attacks or convulsions occasional-
ly occur,  and even terminate existence, rather
by the attending or superinduced asphyxia than
by the amount of injury sustained by the hrain.
   152  C.  The prognosis of palsy depends much
upon the grade of severity, or the complete or
general character of the malady, and upon its
duration.  In forming a prognosis, the circum-
stances alluded to when noticing  the conse-
quences and terminations of the disease should
be taken  into account.   When the palsy is lo-
cal, and independent of lesions  in or near any
part of the  nervous centres, or where  it is
caused by any of the metallic poisons, hopes of
recovery may be reasonably entertained.   But
when the disease depends upon organic change
of these centres or  of their envelopes ; when
it is complete and extensive;  when a whole
side of the body is affected ; and when it has
been of considerable duration,  perfect recov-
ery rarely takes  place.  I have met with  this
favourable result only in two or three cases.
Yet, although perfect  recovery so rarely oc-
curs, the state of the patient may be ameliora-
ted, and the patient may live many years with-
out the occurrence of any of the unfavourable
consequences or terminations of the malady,
if a suitable diet and regimen  be pursued.   In
all cases, the causes of the attack, and the na-
ture of the antecedent disorders and attendant
symptoms, should be considered.  When  the
palsy is attended by great  disorder of the di-
gestive organs, when the urinary organs are re-
markably affected (y 57), and when the sphinc-
ters are relaxed, when spasms or contractions
of the  muscles are present, or convulsions su-
pervene, and when the nature of the  organic
lesion  implicating the brain,  spinal chord,  or
their envelopes  is manifestly such as cannot
be entirely removed,  the  most  unfavourable
opinion may be formed of the result, although
the ultimate issue may be  deferred for a con-
siderable time.
  153.  The complications, also, of palsy should
influence the prognosis.  The most unfavour-
able of these are the associations of hemiplegia
with apoplexy or coma ; with inflammation of
the substance of the  brain,  as indicated by
spasms, contractions, and pains of  the limbs;
with neuralgia of the nerves of the face  or
head ;  with epilepsy or convulsions; with in-
sanity, imbecility, or idiocy;  with  disease of
the heart  or  of the liver;  with lesions of  the
cervical spine ; and with inflammation of  the
kidneys.   If the palsy supervene in the course
of these, it may be generally  assumed as  the
result  of severe, if not irremediable,  organic
change in the brain or spinal chord.
  154.  Palsy of the muscles of articulation, of
the tongue, or of deglutition,  whether  appear-
ing alone  or  in connexion  with hemiplegia, is
a most dangerous state of the malady, and oft-
en precedes more complicated and severe forms
of the  disease, that will soon pass into fatal
convulsions, or apoplexy, or asphyxia.   Fully-
developed  shaking  palsy is rarely  materially
ameliorated by treatment, although patients af-
flicted  with it  may live many years without
much increase of the symptoms.
  155.  Recovery often takes  place from the
hysterical  or  uterine complications of palsy, al-
though even in these the absence of all organ-
ic lesion of the nervous centres or of their en-
velopes ought not to be generally inferred, for
irritation of the uterine organs, or suppression
of the  catamenia, may be  followed by inflam-
mation and its  usual  consequences in these
parts,  particularly in  the  spinal  chord, or by
congestion, especially of the venous sinuses of
the spine,  sufficient to produce interruption of
the act of volition from the brain to  the nerves
of the extremities, ow ing to the pressure which
such congestion  may occasion.
  156.  Recovery from the less complete and
least complicated states of palsy from the me-
tallic poisons is sometimes brought about by
careful treatment and suitable precautions and
regimen.  A  case of complete hemiplegia con-
sequent upon apoplexy caused by monkshood,
respecting which I was consulted many years
ago, quite recovered after  a protracted treat-
ment.
  157.  VII. Causes—i. The  remote causes of
palsy are more strictly the causes of those mal-
adies in the course of which alterations of the 
PARALYSIS—Causes op.                              35
 nervons centres most frequently occur, and are
 so entirely the same as those which I have ad-
 duced in the  articles Apoplexy, Epilepsy, In-
 flammation of the Brain, &c, as  to require
 merely to be  enumerated at this place.
   158.  A. The predisposing causes are  chiefly
 hereditary predisposition,  advanced age, the
 male sex, mental labour, luxurious habits, and
 sexual  indulgences.  I have observed a great-
 er frequency  of palsy in the children of those
 who have died of diseases  of the brain than in
 others.   Palsy  is much less frequent in chil-
 dren and young persons, or in those under thir-
 ty years of age, than in persons farther advan-
 ced.  According to the registrar-general's re-
 port, the deaths in the metropolis in two years
 from palsy were 33 under fifteen years of age,
 614 from fifteen to sixty, and 932  at sixty and
 upward ; and from the same authority it would
 appear that the number of deaths is as great
 in females as  in  males.   Palsy is most  fre-
 quently observed in persons  whose  habits are
 sedentary, and in those of feeble constitution.
 It is said to be more frequent in  the sanguin-
 eous and nervous than in other temperaments;
 but this is not established.  There  can  be no
 doubt of mental labour, depressed  and anxious
 states of mind, luxurious habits,  and venereal
 indulgences being most influential causes of
 predisposition to palsy.  Indeed,  the various
 circumstances which I have assigned as pre-
 disposing  to  Apoplexy  (y  77), have a similar
 influence in respect of palsy.  Among  these
 vascular plethora may be mentioned ; and when
 this state is present, hemiplegia, either alone,
 or complicated  with, or consequent upon, ap-
 oplexy, is the form of palsy most frequently
 observed.
   159.  Various arts and employments (see that
 article) remarkably predispose  to  palsy,  espe-
 cially all those in which lead, arsenic, and mer-
 cury are much used, as  painters,  plumbers,
 glaziers, &c , &c.; and in  persons thus expo-
 sed, the disease occurs at earlier epochs of
 life than  in other circumstances.   It is  least
 frequently observed in those who lead a sober
 and active life, and  are  much in the open air.
 It is rarely met with in sailors and  soldiers, but
 this is  partly owing to  comparatively few of
 them being far advanced in life.  The influence
 of the seasons, or of weather, in favouring at-
 tacks of palsy has not  been shown with any
 precision; but  cold  and moist seasons  and
 weather, and  cold, humid, and miasmatous lo-
 calities  are certainly more  productive of para-
 lytic affections than other seasons, weather, or
 situations.
   160  B.  The exciting causes of paralysis are,
 1st. Physical,  mechanical, and external agents ;
 2d. The mental emotions ;  3d. Pathological states,
 or pre-existing lesions ; 4th.  Poisonous substan-
ces.  These may act (a) directly upon the ram-
ifications  or trunks of nerves; (b) or directly
or mediately upon the cerebro-spinal  axis.
   161  a.  Of the physical agents the most influ-
ential is certainly cold, particularly  when  se-
vere in grade, or long applied  to any part, or to
the general surface.  Cold  directly depresses
 the nervous  power, and benumbs sensation,
thereby affecting  the  nerves  themselves ; it
may also  occasion congestion of the nervous
 centres, and  particularly of the veins and si-
nuses of the spine, and, consequently, more or
 less complete forms of paraplegia, or general
 palsy, as in the cases already alluded to.*  All
 applications to the surface of a part that con-
 duct either  the animal heat or the electricity
 from it  may excite paralysis of it, particularly
 when long continued, as sleeping, sitting, or
 lying on the ground, or on stones ; wet or damp
 clothes ; the continued contact of metallic or
 earthen  substances, &c.   Pressure of any kind
 upon a  nerve,  whether produced by  external
 substances or  by tumours,  abscesses,  aneu-
 risms, dislocations, or other lesions  in the vi-
 cinity of the nerve, or by disease of the  nerve
 itself, or of its neurilemma, and wounds, con-
 tusions,  or other injuries of one or more nerves,
 are occasional causes of local palsy.t   Causes
 of a similar kind, implicating the brain or spi-
 nal chord, especially depressions or displace-
 ments of the cranial or spinal bones ; concus-
 sions  or other injuries of the  cerebro-spinal
 axis;  depending or constrained positions of
 the head or spine ; congestions,  tumours, mor-
 bid depositions, or other changes in  the ner-
 vous centres, their membranous envelopes, or
 bony cases, occasion hemiplegia, paraplegia, or
 general  palsy, according to the  seat  of lesion
 as above assigned.  To these may be  added
 intemperance, fatigue, or exhaustion,  changes
 of temperature  and of the atmosphere, inani-
 tion, &c.
  162. b. The influence of the mental emotions
 in causing palsy is undoubted ;  but it is not so
 directly manifested on the brain in all cases as
 may be at first supposed.  The emotions, wheth-
 er exciting or depressing, act primarily  upon
 the heart  and circulation, and  through  them
 upon  the brain  and spinal chord.  Undue  ex-
 citement of  the imagination, sudden mental
 shocks, fits of anger, and venereal excesses, or
 masturbation, are not infrequent causes of pal-
 sy.   Indeed, the several states  of paraplegia
 and general palsy are oftener produced by the
 last of these causes, or  by masturbation, than
 by any other.
  163. c. Pathological states, or lesions occur-
 ring in the course  of pre-existing disease, as
 already stated and  sufficiently insisted  upon,
 not only  in this article (y  34-53), but  also un-
 der the  heads  Apoplexy  (y  34, et seq.)  and
 Brain (y 50, et seq.), are the most frequent and
 immediate exciting causes of  the several vari-
eties of  palsy in their primary and associated
forms.  These, in fact, constitute the chief mor-
bid  appearances  furnished  by  paralytic cases,
and consist chiefly of exostosis, tumours, or
morbid growths, in the cranial bones (see art.
Cranium); tumours, effusions of blood, or of
serum, fungoid  productions, congestions, and
the more common consequences of inflamma-
  * The celebrated Scarron was deprived of the use of
his limbs by prolonged exposure to cold during a fit of dis-
sipation.  His mental faculties were, however, unaffected,
as in most instances of paraplegia, and of general palsy
caused by lesion of the spinal chord.  The fascinations of
his wit were  unimpaired, and he became the husband of
the beautiful and witty Mademoiselle D'Aubigne, after-
ward  the famous  Madame de Maintenun.   Scauron
lived twenty-three years in a paralyzed state.
  t [See an account of a peculiar form of paralysis in New-
York Journ. of Med., vol. ii., p. 34, by William P. Fuel.
It affected the nerves and muscles of the forearm, the hand,
the thumb, and the fingers, producing loss of muscular
power, and loss of sensation, partial or complete, from the
bend of the elbow to the tips of the fingers.  The cause ii
ascribed to long-continued pressure of the weight of the
body upon the nerves of the forearm in sleep.] 
36                             PARALYSIS—Pathology.
tion of the membranes of the brain ; congestion
and inflammation, extravasations of blood, ef-
fusion  of serum, abscesses, softening, indura-
tion, atrophy, ulceration, apoplectic  cysts,  tu-
mours, tubercles, morbid or malignant produc-
tions, aneurisms, hydatids, watery cysts, slough-
ing or gangrene  consequent on  severe inju-
ries in parts of the brain ; effusions into the
ventricles, or between the membranes ; disease
of the blood-vessels or aneurismal tumours, os-
sification of the coats of the arteries, varices
or dilatations of the veins or sinuses, and co-
agula, or fibrinous, or other concretions in these
vessels, are the chief lesions which have been
found in cases of hemiplegia, and of partial pal-
sy of the senses.   The changes just particu-
larized, affecting the spine, or the membranes
or substance of the spinal chord, or medulla
oblongata, are the usual causes of the sponta-
neous cases  of paraplegia and  general  palsy,
or those  cases which occur independently of
the more direct effects of external  injuries.
The occurrence of these forms of palsy in the
course of caries of one or more of the vertebrae,
owing either to the extension of inflammation
to the membranes, to effusion of lymph, or of
serum, or to pressure on the chord, owing to
the acute angle formed by the consequent cur-
vature, is  sufficiently familiar  to physicians.
But cancerous or malignant disease of the ver-
tebrae,  consecutive of cancer of the mammae,
or occurring primarily in these parts, may also
occasion paraplegia.   Mr. Caesar Hawkins has
adduced  three interesting cases of paraplegia
from this cause, and my friend  Dr. Abercrom-
bie, of Cape Town, has communicated to  me
a similar case to two of those observed  by Mr.
C. Hawkins, which had occurred in his prac-
tice.  In this instance,  the breast was grefetly
enlarged, was quite adherent  to the ribs, and
its lower surface ulcerated.   A prominence
was observed in the situation of the second
and third dorsal vertebrae, with tenderness on
pressure ;  paraplegia, followed  by its most  un-
favourable  consequences,  shortly  afterward
took place.
   164. Periostitis, especially scrofulous perios-
titis, is not infrequently productive  of partial
palsy, and  of paraplegia, or even of  more gen-
eral palsy, when affecting portions of the ver-
tebral  column.  In these cases,  as  far as  my
observation has enabled me to  state, the blad-
der is more or less paralyzed, the urine soon
becoming alkaline, and  neuralgic pains of the
limbs are often present to a distressing degree.
   165. d. Sufficient notice  has  been already
taken (y 100, et seq.) of the poisonous substances
which occasion palsy.  The slow introduction
of mineral  poisons, as lead, arsenic, mercury,
&o, sometimes is followed by this effect; and
in  some cases, at least, their influence is  ex-
erted as much,  if not more, upon the  nerves
supplying the paralyzed limb as upon any part
of the nervous centres.   The poisonous effects
consequent upon the vegetable or acro-narcot-
ic  poisons are owing more to  contingent le-
sions sustained by a part of these centres, while
they and the circulation in them  are under the
influence of the poison, than to any  effect pro-
duced by them on the nerves themselves.
   166. VII.  Of certain Points in the Pathol-
ogy of Palsy.—It is obvious  that  palsy may
arise from two distinct  conditions of the ner-
vous centres, viz.: 1st,  from  the  suppression
or diminished evolution of the cerebrospinal ner-
vous power and of volition, owing to  interrupteu
circulation, to depressed vital influence, or to
other alterations, in that part of the cerebro-
spinal axis which  is chiefly concerned in Pro-
ducing or originating that power ; and, 2d, from
whatever may prevent the transmission of cerebro-
spinal nervous power and volition from the parts
concerned in producing them to the limbs and
organs which they actuate.
  167. (a) If it be  conceded that the gray sub-
stance of the brain and spinal chord be chiefly
concerned in originating volition and the other
cerebro-spinal functions, we  may readily admit
that, when this substance becomes manifestly
diseased  throughout the convolutions of the
brain, a general state  of palsy, more  or less
complete according to the extent of change ex-
perienced  by it, may be  anticipated; and this
is actually observed in all cases where the gray
structure is  extensively changed, more panic-
ularly in those cases of general palsy complica-
ted with Insanity, as shown in that article (y
235).  In these the cerebro-spinal functions—
the emotions, intellects, volition, &c.—are more
or less impaired, and the gray  matter  of the
brain and spinal chord  is generally  found atro-
phied, indurated, or otherwise  changed, and
the structure especially concerned in the mani-
festations of these powers is no longer in a
state capable of originating or developing them.
  168. (b). The transmission of cerebro-spinal ner-
vous power and volition may be prevented, al-
though they are produced by  injury, disease,
or pressure  of the medullary substance of the
brain or spinal chord, or  of  the  nerves.  Most
of the lesions adduced when describing the sev-
eral forms of palsy and their efficient causes
act chiefly by arresting or interrupting the trans-
mission of volition ; although, even in these or
in other cases, many alterations of structure
both interrupt the transmission, and prevent the
evolution  or the production of nervous power
and volition ; as when  the lesion implicates
both the gray and the medullary substance, both
the origins and the course of certain nerves.
   169. The  well-known fact  that  disease on
one side of  the brain causes palsy of the oppo-
site side of  the body, has been attributed to the
decussation of fibres in the medulla oblongata.
This decussation  was supposed to  be confined
to the anterior columns only.   But, although it
might account for the crossed paralysis of mo-
tion, it could not  equally explain the  circum-
stance of paralysis of sensibility following the
same law.   Sir C. Bell has, however, shown
that the middle columns decussate as well as
the anterior, and thus accounted for the crossed
effect in both cases.
   170. It has, moreover, been objected that le-
sions of the cerebellum also produce a crossed
effect, although this organ is seated above the
point of decussation ; and that paralysis  of the
face follows the same law, and arises from dis-
ease in the opposite side of the  brain, although
the nerves  distributed to this  part also  arise
above the decussation.   As to  the first objec-
tion, it may be remarked that the dissections
of  Mr. Solly have demonstrated that numer-
ous fibres run between the  spinal chord  below"
the corpus  olivare and the cerebellum,  which
he believes  to decussate with their fellows of 
PARALYSIS—Pathology.
37
the opposite side, forming, in  fact, part of the
apparatus of decussation.  But this  discovery
establishes merely a direct communication be-
tween the  cerebellum and spinal chord in the
immediate  neighbourhood  of the decussation,
without proving the fact of the crossing of these
fibres.  As to the second objection,  it may be
answered in the  words of Dr. Bennett,  that
Sir C. Bell has shown that  the fifth pair of
nerves arise below the  decussation, and Mr.
Solly has traced one of the origins of the por-
tio dura from the  fibres he has described, which
run between the  spinal chord  and cerebellum.
Thus the sensitive and motor  branches  of the
face ought to follow the same  law as the other
spinal nerves,  which  is consonant with what
actually  takes place.
  171. Cases have been recorded, however, in
which paralysis has occurred on the same  side
as the lesions  in the brain.   Mr. Hilton has
endeavoured to explain this exception by refer-
ring it to a disposition of fibres in the decussa-
tion ; but, as Dr. Bennett has justly argued,
there is  strong reason for doubting  whether
disease in the brain ever causes a direct influ-
ence ; for of the many thousand cases of cere-
bral haemorrhage, tumours, &c,  which have
been recorded,  we are acquainted with twenty-
one  only in which paralysis is  said to have re-
sulted from disease in the  same side  of the
brain as the palsied side of the body, and, on
analysis  of these, more than one  half are im-
perfect and doubtful.  As the instances, there-
fore, of  this occurrence  are so few,  may we
not consider that the  palsy even in them  was
produced in the usual manner, and that the le-
sion which attracted attention had no reference
to the complaint 1  Numerous instances have
occurred of abscesses, softening, and other al-
terations of the brain having been found, but in
which no paralysis had been observed during
life ; and a still greater number are on record
in which there  was well-marked paralysis, but
no appreciable lesion of structure after  death.
It is by no means improbable, therefore, as pa-
ralysis may be induced without leaving any tra-
ces, that, in those few cases where the palsy
and  the  lesion  in the  brain were in the same
side, it was really caused by undetected chan-
ges  in the  opposite hemisphere of the brain  ;
and, as is sometimes the case, that the disease
found in  the hemisphere of the paralyzed  side
had  not occasioned the loss of motion.
  172. Lesions in the vertebral portion of the
spinal medulla produce not a crossed, but a di-
rect  effect;  and when they interrupt the func-
tions of this part of the nervous system, all the
parts furnished with  nerves arising  from be-
neath the seat  of lesion  are affected.  Hence
the  paralysis is the more general, the nearer
the  disease of the chord is to  the brain.   But
disorganization has sometimes gradually pro-
ceeded to a considerable extent in the  spinal
chord as  well as in the brain, while such fibres
or portions  of the former as remained unaffect-
ed appeared sufficient to perform the limited
extent of function  which the state or exertions
of the patient required.  Cases have even been
recorded in which individuals  have performed
voluntary movements  of the lower extremities
almost up to the time  of death, and yet, on ex-
amining  the chord, it  has been found entirely
destroyed.   Such statements should, however,
 be  received with distrust;  for, although the
 presence of sensibility in the lower limbs may
 be explained in these circumstances (see y 181,
 etseq), the transmission of volition, so as to act
 upon the extremities, cannot be accounted for.
 It is much more probable that the lesions ob-
 served had taken place chiefly after death, and
 had only commenced shortly before it; for the
 spinal medulla  when  inflamed, and even in
 health, often undergoes rapid changes after dis-
 solution.   We know, also, that when the spinal
 chord  is inflamed, or  is undergoing  softening,
 involuntary, spastic, and automatic movements
 are produced  in the muscles and extremities,
 that may be mistaken for voluntary motion, and
 it will hereafter be shown that, even when ex-
 tensively diseased and incapable of transmitting
 the  usual  acts  of volition, various  reflected
 movements of sympathy may be made by the
 paralyzed  limbs.  Several cases have been re-
 corded, where the spinal chord has  been said
 to have been softened throughout, disorganized,
 quite diffluent, or even entirely divided, and yet
 sensibility, and  even  voluntary  motion, have
 been preserved  or but very slightly impaired.
 The case  of Dessault, that recorded by M.
 Rullier, and others, are of this kind ;  but they
 are related with insufficient precision for im-
 plicit confidence, and they may, moreover, be
 explained  as just stated, and thus furnish no
 basis of argument.
  173. (c)  The physical conditions of the brain
 and spinal chord ought to be taken into consid-
 eration in  estimating the influence of lesions
 of these parts of the nervous  system, or of their
 envelopes, in producing paralysis.  These con-
 ditions are, 1st. The bony and unyielding cases
 enclosing them ; 2d.  The membranes interpo-
 sing between them and these cases ; and, 3d,
 The fluid interposed between the membranes,
 especially between the arachnoid and pia mater.
  174. a.  The unyielding cases enclosing the cer-
 ebro-spinal  axis give rise to  several  accidents
 and changes consequent upon external injury,
 notwithstanding the  influence of the mem-
 branes, of the  processes of the dura mater, and
 of the  fluid interposed between the membranes
 in preventing them.   The pressure, laceration,
 &c, caused by fractures, depressions, &c, ot
 portions  of these cases;  the  concussions,
 counter-strokes, shocks, and succussions pro-
 duced by falls  on the back, shoulders, feet, and
 extremities ;  the direct pressure following the
 extravasation of blood, or of serum, the devel-
 opment of tumours, or venous congestion and
 interrrupted return of blood ;  the counter-press-
 ure  consequent upon  these  changes, and ex-
erted chiefly on parts distant from, or opposite
to, the  seat of lesion or effusion ; and the shock
sustained by the vitality and  nervous power of
the  frame, upon severe injury of the nervous
centres, should all be taken into account when
we  attempt to explain resulting phenomena;
 inasmuch  as they complicate the effects, and
render their causes or sources more obscure
and doubtful.
  175  /?.  The physical influence of the membranes
 in preserving the nervous masses they enclose
from injury and disease is obvious.  They sup-
port, secure, and protect their contents;  while
they interrupt or prevent the  extension of inju-
 ry or disease  from the external cases to the
contained  vital parts.   Still,  when  they are 
38                             PARALYSIS—Pathology.
themselves the seat of disease, particularly of
tumours or of inflammation, the pressure or ir-
ritation, or the extension of the disease and its
more remote consequences, affect more or less
the nervous centres and interrupt or disorder
their functions, although the interposed fluid
tends to prevent or to lessen these effects.
  176  y.  The cerebro-spinal fluid interposed be-
tween the arachnoid and pia mater is not mere-
ly requisite to the healthy discharge of the func-
tions of the brain and spinal chord, as shown
by Cotugno, Magendie,  and Todd, but is also
most serviceable  in preventing the extension
of injury  and disease from the bones and mem-
branes enclosing these organs.   The  motions
alone of  the spine would be productive of se-
rious consequences, if this fluid, which is more
copiously interposed in this part of the nervous
system, did not prevent them from materially
affecting  the chord itself, and the roots of the
nerves which it transmits.  When we consid-
er the effects of this fluid upon the functions of
the cerebro-spinal axis,  it is impossible not to
infer that the quantity of it will vary with the
states of the nervous masses and of vascular
determination to, or congestion of, them and
their membranous envelopes.  It may reason-
ably be concluded that, when  these structures
and the blood supplying  them do not sufficient-
ly fill the unyielding cases of the  cranium and
spine, the fluid interposed between the arach-
noid and  pia  mater will  supply the defect, and
prevent the existence of any vacuum, and that,
on the other hand, when the  states of these
centres and of the circulation in them are such
as give rise to much fulness, the quantity of this
fluid will be diminished.  Anaemia will thus be
attended  by an increase of the cerebro-spinal
fluid, and vascular turgescence by a diminution
of it, the included masses being thereby pre-
served from much diminution of pressure in the
one case, and from much increase of it  in the
other.  Thus, also, in cases of atrophy, partial
or general,  of the brain or spinal chord, the
quantity  of this fluid is increased, showing the
importance of it to the functions of these parts,
while in  cases of hypertrophy it is diminished
or almost wanting.
  177. It is obvious that in health the presence
of a considerable portion of the cerebro-spinal
fluid is always necessary to protect the nervous
centres with which it is in immediate contact.
It is very justly remarked by Dr. R. B  Todd,
that by the interposition of a liquid medium be-
tween  the nervous mass and the wall of the
cavity in  which it is placed, provision is made
against a too ready conduction of vibrations from
the one to the other.  Were these centres sur-
rounded by one kind of material only, the slight-
est vibrations or shocks would be continually
felt; but when different materials on  different
planes are used, the surest means are  provided
to favour the dispersion of such vibrations. The
nervous mass floats in this fluid, being maintain-
ed i/i equilibria in it by its uniform pressure on
all sides, and the spinal chord is  farther secured
by an additional mechanism, preventing its lat-
eral displacement.  The abundance of this fluid
at the  base of the brain  and medulla oblongata
protects  these parts, the nerves, and vessels,
from unequal or excessive pressure and coun-
ter pressure during disease, or from accidents ;
while a diminution of it favours or even indu-
ces most serious consequences, as shown by
the experiments of M Magendie.
  178.  From what I have now adduced it may
be inferred  that the effects often imputed to
the abundance of this fluid, particularly in the
spinal canal, by several  pathologists, when de-
tailing the morbid appearances after death from
diseases of the nervous  system,  have been im-
puted to a wrong source ; that the serous effu-
sion in these cases, as I have elsewhere argu-
ed, is neither the cause of pressure upon, nor
of induration of, the nervous centres, nor the
source of the  palsy sometimes  observed in
these cases ;  but that  it is  a result of those
changes of the nervous structure and of the lo-
cal circulation with which it is  found associa-
ted, in connexion with, or  aided  hy, the un-
yielding state of the surrounding parts.
  179.  (d) Of the Influence of the different Col-
umns of the Spinal Medulla and Roots of the Spi-
nal Nerves upon the Sensitive and Motor Powers.
—Since the  researches  of Sir C. Bell and M.
Magendie on this subject, it has  generally been
supposed that, while the anterolateral columns
of the chord convey the motor power, the pos-
terior transmit sensations.  Several pathologi-
cal facts, independently of the experiments of
some physiologists, have, however, made it ap-
pear doubtful whether or not the power of mo-
tion and  sensation are severally conveyed
through these channels only, and in the pre-
cise manner just assigned.   There can  be no
doubt,  however,  that volition  is  transmitted
along the anterior columns  of  the chord, the
anterior roots of the  nerves and the corre-
sponding nervous fibrils, to the muscles which
are acted  upon ;  and that sensation generally
is conveyed in an opposite direction, namely,
from the surface of the  body along the sensory
nervous fibrils, the posterior roots of the nerves,
and the posterior columns of the chord, to the
brain.   But, although   it seems satisfactorily
proved that  the acts of volition cannot be fully
and precisely performed unless the channels by
which volition is transmitted continue sound, or
not materially injured, together with the corre-
sponding  portions of the fibrous structure of
the  brain, still it is very doubtful whether or
not  the posterior columns of the chord are as
exclusively devoted to the conveyance of sensa-
tion as the anterior are  to the transmission of
volition.  Indeed, the cases  recorded by vari-
ous writers, and especially those  by Stanley,
Webster, and others, prove  either that the le-
sions observed in the posterior columns of the
chord have  taken place at the  moment of, or
immediately after,  dissolution,  or that  sensa-
tion may  be transmitted through  other chan-
nels besides these columns, or even independ-
ently of the spinal chord itself.  That the for-
mer of these alternatives cannot be the cause,
at least to  any considerable extent, is shown
by the history of the cases and the nature of
the changes which have been  observed.  It
should, however, be admitted that, where soft-
ening  of the chord  is observed greater doubt
may be entertained; for this change, when it
has commenced before  death, particularly as a
consequence of inflammation,  will often pro-
ceed and extend very  rapidly immediately af-
terward, so as to be both complete and, exten-
sive at the time of inspection.  Still, conceding
all that may be inferred  from  this circumstance, 
PARALYSIS—Pathology.
39
pathology furnishes sufficient proofs that sensa-
tions may be  conveyed to the  brain by other
channels in addition to the spinal chord, espe-
cially when  the alterations in the  chord, ren-
dering it incapable of discharging this function,
take place slowly  or gradually.
   180.  Experimental  proofs of the existence
of these other channels, and evidence respect-
ing them, cannot  be furnished  with the force
of demonstration, as, however  conclusive ex-
periments performed  on the  higher  animals
with the view of furnishing such evidence may
appear in the eyes  of the experimenter, they
will admit of other, and  often  very different,
conclusions, and  the  phenomena observed  in
the  lower  animals,  particularly  those  which
cannot audibly express their feelings, maybe
ascribed to other causes, or differently explain-
ed.  We can, therefore, in the  present state
of our knowledge, only infer from  the history
of diseases  implicating the  spinal  chord,  and
from what we  know of  various inconclusive
and not always truly or correctly observed ex-
periments, that changes produced  in  parts  or
surfaces of the  body may become  objects of
consciousness,  in  certain  circumstances   at
least,  without the  intervention of the  spinal
medulla ; but  as this  cannot take place unless
the  sensation  be transmitted  by  a different
channel, it remains  to inquire what that chan-
nel  is, or whether or not various parts of the
nervous system may,  in certain circumstances,
or to a certain extent, perforin  this function.
   181. When we recollect that communicating
branches run between the ganglionated or pos-
terior roots of the  nerves and  the  great sym-
pathetic  on eacfc side ;  that ganglial nerves
may be traced in  their course from  the sympa-
thetic into the spinal  ganglia and chord on the
one hand, and from the latter into  the sympa-
thetic and ganglia on  the other, we cannot but
infer,  not only that sensation may be transmit-
ted, or, more correctly, that impressions on the
surface may be conveyed to the brain, so as to
excite consciousness/by a different route than
that of the  spinal chord, especially under cir-
cumstances of gradual change in   the  chord,
rendering it ultimately  incapable  of dischar-
ging this function,  but that this other route is
through  the sympathetic nerves and their com-
munications with the posterior  roots of the
nerves and spinal medulla.*
h  * {The following remarkable case would seem to prove
that sensibility is entirely owing to the integrity of the spi-
nal chord;  anil that, contrary to the opinion of our author,
the intervention of the medulla spinalis is necessary to the
transmission of sensations from parts below the seat of in-

  By an accidental fall, Mr. I. S. S. pierced  the spinal
marrow by  a chisel one inch in width, which  passed in to
the depth of five inches in that space opposite the spinous
process of the lower dorsal vertebra on the left side.   The
wound, at its superior extremity, was half an inch from the
spinous process, and one inch at its inferior  extremity ; so
that a line drawn parallel to the spinous processes of the
vertebra;, and three fourths of an inch to the left, would
have intersected it  in the middle. The direction of the
instrument was upward, at an angle from  the surface of
twenty to twenty-five degrees, and to the right of about
twelve degrees, penetrating the spinal column, and un-
doubtedly entirely dividing the chord.  The  immediate
consequence was total insensibility below the wound, with
cumplete pa™l>«'S "f the lower extremities, bladder, and
rectum.  The  shock that  the system  received produced
great prostration for some forty hours, when reaction  took
place, and  was  followed by fever for ten or twelve days.
The urine was drawn off by a catheter for about one week
»fier Ihe accident, when the bladder began to resume its
  182. The indirect character of this channel
may appear an argument to some against the
accuracy of this inference ; but we know that,
in cases of obstruction to the usual channels of
circulation in the vascular system, very circu-
itous courses are developed in order to preserve
an organ or limb, and the nervous system pre-
sents many points of analogy with that system,
especially a transmission of sensation from the
periphery of the body, and from the several or-
gans and structures to the more central ner-
vous masses, and a similar circulation or return
of nervous agency in  the form of motion and
determinate muscular contraction.   The anal-
ogy  may  be  farther pursued, but the several
points are so  obvious  that  they require not
even enumeration at this place.  Moreover, it
should be considered that, in respect of sensa-
tions excited in any of the abdominal or other
viscera,  it is  very doubtful whether  the spinal
chord is the channel by  which the impressions
or changes in  the  viscera are  transmitted to
the  brain, or whether the sympathetic  nerves
and  communicating branches between the gan-
glia  are  the courses which are  pursued.  In-
deed, there appears little doubt of the latter be-
ing the actual channel of conveyance ;  for im-
pressions on  or changes in the  viscera, espe-
cially those of digestion and  assimilation, are
as  vividly and as  rapidly  conveyed to, and
made objects of consciousness in, the brain, in
cases of injury, or even of complete division of
the chord, as in sound health.
   183. The above considerations may serve as
reasons wherefore sensation remains unimpair-

functions.   For nearly the  same period  the bowels had to
be relieved by eneumta.  Returning sensibility was experi-
enced in the skin about the fifth day, and an imperfect use ot
the limbs about the fifteenth.  The patient first commenced
locomotion on his hands and knees, then by pushing a chair
round, and afterward by means of crutches; but sensibility
in the skin and power of motion in the inferior extremities
returned very slowly, so much so that, four years and sev-
en months after  the accident, he burned his knee very se-
verely, without feeling  any pain or being conscious of suf-
fering, by sitting too near a hot fire.  Recovery eventually
took  place, without any curvature of the spine or spinal
weakness, the patient being able to get into and out of a
carriage and mount a horse without any assistance.
  The case is an important one, as it goes to establish the
fact  that  the spinal marrow is the  sole channel for the
transmission of sensations, and that  it may unite, and its
functions be restored, after complete division.—(JVeio York
Journ. of Med., vol. v., p. 166.)
  Two cases of fracture and dislocation of the spine, which
have fallen under our  care, were also attended with total
loss of sensation and motion below the scat of the  injury.
  Dr. II. A. Potter relates  (N. Y. Journ. Med.  and Col-
lat. Sci., vol. iv., p. 174) the case of Mr. E-, who was struck
by the limb of a falling tree on the back, by which he was
rendered insensible, with stertorous breathing,  &c.  He
partially rallied from this state in about forty-eight hours,
when it was found that there was no sensation nor motion
below the upper part of the thorax.  " The patient could
not tell when he was pricked nor handled, unless  moved so
as to stir his neck; in that case the sensation was very
irreat." " He continued for more than three  months una-
ble to move a finger or  toe, or to tell, by feeling,  when he
was handled."  At the end of this time, Dr. Potter, by a
surgical operation, removed parts of the four inferior cervi-
cal and the two superior dorsal vertebrae.  Four of the ver-
tebra; were fractured so as to produce compression of the
spinal chord. Ossification  of the broken fragments had ta-
ken place.   " Before the operation coded, the patient said
he felt as though we were  pricking him all over.  Sensa-
tion  appeared to return almost instantaneously, and for the
first  tune that he was conscious'of it, below  the  compres-
sion, after the receipt of the  injury."  In five hours after-
ward sensation was nearly perfect.  The patient lived eigh-
teen days  after the operation, and died of disease of th«
lungs {loc. cit.).  The opinion of our author, however, it
doubtless correct, so far as it relates to those organs that
are supplied with nervous  influence by the ganglionic sys-
tem of nerves.] 
40
PARALYSIS—Pathology.
 ed, or but little affected, in very many cases
 where the chord is diseased or injured so as to
 be incapable of transmitting the impulses of vo-
 lition, particularly when the lesion is high in the
 chord, and when it has advanced slowly or grad-
 ually.  They may also account for the rare oc-
 currence  of  entire loss  of sensation in  any
 form of palsy of motion.
   184. (e)  Congestion of the venous sinuses seated
 between the theca of the chord and the bodies of the
 vertebra has been already assigned as a patho-
 logical cause of palsy, or one of the most im-
 portant changes upon which the paraplegic
 states of palsy depend.  It seldom is found un-
 associated or alone after death and in the most
 complete states of the disease, as it generally
 superinduces more or less extensive changes
 in the chord and its membranes before dissolu-
 tion takes  place.   Several of the more remote
 causes of  palsy act by producing, in the  first
 place, congestion of these sinuses, which were
 even imperfectly described by anatomists until
 M. Breschet directed more particular attention
 to their structure  and connexions.   But the
 pathological relations of congestion and of ob-
 structions  by fibrinous coagula or concretions
 in these sinuses have been entirely overlooked.
  185. It  will soon become  obvious to those
 who make the early phenomena of disease ob-
 jects of observation and  study, that  whatever
 depresses organic  nervous power will soon be
 followed by venous  congestion ; and when  this
 depression—whether primary or consecutive of
 nervous or vascular excitement—has been  pre-
 ceded or is attended  by circumstances produ-
 cing increased determination to, or fullness of
 blood in, the capillaries of the chord or its mem-
 branes, this consecutive congestion of the spi-
 nal sinuses is the more prone to occur.  In its
 primary or uncomplicated states, it seldom  pro-
 duces more serious effects than pain, stiffness,
 or weakness of  the back, loins, and lower ex-
 tremities,  sometimes amounting to incomplete
 palsy of motion  of  the latter; often with pain
 and  constriction around  the abdomen ;  and
when the weakness or imperfect power of mo-
tion  is associated with pain, this  state is gen-
erally  confounded   with  rheumatism  or with
neuralgia, if the pain is severe and follows the
course of a nerve, or with an attack of gout,
when it occurs in the  gouty diathesis.
  186. Congestion of  these sinuses occasions,
first, retarded circulation in  the  chord and its
membranes; subsequently, an increased serous
secretion or effusion between the membranes
Unless  the congestion be very great, it  can
hardly be expected that it should act injurious-
ly on the chord by pressure, or counter-pressure
of it against the posterior parietes of the spinal
canal.   Still, one injurious effect may be  pro-
duced in this way, particularly when the con-
gestion has superinduced distention of the  cap-
illaries of both the  chord and  the membranes,
with  increased  serous effusion between  the
latter.
  187. In these more  extreme cases, when ul-
terior changes have, taken place, it is not  un-
likely that the roots of the nerves will also suffer
from unaccustomed pressure, and in  those ca-
ses the posterior or gangliated  roots are the
more likely to experience it, and paralysis of
sensation  will be present in  a greater or  less
degree, and even be the  more complete, inas-
 much  as  the lesion implicates those parts, of
 me roots of the nerves  which  communicate
 with the  sympathetic, as insisted upon above
 (6 181).   In cases, also, of canes and  angular
 curvature of the spine, where not only conges-
 tion of the vertebral sinuses, but also pressure
 and counter-pressure of both the chord and the
 roots of the nerves, and even of the  nerves
 themselves, as  they pass through  the spinal
 foramina, are apt to take place, palsy of sensa-
 tion is then present, but only in degree  propor-
 tionate to the  extent of pressure on the roots
 of the nerves, and only in  those cases where
 the nerves or their roots, especially the poste-
 rior, are implicated.
   188. Congestion of the spinal  sinuses, with
 more or less of the  consequences  now men-
 tioned, is a  frequent attendant upon  fevers,
 particularly the more adynamic and congestive
 forms  of  fever, occasioning not  merely pains
 and weakness of the back  and limbs, and in-
 complete palsy of motion of the lower extrem-
 ities, but also more or less of the affection of
 the urinary organs already mentioned  ($ 57).
 Many of the cases described as spinal irritation,
 of hysterical neuralgia,  of uterine  irritation,
 &c, actually are instances of congestion of the
 spinal  sinuses, occasioning  remote  or sympa-
 thetic  phenomena in addition to those which
 are more  strictly local.  These are often re-
 moved or partially relieved for a time by the
 natural recurrence of the catamenia ; but when
 more extensive or severe, or when associated
 with suppression of this discharge, they some-
 times lapse into  paraplegia or partial palsy, es-
 pecially when neglected or injudiciously treat-
 ed,  owing to an  increase of^.he congestion or
 of its consequences.
  189.  (/) Various sympathetic phenomena occur
in connexion with paralysis, especially with the
 paraplegic states of the disease, that require
 particular  notice. Some of these admit of differ-
 ent explanations, and thus have been differently
 accounted for, both by former and by contem-
 porary  writers.  Of these, the reflex motions,
 which sometimes are observed upon irritating
 the surface of a paralyzed limb, have attracted
 most attention, and have directed  the research-
es of physiologists more particularly than here-
tofore to the structure and functions of the spi-
nal chord.  These researches are  fully noticed
 in the article on the pathology of this part of
the  nervous centres, with my opinions respect-
ing  them ; and I therefore need no farther ad-
vert to them at this place than to remark that
the  phenomena which Dr. M. Hall has assign-
ed to a reflex function of the spinal chord were
fully recognized  by  Whytt,  but not  explained
by him as occurring independently  of  sensa-
tion.  He, however, believed  that the  power
of feeling was not limited to the brain, but was
extended to the spinal chord.  Prochaska af-
terward more correctly appreciated the  true
source  and relations of these phenomena; and
 in the articles Cholera, Chorea, Convulsions,
 &o, in this work, the characteristic symptoms
 of these maladies were explained, and ascribed
 to reflex actions excited in the voluntary mus-
 cles by irritations transmitted to  the roots of
 the spinal nerves  and  spinal chord.   Subse-
 quently to the  publication of these articles, Dr.
 M. Hall's researches appeared.  He referred
 these phenomena to a special organization of 
PARALYSIS—Pathology.
41
 the chord; and his opinion received the  sup-
 port of Mr. Grainger, Mr. Newport, and  oth-
 ers, although opposed by some eminent anato-
 mists.   The structure of the nervous  system
 in  the class articulata is the chief circumstance
 that can be adduced in favour of the existence
 of a spinal organization for reflex  actions  in
 the higher  animals.  But reflex actions—phe-
 nomena which I denominated, many years ago
 (1824), " reflex sympathies"—are performed not
 only by the spinal chord, but also by the brain,
 and by the  organic or ganglial nervous system.
   190.  a. As respects the brain, no sooner are
 the impressions on  the senses made objects  of
 sensation  or consciousness than  they are re-
 flected upon, or treasured in the memory,  and,
 either instantly or  at some future period, ex-
 cite to  action.   The  manifestations  of life
 through the medium of an encephalon  are the
 phenomena to which the term mental has been
 usually  applied which  consist chiefly  of im-
 pressions  on the senses, rendered  objects  of
 consciousness and  of reflection by this organ,
 and which  subsequently are recombined, com-
 pared, &c, and  thus often become causes  of
 volition.   Many of the impressions on the  sen-
 ses are  so  strong as instantly to  impel to ac-
 tion, without any intermediate state of reflec-
 tion ;  or, in other words, the actions  or voli-
 tions are so instantaneously consequent upon
 the impressions  and impulses, that the inter-
 mediate reflections  are not made  objects  of
 consciousness, or are not remembered.  This
 is especially the case when the impressions on
 the senses  excite the  passions, and when the
 individual  has  been habituated  to  act upon
 them without allowing, or being capable of, in-
 termediate  reflection.   These  reflex actions,
 even when not directly proceeding from  im-
 pressions  on, or  reports  of, the  senses,  are
 nevertheless  the  results of such impressions
 or  reports,  received, remembered, or reflected
 upon at some antecedent period.
   191. (3. The reflected actions  of  the spinal
 chord may  occur, as Dr. M. Hall has  shown,
 independently of sensation, although sensation
 often attends, or is  excited by the impressions
 which occasion them.   They may even be so
 morbidly strong as  not to  be controlled by the
 will, when  the individual is most  conscious  of
 their presence, as in tetanus.   The reflected
 actions of  the  ganglionic  nervous system  are
 only objects of consciousness  when they are
 excited by powerful stimulants or irritants.*

  *[Dr. B. Dowler, of New-Orleans, has recently attempt-
 ed to disprove  the theory of the reflex function by a series of
 ingenious experiments and reasonings, which may be found
 in the 6th vol. of the New- York Jour, of Med., p. 305. Theso
 experiments fully establish the post-mortem contractility of
 the muscles, and that too, in many cases, for many hours after
 death. Dr. D.  denies that experiments on the frog, and other
 inferior animals, are at all conclusive in establishing the com-
 plicated physiology of man : and he shows very conclusive-
 ly that post-mortem contractility in the human cadaver has
 no connexion with, or dependance on, the  spinal  marrow.
 The following  are selected from a large number of cases,  il-
 lustrating the general phenomena of post-mortem contrac-
 tility: " R. C, aged 25.  In  two hours after death, when
 the  arm was extended to an angle of 45° from the trunk,
 and was struck with the hand, or side of a hatchet, it was
 carried to the epigastrium ; but when the arm was extend-
 ed upon the floor, so as to form a right angle with the body,
 he slapped himself upon the mouth  and nose. The  con-
 tractility began to decline in the third hour, and by the
 fourth hour all motions of the limbs ceased, although the
 pectoral  muscles assumed the ridgy or lumpy form when
percussed-  An hour after death the thigh was moderately
contractile.  The leg hung down near the floor; its  flex- |
   192. Thus there may be said to be three class-
 es of reflected actions, viz.: 1st.  That class of
 actions which may be denominated psychical,
 or  cerebral, or  which results  either  directly
 from impressions made upon the senses, or in-
 directly or reflectively from these impressions.
 2d. That class which may be  termed animal, or
 spinal, which  proceeds from impressions or ir-
 ritations  transmitted to the spinal chord or
 roots  of the  spinal nerves, and is  reflected
 thence by the motor nerves to  voluntary mus-
 cles,  and which  may occur  independently of
 the brain.   3d.  That class which is organic or
 vital, which takes place  in parts supplied only
 or chiefly by the ganglial system, and which is
 independent of both the brain and spinal chord.
   193. y. There are several circumstances con-
 nected  with the voluntary actions as  involving
 consciousness, to which  farther  allusions may
 be  made.   The actions which occur during
 sleep, when the  mind is  incapable  of perceiv-
 ing impressions  made on the  senses, unless
 they  be  inordinately intense,  to  which  the
 terms somnambulism, sleep-waking, sleep-walk-
 ing, &c , have been applied, are merely the  re-
 sult of suggestions arising out  of previous or
 recollected  impressions and reflections ;  these
 suggestions and reflections giving rise to voli-
 tions which excite the voluntary organs to ac-
 tion without awakening the senses, or permit-
 ting the perception  of external  objects in a
 distinct manner.   Somnambulists may perform
 any of the common occupations of life, or may
 even  execute difficult intellectual  tasks with
 much ability.  I have seen them compose, sing,
 play on musical instruments,  &c, according to
 their respective tastes or occupations, and be
 still unconscious  of the various surrounding
 objects of sense.   Consciousness, however, of
 the act which the somnambulist is performing,
 and of objects connected with it, undoubtedly
 exists for the moment,  to the  abstraction  of
 every other sensation.  In this  state, the sug-
 gestions, mental operations, and the resulting
 actions are often perfectly performed, as  re-
 spects the  ability of the individual ; but,  as
 they commence  and  are  continued during a
 state of the brain unfavourable  to sensation
 and perception,  they are  faintly, or not at  all
 recollected.    The concentration, also, of  the
 mind on  the  subject engaging it, still  more
 completely prevents  other objects  from being
 perceived.   The somnambulist, in fact, acts his
 dream, and often in such  a manner as to ena-
 ble  him to shun  the dangers  attending the ac-
 tion as completely as if he saw them distinctly,
 and thus avoided them.   And yet there is rea-
 son for believing that they  are  not  seen  by
 him, but avoided from the circumstance of his
 having  followed  an  accustomed  and well-re-
 membered track, each successive part of which
is suggested to  him as he proceeds, just as a
person  passes through  a room in the  dark,
avoiding all impediments in his way from  his
recollection  of their positions.
  194. 6.  Many  of the above  remarks apply to
ors, after being struck, drew up the heel against the but-
tock.   Heat, for seven hours, from 101O to  102°.   Five
hours nfter death, contractility ceased, and rigidity prevail-
ed."—Loc. cit., p. 319.
  Dr. D. also shows, from a number of well-conducted ex-
periments, that the muscles possess the same power of con-
tractility when entirely separated from the trunk, as in the
arm and leg.] 
42                                   PARALYSIS—Pathology.
 dreaming, and in part also to the motions of the
 body in sleep.   Dreaming may, or may not, be
 attended by movements of the body ; but these
 are generally imperfect or partial, if observed
 at all, and have  reference to the  idea passing
 in the mind.  In this case the mental sugges-
 tion either fails of exciting precise  and corre-
 sponding  actions and expressions,  or excites
 them  so  partially  or  imperfectly  as  not to
 amount  to somnambulism.   The  chief differ-
 ence between dreaming and  somnambulism is,
 that the individual  during a state of sleep, or
 while the  senses are closed  against perception
 —or,  rather, while   the brain is  incapable of
 perceiving the impressions made upon the  sen-
 ses in their usual states of intensity—not  only
 dreams,  but also actually executes  what  he
 dreams,  without  awaking from the state of
 which I  have just defined sleep to consist.
   195.  But the  motions of the  body during
 sleep are often independent  of dreaming,  or of
 those  sensations  and  suggestions which  pass
 through  the mind during  sleep,  and which are
 faintly  remembered  afterward  ;  for  obscure
 sensations may be excited for the moment by
 external  objects  or physical  causes  during
 sleep, although they are  not at all recollected.
 A person turns or moves while asleep, owing
 to a feeling  of uneasiness, which, although not
 remembered by him when awakened, has  nev-
 ertheless  been  produced so as to  cause  the
 change of position.   These  movements  have
 recently been adduced as instances of reflex
 actions occurring independently of  sensation ;
 but that momentary sensation  has not  been
 excited  is  not established.   Even  in experi-
 ments showing the  occurrence of motion  after
the removal of the  cerebral  hemispheres, the
 non-existence of sensation  is not demonstra-
 ted, inasmuch as sensation has not been proved
to  be limited to  these  hemispheres, nor  even
 to  exist  in them; they have to  perform other
 functions, of which  the sentient  principle, pre-
siding, most probably, in some other part, as in
 the medulla oblongata or in  its  vicinity, takes
due cognizance.*
  * The following observations on the Forms  and Modes of
 Sensibility were published in 1824, among my Physiological
 Notes, already referred  to in various parts  of this  work.
 They may  serve to elucidate many of the phenomena which
occur in several states of paralysis.
  The  phenomena considered by several authors as evin-
cing the existence of sensibility are referrible only to con-
 tractility, with which all classes of animals  are endowed,
and which, in  the lowest orders and in some vegetables,
 assume the appearance of sensibility.  In these latter, how-
ever, we have no reason to infer the presence of sensibility
 merely because they contract  under  the influence of a stim-
 ulus; for the contraction may take place without the exist-
 ence of this property, from the effect produced by the stim-
 ulus upon the organization of the contracting part. Indeed,
 we cannot suppose that sensibility is present where the parts
 generally observed to be  instrumental in its production are
not found  to exist.  A sensation cannot  be supposed to be
 produced where there is  neither an organization suitable to
 receive, nor a channel to  convey, nor an  organ to perceive,
 an  impression.  We should, therefore, limit this term to
 those phenomena which the mind perceives or is conscious
 of when in a state capable of exciting perception or con-
 sciousness.
  With this limitation, sensibility may be called the  func-
 tion of sensation, and a  property peculiar to the animal
 kingdom.  The sensations are derived through the medium
 of the senses, and of the  nerves wnich communicate with
 the encephalic centre.  On this centre the existence of sen-
 sibility chiefly depends, the ramification of its nerves, or the
 subordinate portions of it, being also parts of  the apparatus
 requisite, but not giving rise to this property.  As we as-
 cend in the scale of creation, and as the  senses and organs
 of volition present a  more  intimate connexion with this
 porvous mass —the  oiicephalon—  to sensibility becomei
   196. t. Catalepsy  is  a  state  altogether  op-
posed to the foregoing—isjhe most complete

more"perfect, until in man it reaches an extent greatly sur-
passing that of other animals.
  In man, and perhaps in the  more perfect animals, the
modes of sensibility seem to vary.  These modes may, how-
ever, be divided into two conditions, as they are more or
less active, namely, conscious or active sensibility, and ta-
conscious or passive sensibility: the former relates to thost
impressions, either from within or from without, which givt
rise to perceptions  or ideas ; the  latter to those that are
frequently produced upon  the senses  and  upon the ramifi.
cations of the nerves, and, owing either to habit or the
want  of due attention to them, are  not perceived by the
mind.  In this  latter mode of sensibility, the organ receiv.
ing, and  the channel conveying the impression, perform
their offices; but the  mind either is not, at the time when
the impression  is made, in a state  to receive it, or receivei
it so imperfectly, from its weakness or its transient nature,
as not to give rise to consciousness.
  This mode does not necessarily imply a difference in the
degree of sensibility, but the condition in which this prop-
erty exists, owing either to its being more excited by oth-
er impressions, or to its being exhausted at the time when
the impression is made.  This condition is one to which
the highest manifestations of sensibility as well as the low-
est may be  occasionally subject; it is, however, merely a
relative  mode of this property ; and  the relation subsists
entirely between the state  of the cerebral organ which per-
ceives, and the  force and duration of the impression made
upon the organ of sense.  Thus,  when the sensibility ii
actively occupied with a particular object, and an impres-
sion is made at the same time upon a different organ from
that through which the perception with which the mind
is engaged was conveyed, the second impression may af-
fect the senses  in an evident  manner,  and even so as to in-
fluence volition, yet we may be unconscious  of its opera-
tion, and no active perception may result from it.  If, how-
ever, the second impression be stronger or more vivid than
the first, or if, from  various other circumstances, it should
excite the cerebral functions,  active sensibility or con-
sciousness is the result.
  As sensibility, according to this view of the subject, is, in
its active state, a term merely expressive of consciousness;
and as this faculty  is evidently dependant upon the cere-
bro-spinal nervous system, especially on that more complex
part of it which holds relation with surrounding objects;
and, also, as we have  no reason  to attribute the possession
of this part of the nervous system to the very lowest or-
ders of animals, particularly to the class Radiata, so we
must conclude  that, although sensibility  is a property of
animal life, its  higher grades are not possessed by all ani-
mals.  It may be also stated, that active sensibility,  being
thus considered as expressive of, or comprising conscious-
ness of sensations, and of the intellectual and moral open-
tions,  varies in its extent  throughout the animal kingdom
according as those manifestations are  more or less numer-
ous and perfect.  How far the passive mode of sensibility,
or that unattended by consciousness, may  be a property of
the lowest orders of animals, is difficult to say.  We may,
however, infer, that as this latter condition of sensibility
may take place without an active exertion of this property
in the highest animals, so it may result from a less perfect
endowment of  sensibility in  the lower; and as this  mode
may require a  less  complex  apparatus for its production,
inasmuch as its relations are more simple, so it may be
possessed by animals whose  organization and manifesta-
tions do not permit us to conclude that they are capable of
evincing sensibility in its  more perfect and active  condi-
tions.  The relations which this form or mode of sensibility
holds with the numerous instincts of animals ntust be ev-
ident to all who consider the  subject.  The relations, how-
ever, which evidently subsist between that form of sensi-
bility cailed organic sensibility by BicHAT, and the animal
instincts, are much more  numerous, more intimate, and
more apparent.
  Organic sensibility refers to those sensations which are
produced in different degrees of intensity, owing to the ex-
istence of certain conditions of those viscera which are im-
mediately subservient to the preservatian of the individual
and the species; to nutrition and reproduction, and which
are not immediately subjected to the  influence of volition.
The conditions of the  parts exciting organic sensibility are
very various, and are  the result of irritations arising from
the presence of a stimulus, of unnatural actions supervening
in particular systems  or textures, and of the  deficiency of
that stimulus or influence to which particular viscera have
been accustomed.   Many  of  the changes preceding thi«
class of sensations seem to interest, in  the first instance,
the ganglial class of nerves ;  hut, owing to the intimate re-
lation subsisting be»ween this part of the nervous svstem
and the voluntary or sentient part, the  impression or change
is propagated to the brain.  This is the only  essential <l)f-
ference which  exists between this and the other forms ol 
PARALYSIS—Pathology.
43
and general  state of palsy of motion that can
exist without terminating  existence ; but  it
rarely continues longer  than some  hours, al-
though it may recur after short intervals, last-
ing on some  occasions for many hours.  In
this  state, the muscles of voluntary motion—
even those of the face and the eyelids—will not
contract upon  irritating them, nor will they be
influenced by the will  of the  patient, which  is
generally attempted to be exerted when con-
sciousness  is  not altogether abolished.  The
sensibility, indeed, is generally not lost during
the attack, although it  is more or less obscured
in most cases.  In a  patient who is liable to
attacks of this  complaint, and whom I  have
often seen during their  continuance, the eye-
lids  and  all the voluntary muscles retain the
positions in  which they are placed, but not the
least appearance of contraction is manifested
upon the  most energetic irritation.  Still, this
lady feels, sees, and hears during the contin-
uance of the seizure.   She even wills the ac-
tion of the muscles, but volition  is not trans-
mitted  to them.  The voluntary muscles of
respiration  are generally the  first to act  upon
the  return  of  voluntary power.   In  another
case which I had an  opportunity of observing
during  the  attack, the sensibility was some-
what more diminished than in  the foregoing ;
but I have not met with an instance of its en-
tire abolition.   The sphincters  are always un-
affected in this disease. The respiratory move-
ments are slight, and perceived with difficulty ;
the  impulse  of the heart  is  weak, and the
pulsations generally accelerated and  soft, but
sometimes slow or irregular.
   197. (g) Mechanism  and Functions of the Spi-
nal Chord.—There are other phenomena besides
those already mentioned, which occur in para-
lyzed limbs,  and which deserve a  brief notice
at this place.    Dr. M.  Hall and Dr. Budge
sensibility.  It is the brain which perceives in them all;
and although stimuli, or the  defect of stimuli, may give
rise to certain phenomena possessing the characters of the
higher manifestations of this property in the organs appro-
priated to the preservation of the organic system, independ-
ently of the scnsorium, consciousness, or the more perfect
form of sensibility, cannot form part of the results.
  Organic sensibility may also be active or passive ; it may
or it may not be attended with consciousness; and even
the unconscious mode of  it may indirectly impel to action,
or give rise to many of the manifestations or instincts which
characterize the lower animals, owing to the ganglial cen-
tres, either from their organization or connexions, or from
both, performing a greater extent of function than  usually
falls to their share.  If, therefore, the  passive form of or-
ganic sensibility may propel to action  without conscious-
ness, or the sensorial sensibility being excited in those an-
imals, we may also account, in the same manner, for many
of the instinctive functions being performed when we can-
not trace them to the influence of a cerebral organ.  Of all
the conditions of sensibility, the active organic form is the
least under the control of  the mental powers.  It also, in all
its modes of existence, more intimately interests the exist-
ence of the individual than the other forms of sensibility ;
organic sensibility involves a feeling in all its active mani-
festations instinctive of life or death.
  From this it will be readily seen how close a connexion
exists between organic sensibility and the animal instincts ;
it does not, however, belong to my plan to trace the con-
nexion in all its relations.
  Of sensibility generally we may observe that, in the hu-
man species, it is very variable, even in health ; in some
persons it is very much exalted, in others very obtuse.  It
is vivid in early life and  in  youth ; after the age of man-
hood it gradually diminishes;  as old age advances it de-
creases rapidly ;  and in persons who have attained a great-
er age it is present in the lowest grade  in which we find it
in the species.  Its morbid conditions—in respect  both of
grade and kind—form or characterize many  of the most im-
portant diseases of the human economy.
have shown that, in cases of paraplegia where
sensibility as well as motion is lost, convulsive
motions  are  produced in the paralyzed limbs
by tickling the soles of the  feet, and even on
defecation and micturition.  But it is doubtful
whether sensibility is entirely lost in these ca-
ses, the  occurrence  admitting of explanation
in the manner stated above (<J 181, et seq.), and
still more readily, if the minute anatomy of the
spinal chord, according to the  researches of
Stilling, Van Deen, and Budge, be taken into
the account.  The chord,  according to these re-
searches, consists, first, of perpendicular fibrils,
forming the white substance  of it; secondly,
of transverse fibrils,  and  of very delicate  Ion
gitudinal  fibrils, constituting the cineritious oi
gray substance of the chord, the traverse fibrils
crossing at right angles, and forming  a  net-
work with the longitudinal both of the gray and
of the white substances ;  thirdly, of corpuscles,
of an angular form, with nucleated or projecting
processes, scattered in groups through the an-
terior gray matter only, and most numerous at
the origin of the anterior roots of the nerves;
fourthly, of transverse fibres, passing directly
from the posterior  to  the  anterior gray sub-
stance of the chord.
   198. The roots of the nerves are direct pro-
longations of the gray substance.  Fibrils pass
from the gray, through the white substance,
into the  roots  of the nerves.  Dr. Stilling
traced fibrils  from  the posterior roots  to the
anterior gray  masses ; and fibrils, almost as
soon as they  enter  the  chord,  run between
bundles of  fibrils of white substance  to join
other bundles of fibrils from adjoining nerves
Others, in fasciculi, form loops with fibrils com-
ing from the next nerve;  and others appear as
continuations of the transverse  ray-like fibrils
of the posterior gray substance, while the con-
nexion of the anterior  roots with the anterior
gray substance is still more distinct.   The nu-
cleated processes, or corpuscles of this  sub-
stance, are in immediate connexion with the
primitive fibrils of the roots of the nerves.
   199. The afferent  properties of the posterior,
and  the efferent properties  of the anterior di-
visions of the chord, are  rendered more mani-
fest  by the  above results, at which the above-
mentioned anatomists have arrived.   But, ac-
cording to Dr. Stilling's  experiments, the lon-
gitudinal fibrils of the anterior white substance
do not transmit volition to the nerves, this of-
fice being performed by the longitudinal  fibres
of the anterior gray  substance.  As the trans-
verse fibrils are prolonged into the nerves, and
as we know that the  posterior nerves are ne-
cessary to sensation, so it may be inferred that
the posterior transverse fibrils are excitors of
the  posterior longitudinal fibres of the  gray
substance, and  that  a sensation, or rather the
sensative impression,  is  transmitted  by  the
posterior transverse  fibrils, and by the longitu-
dinal fibres, to the sensorium ; the same rela-
tions, mutatis mutandis, being conceded  to the
anterior gray fibres.   As centripetal impressions
pass from the sensitive nerves along the trans-
verse  and longitudinal fibres of the posterior
gray substance to the brain, so centrifugal im-
pressions may pass in a oontrary  direction, that
is, from the brain along  the longitudinal  and
transverse fibrils of the anterior gray substance
to the roots of the motor  nerves. 
44
PARALYSIS—Pathology.
  200. Such being the mechanism of ordinary
sensation and motion, according to the  recent
researches of Stilling, Van Deen, Budge, and
others, it can be no longer difficult to account
for those involuntary movements  which are
produced in a paralyzed limb when the surface
of it is irritated, pinched, or tickled, and which
have been termed by Dr. M. Hall reflex ac-
tions, depending, according to him, upon a re-
flex function of the spinal chord, which func-
tion he refers to a distinct mechanism  in the
chord.  It  has  already been contended  by the
author that no such mechanism exists, and that
these actions are sympathetic, and result from
the conformation  of this part of the nervous
system, transverse fibrils passing, as shown by
the anatomists just referred to, directly from
the posterior to the anterior gray substance, to
convey impressions  from the sensitive  fibrils,
and to excite the roots of the motor nerves.
That no  appropriate and peculiar structure ex-
ists in the chord for the purpose of performing
these sympathetic or reflex movements, be-
yond what has now been noticed, is the opin-
ion not only of the author, but also of the wri-
ters already mentioned, as well as of many oth-
ers who  have investigated the subject.
  201. Dr. M. Hall has contended that the spi-
nal chord is the source of muscular irritability,
and that this irritability is exhausted by voli-
tion.  In proof of this position, he states that
paralytic limbs are  more  readily agitated by
galvanism  and strychnine  than sound  limbs
when the  cause of palsy is in the brain, the
paralyzed muscles being in such cases more ir-
ritable than natural, while they  are less irrita-
ble  when the palsy proceeds from the state of
the chord.   The irritability is thus  considered
to be increased in the former  case, owing to
its  not being exhausted by volition, and  to be
diminished in the latter, owing to the  lesion
affecting its source.  But experience shows the
inaccuracy of this inference, for the paralyzed
muscles, in eases of cerebral paralysis, are not
more irritable than the sound muscles, but, on
the contrary, less so, as tested by Voltaic elec-
tricity ; and Dr. Pekeika has come to a similar
conclusion.  In the article Irritability,  I have
adduced  my views, as promulgated many years
ago, respecting the  source of this  property—
have stated that it proceeds from, and depends
upon, the organic or ganglial nervous system ;
and have contended that it does not arise from
the spinal chord and nerves, although it  is ren-
dered more energetic and perfect in the  volun-
tary muscles by the supply of nerves  which
they receive from the chord.   The truth is,
that the  tone, rigidity, and irritability of all par-
alyzed muscles are more or less impaired, the
less so when the lesion is in the brain and high
in the chord.  Still it cannot be doubted that
strychnine or nux vomica affect these muscles
more readily and more remarkably than the
sound  muscles.   These  facts may be explain-
ed  partly by referring to the minute structure
of the chord, and partly by the circumstance of
this substance being rapidly absorbed and act-
ing energetically on the structure of the chord
and origins of the spinal nerves.
  202. The fact that mental emotions  often
excite parts  which  are  paralyzed is  also ex-
plained by  the mechanism of the chord, and by
the circumstances so strongly insisted upon by
Bichat  but since so much  overlooked, that
itntaremotions powerfully affect the gangly
and  sympathetic  nerves,  and, through  them,
the spinal chord and the nerves  proceeding
from it, the sympathetic nerves communicating
freely with the  chord and roots  of the  spinal
nerves,  and contributing  numerous  fibrils  to
the latter to  be distributed with them to the
parts they supply.*   That volition, when con-
tinued or energetic, exhausts the irritability  of
voluntary muscles, is admitted, and hence the
sense of fatigue, lassitude, and  even of sore-
ness or pain, which often follow such exertion.
  203. (h)  The relaxation of the sphincters occa-
sionally  observed in palsy, especially in para-
plegia and general palsy, has been viewed as a
phenomenon of more general  occurrence than
it really is.   The fact is,  that the sphincters
are not so frequently relaxed, as they are im-
perfectly influenced  by the will, or are not at
all affected  by it.  They still  retain much of
their tonicity, but volition  is  not so energeti-
cally exerted on them as to counteract the ac-
tions of the  hollow viscera when these viscera
are excited by an accumulation of their respect-
ive contents, or by medicine.  The tonicity or
power of the sphincters has been attributed en-
tirely to the spinal chord, and without reference
to any influence  they may derive from the or-
ganic or  ganglial nervous system.  But al-
though they derive a share of their power, more
especially the voluntary increase of power, as
circumstances may require it, from the cerebro-
spinal  axis, their continued state of tonicity is
chiefly to be attributed to  the  organic system
of nerves.   This is shown in paraplegia and in
general palsy, in both which the sphincters very
often retain a natural condition of contraction;
but that contraction is frequently not increased
by volition so as to resist the action of the bow-
els or urinary bladder.  In  some cases of these
states  of palsy,  the  sphincters are not much
affected, especially when  the  palsy is incom-
plete, or seated high in the chord.  Pathologi-
cal evidence, indeed, clearly leads to the infer-
ences, 1st. That the power of  the sphincters is
attributable chiefly to the organic nervous sys-
tem, but that it is increased by volition exerted
through  the medium of  the spinal  nerves, es-
pecially  in  circumstances   requiring such in-
crease, as when the  disposition to the actions
of the bowels or bladder has to be resisted; and,
2d. That it is chiefly this latter influence, or
that which is exerted through the spinal chord,
that  is either lost or impaired, in cases where
the voluntary contractions  of the sphincters are
insufficient to prevent the passage of the excre-
tions when  the  patient wishes to retain them.
It  is not, therefore, to be  inferred  that where
there is insufficient  control over the evacua-
tions, the sphincters are either relaxed or ma-
 * The views published by the author in 1822, in the London
Med. Repository, and, in 1824, in his Physiological Notes-
Ac, respecting the independent and distinct constitution of
the organic or ganglial class of nerves, as to the functions and
relations of this part of the nervous system, and as to the in-
fluence exerted by this system on the vascular system on the
one hand, and on the cerebral system on the other ; in short,
the positions thus taken, from researches in various classes
of animals, that all organs and parts which are necessary
to the life of the individual animal, and to the perpetuation
of its species, nre supplied by ganglial or organic nerves in
proportion to the importance of each organ, and to the ac-
tivity of the several organic processes, have been recently
fully confirmed by the researches of  Stilling, BiddfR,
Volkmann, Wallach, Hannover, R. Lee, and others. 
                               PARALYSIS-

tenally  deficient  in power; but that they are
only insufficiently influenced by volition,  rela-
tively to the power which overcomes their nat-
ural tonicity.
  204. VII. Treatment op Palsy.—There is
no  disease which more requires  an intimate
study of its nature and relations  before a de-
termination should be formed  as  to its treat-
ment than the one now under consideration.
The seat,  grade,  pathological  condition,  and
constitutional peculiarities of  paralytic mala-
dies are so diversified, that each case should be
made a separate study, and such means only as
are appropriate to existing pathological condi-
tions ought to be employed.  I shall endeavour,
1st. To point out the plans of treatment which
are most serviceable  in  the principal  forms,
states, and complications of palsy; and, 2d.
To appreciate  the character and  value of the
numerous medicines and methods of cure which
have  been recommended  for this  disease, and
their  applicability to the several conditions in
which it comes before the physician.
  205. i.  Of Paralysis of  Sensation.—The
means to be employed in this form of the dis-
ease  should be selected with strict reference
to the remote causes,  to the pathological  con-
ditions  inferred to exist in each  case, and to
the particular circumstances of the  individual.
If this affection occur in a spare habit of body,
if it be unconnected with  general or local vas-
cular plethora, and if it have been caused by cold
or  other depressing agents,  the means about
to be recommended for the more chronic states
of paralysis of motion (§ 213, 214.) may be em-
ployed, especially local stimulants and irritants,
internal excitants, external derivatives, galvan-
ism, &c.   In all  cases, however,  the strictest
attention  should  be paid to the several digest-
ive, secreting, and excreting functions.
  206. If the senses of sight, smell, or taste are
singly or generally affected, the same  princi-
ples of treatment should be adopted as are here
espoused  in respect of anasthesia; the several
means being selected or modified  according to
the peculiarities of the case, and the organ es-
pecially disordered.
  207. Local congestions  are concerned in pro-
ducing many, probably the majority  of cases of
anasthesia.   If the loss of feeling be  associated
with hesitation or other affection of the speech,
these conditions may be  more confidently in-
ferred ;  and  if the anaesthesia be hemiplegic, a
limited  congestion, haemorrhage,  or softening
of  some  part  of the  brain  probably  exists.
When anaesthesia occurs in plethoric  and robust
habits of body, in persons who have  lived  fully,
or of sedentary habits, or  consecutively of sup-
pressed evacuations or discharges, then  these
pathological states most probably exist, and the
affection,  if not  quickly  removed,  will  often
soon  be  followed by paralysis  of  motion.  In
these circumstances, the treatment advised for
the acute states of palsy  of motion, especially
general and local vascular depletions, cholo-
gogue and other purgatives, and derivatives, is
that which is most appropriate.   Subsequently,
external excitants, as sinapisms, vesicants, ur-
tications, &e., or the other means noticed for
the more chronic  states of palsy (() 213, et  seq.),
may be prescribed.  When anaesthesia is  asso-
ciated, as it  generally is,  with  loss  of motion,
the treatment is  in all respects as about  to be
-Treatment of.                            45

 stated with reference to palsy of motion, which
 is then  the  most important  phenomenon,  and
 the one which should chiefly engage attention
 as respects its immediate cause.
   208. ii. Treatment of Palsy  of Motion,
 &c.—When the faculty of motion is paralyzed
 either alone or conjointly with  partial or more
 complete  palsy of  sensation,  the  treatment
 should be directed with the same intentions as
 have  been just mentioned, viz ,  1st, with the
 view  of removing  the morbid  states  or  the
 structural lesions inferred to  exist in each case
 which may present itself; and, 2dly, with the
 object of restoring the transmission of nervous
 influence to the paralyzed muscles.
   209. A. When the palsy is strictly local or par-
 tial, the treatment should necessarily depend
 upon  the peculiar features of the case.  In  this
 state  of the  complaint (§ 21)  the lesion may be
 either in  the  origin  or  in the course  of the
 nerve supplying the paralyzed muscles ;  but it
 may also be  limited to the  ramifications of the
 nerve, as when the  affection is caused by the
 continued influence of cold, &c.  If the lesion
 be inferred to  exist at or near the origin of the
 nerve, local  depletions, derivatives, alteratives,
 especially a  carefully regulated course of mer-
 cury or of the iodides, with sarsa, &c. ; exter-
 nal irritants and drains; and a due promotion
 of the several secretions and excretions, com-
 prise  the most efficient means of cure.
   208. If the  nerve  have  its functions  inter-
 rupted by changes in  any part of  its course, as
 by thickening  of the periosteum, by abscesses,
 tumours, &c,  alteratives,  particularly the  io-
 dides, with  the solution  of potash and sarsa-
 parilla ;  various external applications, particu-
 larly the tincture of iodine, or solutions of the
 iodides, the  plaster of ammoniacum with mer-
 cury,  &c, and other  means  suited to the  na-
 ture of the case, may be resorted to, if the ram-
 ifications of the nerve be chiefly affected ;  and
 particularly if colds have been the cause of the
 disorder, sinapisms, blisters, or applications con-
 taining  capsicum  or mezereon,  may be pre-
 scribed, and if these fail, the  part may be stim-
 ulated by either of the means  hereafter to be
 mentioned (<J 249, et seq.).
   210. B. The hemiplegic form of palsy, whether
 occurring primarily  and  simply,  or  associated
 with apoplexy or convulsions, or appearing con-
 secutively of these, is the most common form
 of the disease, and  requires the greatest  dis-
 crimination  in estimating  the   pathological
 changes and in prescribing the  means of cure.
 —a. In the acute or early period of the malady,
 prompt and decisive  measures are generally re-
 quired ; yet these should  be varied according
 to the mode of accession and character of the
 attack, as already noticed (y 35-40).  If the
 complaint approach in the gradual manner above
 noticed (§ 35, 36), alteratives and derivatives'
 are chiefly indicated  with the view of removing
 or arresting the lesions which may be inferred
 to be  the causes of the complaint, and of allay-
 ing the irritation they may be  supposed to oc-
 casion.   Local depletions, especially by cup-
 ping  on  the nape of the  neck;  sinapisms or
 blisters in this situation and behind  the ears;
 purgatives and alteratives ; setons in the nape,
 and mustard pediluvia, are severally indicated.
 In this form of palsy, vascular depletion, unless
 local  and moderate, is seldom of much service. 
46
PARALYSIS—Treatment of.
Purgatives are generally required ; and mercu-
rials, in alterative doses and combinations, es-
pecially Plu.mmer's pill with soap, or the bi-
chloride of mercury, in small  doses, taken ei-
ther soon  after a meal, or with preparations of
sarsaparilla, sometimes either  ameliorate  the
symptoms, or arrest for a time the farther prog-
ress of the disease.   It is in this form of hemi-
plegia that the iodides are more particularly in-
dicated.   I have given the iodide of mercury,
or Plummer's pill, nightly, and  the iodide of
potassium, with  solution of potash and com-
pound decoction of sarsaparilla, during the day,
with manifest advantage, a seton  being  kept
open in the nape of the neck.
  211.  When the attack of palsy seems conse-
quent upon inflammatory softening of a  portion
of the brain, &c. (§  37, 38), local vascular de-
pletions,  or  even  general blood-lettings,  are
manifestly required.   Active  purgatives  and
mercurials are  also requisite ; and, in the in-
tervals  between the exhibition  of  purgatives,
the bichloride of mercury  should be  given in
small and frequent doses, until the gums be-
come affected, external derivation being also
produced  by the usual means, while the head is
kept cool and elevated.   In this form of the
disease, I have not  seen any advantage accrue
from the iodides, especially in the early or acute
stage, or  while inflammatory action continues
to exist.  In other respects, the treatment in
this variety of the disease should be conducted
as advised for inflammation of the brain.  (See
art. Brain, $ 191, et seq.)
   212.  If hemiplegia occur in a sudden manner
(§ 39), the treatment should be as  prompt and
energetic as in cases of apoplexy.  In many ca-
ses, particularly in robust  and  plethoric  per-
sons, copious general or local blood-letting, or
both general and local, is required ; and either
one or the other, or even  both, may be again
necessary some days after the accession of the
attack, owing to the vascular  reaction conse-
quent  upon  it and  the previous depletions, or
attending the inflammatory action produced by
the extravasation of blood causing  the seizure.
In this form  of palsy the pulse should be  care-
fully watched during the first fourteen or twen-
ty-one  days  after the accession of the symp-
toms ;  and as soon as it acquires fulness or
hardness, blood-letting, according  to  the cir-
cumstances  of the case,  should be  repeated.
But, in order to prevent the necessity of recur-
ring to depletions, purgatives, external deriva-
tives,  and refrigerants or cooling diaphoretics,
should also be prescribed at the commencement
of the attack.  In this variety of the disease I
have seen much  benefit derived from the bi-
 chloride  of  mercury,  either alone, and taken
 soon after a meal, or with sarsaparilla, until the
 system became affected by it; but  vascular de-
 pletions should be premised, and the secretions
 and excretions  duly promoted.  In  this state
 of the malady, as well in that which  is associa-
 ted with, or immediately follows, the apoplectic
 seizure (§ 40), the treatment  in the early  or
 more  acute  stage is in every respect similar to
 that which I have  recommended in the article
 Apoplexy, when that malady is  attended or fol-
 lowed by hemiplegia.   (See  art. Apoplexy, §
 146, et seq.)
   213. b. The chronic or persistent state of hemi-
 plegia is seldom altogether removed.  The  in-
jury received by the fibrous  structure  of the
brain, in the great majority of cases, is such as
admits  not of the restoration of the complete
power of volition over the paralyzed limbs  In
this state, setons or issues may be tried;  but
they should be kept discharging for many weeks
before much advantage can  be expected from
them.   At the same time, the iodides, particular-
ly the iodide of potash, may be exhibited either
alone or with liquor potassae, or as already rec-
ommended ; and the bowels should be kept free-
ly open  by means of chologogue purgatives.
   214. Duringthis period of the disease, various
internal and external  stimulants and irritants
have been advised, with the view of accomplish-
ing the  second indication of cure ($ 208); but the
selection of them requires great discrimination
as regards their  respective properties and the
existing pathological conditions.  The prepara-
tions of nux vomica, strychnine, &c, have been
recommended in this state of hemiplegia, but I
have rarely or  never found them of service in
this form of palsy;  but,  on the contrary, pro-
ductive of  more  or  less mischief, especially
whenever increased determination or fulness of
blood in the head was present.  They are indi-
cated only when an opposite state  of the cere-
bral circulation is inferred to exist, and in some
other forms of the disease.  The same may be
said of the  use  of other internal stimulants,
when a disposition to increased vascular action
or effusion exists in the substance and mem-
branes  of the brain ;  for in such cases the prep-
arations of iodine, aconite,  cantharides, ser-
pentaria, phosphorus, camphor, electricity, gal-
vanism, &c, of which more particular notice
will be  taken hereafter, are very rarely of use,
but often injurious.  The remarks which I shall
have to offer respecting certain modes of cure,
and various medicines more or less praised for
this complaint, apply so entirely to this period
of hemiplegia, that I shall add no more  at this
 place as to the means which may be farther em-
 ployed  in the treatment of it.
   215.  C.  The treatment of paraplegia so entirely
 depends upon the nature of the lesion producing
 this form of palsy, that a continual reference to
 such lesions must be had in the observations
 which  I shall have to offer on this subject. I
 have stated above (§ 53) the several changes
 causing paraplegia ;  and it  will be  seen that
 these require a treatment appropriate to  each
 individually.—a. It is obvious that the means re-
 quired  for paraplegia consequent upon concussion
 or fracture of the spine, or upon laceration of, or
 pressure on the chord by displaced bone, are
 chiefly surgical at an early period ;  and that the
 selection of these means should depend  upon
 the peculiar features of the case, and the extent
 of local injury.   At a later  period, when the
 palsy still continues, the treatment will neces-
 sarily hinge upon the physical condition of the
 parts,  and the presumed consequences of the
 lesions immediately resulting from the injury.
 In such cases the paraplegia  sometimes  per-
 sists,  although the  physical  condition of the
 spine appears but little or not at all altered. In
 these  it may be presumed that softening, effu-
 sjon, or some other  consequence of inflamma-
 tory action is present in the  chord or its mem-
 branes ; and, consequently,  these  cases  come
  under the same category as  others about to be
  considered (v 216). 
PARALYSIS—Treatment of.
47
  216.  b. In  cases  of paraplegia which com-
mence  with severe pains or tenderness in the
spine or loins, or with a sense of heat or burn-
ing, followed by spasms, numbness, and loss of
power, indicating an acute or inflammatory char-
acter (() 56), a decided antiphlogistic treatment
is requisite,  especially at  an early period.  In
these, cupping on each side of the spine near
the seat of pain or tenderness, repeated accord-
ing to circumstances,  mercurial purgatives and
terebinthinate enemata, are the most efficient
remedies, especially when these symptoms have
not been of long duration.  If pain or spasms
still remain after a due recourse to these means,
calomel,  or other mercurials,  should be  given
with opium until the mouth is slightly affected,
attention being paid to the states of the urinary
bladder and bowels, and of their excretions.
  217.  In cases  of paraplegia of a more insidi-
ous character—in those which occur gradually
and slowly, or which  are consequent upon ex-
posure to cold, or are attributable to congestion
of the  spinal sinuses,  to increased serous effu-
sion, or to chronic lesions affecting the chord, or
to scrofulous changes  in this part, its envelopes,
or vertebrae,  the bichloride of mercury as ex-
hibited above (Y 211, 212), or conjoined with the
compound tincture of  bark ;  or the iodide of po-
tassium with liquor potassae and the fluid extract
of sarsa, or an alternation of these ; stomachic
purgatives, warm salt-water baths followed by
active  friction of  the trunk and limbs, and
strict  attention to the excreting functions, and
to the states of the discharges, are the measures
which  have proved most beneficial in my prac-
tice.  The bichloride of mercury, or Plummer's
pill, should be exhibited until the gums are af-
fected, or until recovery takes place ; and, when
the motions  are tar-like, and are procured with
difficulty, calomel should  be given with active
cathartics, such  as the compound extract of
colocynth, scammony, &c  , sometimes quicken-
ed with a drop of croton oil.  Blisters, or rube-
facient applications, may be placed on the back,
and be repeated according  to  circumstances
The liniments prescribed in the Appendix (Form.
308, 311) may be applied as embrocations in the
course of the spine,  from time to time, or be
rubbed assiduously in this situation.
  218. Setons or issues  on each side of the
spine  have been advised, and in some instan-
ces have proved serviceable, particularly  when
aided  by a judicious internal and constitutional
treatment,  but they require discrimination in
respect both of the pathological causes of the
paraplegia, and the general health  of the pa-
tient.   When the disease appears to have pro-
ceeded from  exhausting causes, as masturba-
tion, venereal excesses, &o, or to  have been
aggravated by these, then setons or issues are
generally injurious, especially when the consti-
tutional powers are much exhausted.  Stimu-
lating and invigorating measures are  required
in  all  such  instances.  In these and  similar
cases, I have found the tincture of the sesqui-
chloride of iron with  the  tincture of canthari-
des ; the compound galbanum pill with the sul-
phate or  oxide of zinc ; the aloes and  myrrh
pill with  the  resinous extract of nux vomica ;
and the valerianate of zinc lately introduced by
Mr. J. Savory, of more or less service.   Sir B.
Brodie recommends a grain of sulphate of zinc
to  be given  three times a day, increasing the
 dose, and to be washed down by a draught con-
 taining twenty minims of the tincture of can-
 tharides.   In cases of this nature, the prepara-
 tions of iodine, particularly a weak tincture, or
 the compound tincture of the pharmacopeia ; or
 small doses of the bichloride of mercury in the
 compound tincture of cinchona and tincture of
 capsicum, or an alternation of these, have been
 of essential  benefit.   Sir  B. Brodie takes  fa-
 vourable notice of the bichloride  of mercury in
 doses of one sixteenth of a grain three times a
 day, with a moderate dose of the tincture of can-
 tharides.   I  have tried this mode of exhibiting
 the bichloride, but the effects should be watched.
 The compound tincture of camphor will be con-
 joined with these two medicines with advantage.
   219.  The treatment of general paralysis in most
 instances is much the same as that just recom-
 mended for  paraplegia ; for the former gener-
 ally depends upon similar lesions to the  latter,
 or is merely an extension  of it.—a. When the
 general palsy is a symptom of the more violent
 states of apoplexy, the  means appropriate to
 these should be prescribed (see art. Apoplexy,
 § 135, et seq.).  When it is the result of concus-
 sion of the brain, or of the spinal chord, or of
 fracture or other injury of the cervical vertebra,
 the treatment must depend upon the violence
 of the shock, on the presence of the primary
 symptoms, or the supervention of reaction—on
 the state of the heart's action  and of the circu-
 lation, both  locally and generally, and on vari-
 ous circumstances which will influence the ex-
•perienced physician.   The intentions of cure
 should, therefore, be not only varied, but  differ-
 ent, or even  opposite  in different  cases and cir-
 cumstances.
   220.  b. In cases  of general palsy from caries
 of the cervical vertebra, after the acute  symp-
 toms have been  removed by local depletions,
 blisters, mercurials,  &c,  issues,  setons,  or
 moxas, &c, should be placed a little distance
 from the seat of lesion ; and an embrocation,
 consisting chiefly of the compound camphor and
 turpentine liniments, placed from time to time
 along the spine.  In the case of  caries of two
 of the cervical vertebra referred to above (§ 68)
 the treatment consisted of active  mercurial and
 other purgatives, of an  alternation of a short
 course  of the bichloride of mercury dissolved
 in the compound tincture of bark, with a more
 prolonged course of the iodide of potassium and
 solution of potash, w ith the fluid compound ex-
 tract of sarsa.  A protracted discharge was
 procured by  means of blisters and savine oint-
 ment, applied to each side of the neck just be-
 low the occiput.  The recovery has been com-
 plete.  The neck, however, is shorter and much
 stiffer, obviously owing  to absorption and an-
 chylosis of the diseased  vertebrae.
   221. c.  When the general palsy is of an acute
 character,  or is caused by inflammatory con-
 gestion, or by any of the more immediate con-
 sequences of inflammation of the membranes or
 substance of the chord, then local  depletions
 near the seat of pain, and the prompt  use of
 mercurials, of blisters, or of the terebinthinate
 embrocation in the course of the  spine, and  of
 the other remedies  recommended above (§ 216)
 for paraplegia, should not be neglected.
   222. d.  When  the  disease is chronic, or has
 been  neglected, or has not yielded to  these
 means, then  the bichloride of mercury, the sul- 
48                           PARALYSIS—Treatment of.
phate or the valerianate of zinc, the iodide of
potassium, the tincture of cantharides, the tinc-
ture of capsicum,  &c, may severally  be  em-
ployed as already advised (v 218).   Indeed, the
treatment of general palsy, in its several forms,
is in every respect the same as that advised for
paraplegia.
  223  iii Paralysis  in  Children  should be
treated according  to the principles above de-
veloped, and with  strict reference to the  pre-
sumed pathological condition.  If the palsy be
partial or hemiplegic, and be inferred to  have
arises  from  injury during  parturition, or ap-
parently acute, the application of a leech behind
the ear (of the unaffected side in  the hemiple-
gic variety),  and  repeated doses of calomel,
should  be prescribed.  Minute doses  of the
iodide of potassium may be  given subsequently,
and  the bowels ought to be kept freely open.
If the  palsy be congenital and independent of
injury,  the iodide  of  potassium  or the iodide
of mercury, or the bichloride of mercury,  may
be tried in minute  doses and with due caution.
In the more chronic cases of infantile paralysis,
these constitute the chief  remedies, but  they
should  be continued for a considerable period
and gradually  increased, a course of the one
being  alternated with that  of the other, as al-
ready advised.
  224.  If the infant be able to take the breast,
recovery to some  extent may be  expected, al-
though it may not be complete.  I have at pres-
ent under my care a patient in a fit of gout,
aged between  forty and fifty  years, who  was
hemiplegic from earliest  infancy,  but he is un-
able to  state  whether it  was congenital or
caused by injury during parturition.  The limbs
of the paralyzed side are considerably smaller
than those of the  sound  side, and their move-
ments weak,  difficult, and constrained.   The
imperfect growth of paralyzed limbs in infancy
is owing chiefly to the very imperfect use made
of them during the epochs  of development.
   225.  iv. Treatment  of  Shaking Palsy.—
Amendment  has not followed any mode of
cure which I have  tried, and I have tried the
most energetic means for this  form  of pal-
sy, when it appears gradually  and in a chronic
form.   When, however, the tremour occurs in
a more acute form, or consecutively  of sup-
pressed evacuations, in strong or plethoric pa-
tients, as in  the case adduced from Frank (§
99), or when it is attended  by pain in the  head
or in the course of the spine, then antiphlogis-
tic remedies, particularly local depletions, blis-
ters, or the terebinthinate embrocation in the
course of the spine, purgatives, mercurials, &c,
followed by the iodides, the bichloride  of  mer-
cury, or the valerianate of zinc, and a  seton in
the nape of the neck, may be severally employ-
ed, according to the peculiarities of the case,
or other energetic means about to be noticed
may be tried.
   226.  In all cases of paralytic tremour, the ex-
istence of an arthritic or  rheumatic diathesis
should be ascertained, and  the treatment mod-
ified  accordingly.   In such  instances, tonics,
opiates, and  antispasmodics, with ammonia or
other  alkaline substances, may be prescribed.
When  the disease has  probably arisen  from
masturbation, or excessive sexual indulgence—
the most frequent of its causes—then the  prep-
arations of iron with the tincture of cantharides,
or of capsicum, or with camphor, or with the
nitro-hydrochloric acids, or the extract of nux
vomica, or opium conjoined with aromatics, may
be tried, according to the peculiarities of the
case, and to the effect produced ; and they may
be aided by stimulating embrocations,  or  plas-
ters applied on the spine, as the liniments in the
Appendix (F. 308, 311), or the emplastrum thuris
comp., &o, &c.
  227. v.  Paralysis  caused  by Poisons re-
quires a treatment appropriate to the nature of
the deleterious  agent.—a. When the affection
is caused by the preparations of lead, the state
of the digestive organs first  requires attention.
(Sec art. Colic  from Lead.)  After the alvine
secretions and excretions are more or  less im-
proved, and their discharge is rendered more
regular and healthy,  the  preparations of nux
vomica or strychnia may be exhibited, but their
effects should be carefully  watched.  In this
disease I  have  preferred  the resinous extract
of nux vomica to strychnia, and have generally
prescribed it in combination with  the  purified
extract of aloes.  In aid of these, the external
stimulants, hereafter to be mentioned,  suitable
exercise of the  paralyzed parts as far as they
may admit of it, and the application  of splints,
extending  from the elbows to the fingers in
cases of palsy of the wrist or arm, should not
be overlooked.   In addition to friction  with
various stimulating substances, electricity and
galvanism, warm salt-water bathing, and warm
baths containing stimulating substances, may
be employed.   Cleanliness and the removal of
the cause always should be  enforced.  During
the treatment the regular discharge of the al-
vine  functions  ought to  be  promoted, and the
patient should be allowed a  generous diet.
  228. b.  The  states of palsy caused by other
poisonous  substances should be treated con-
formably with the principles already explained
—with strict reference to the states of vascu-
lar action and vital power, both general and lo-
cal.   The tremulous form of palsy sometimes
caused by mercury (see Arts and Employments,
§ 23, et seq.) requires similar means to those
just recommended for palsy from lead.   This
observation also applies to the  palsy of the ex-
tremities sometimes  produced by arsenic.  In
all these, internal stimulants, tonics, and resto-
ratives ; attention to the digestive and defeca-
ting processes ; external excitants, electricity,
&c,  and nutritious diet, are requisite.
   229. Palsy consequent  upon narcotic poisons
should  be treated according to the states of
vascular action and nervous power.  After due
recourse  to their  respective,  antidotes, &c,
local depletions, purgatives,  external deriva-
tives, &c., in order to remove congestion  of
the nervous centres, should be prescribed, and,
if the malady still persists,  the several altera-
tive, restorative, and stimulating remedies rec-
ommended for  the chronic states of palsy ought
to be employed, according to the  peculiarities
of the case, and the  circumstances of the pa-
tient.
   230.  vi. The Treatment of the Complica-
tions of Palsy requires but few remarks, as
the  most important of these complications is
duly considered in the articles on the diseases
of which palsy is a part, or of which  it is con-
 secutive.  Under the heads Apoplexy,Inflam-
 mation of the  Brain, and  Insanity, the asso- 
PARALYSIS—Treatment of.
49
ciations of paralysis  with  these  are  fully dis-
cussed.—A. I have already noticed that palsy
may either follow or precede inflammation of the
nervous centres, and have explained  how this
may arise  ($ 125).  Hence it  is  requisite  to
watch carefully all cases,  especially of hemi-
plegia, where  it is inferred  that the palsy is
caused by extravasation of blood, particularly
during the  first three  or four weeks of the dis-
ease ;  and, upon the first indication of  inflam-
matory irritation, to have recourse to antiphlo-
gistic measures co-ordinately with  the  indica-
tions for their use.   The evidence  of  inflam-
matory action in the vicinity of the lesion pro-
ducing paralysis, at whatever period it may ap-
pear, as described above (i) 128), is a  sufficient
reason for  the having recourse to local deple-
tion, purgatives, external derivatives, and al-
teratives, and for relinquishing tonics, stimu-
lants,  or excitants of any  kind,  should those
have been  resorted to.
  231. B. The complication of insanity with gener-
al palsy admits of little or no hope, even of par-
tial  benefit.  Still, the alteratives already no-
ticed,  combined with tonics and restoratives,
should be prescribed, particularly the iodide of
potassium with sarsa, or with bitter infusions ;
the extract of nux vomica  with aloetic  or oth-
er aperients;  the  bichloride of mercury with
the compound  tincture of cinchona ;  the va-
lerianate of zinc, and other means already no-
ticed (see art. Insanity,  §  444-446).    In the
association of  palsy  with  puerile imbecility  or
idiocy, the case is hopeless, for the reasons as-
signed above (§ 127).
  232. C. The treatment of disease of the cra-
nial bones, or of the vertebra, associated with pal-
sy,  may be said to have been already noticed
(!) 217), since the same  means as have  been
advised for the more  chronic cases of paraple-
gia, or of general palsy, are also appropriate to
this complication.  In the more common cases
of this kind, namely, in those where the ver-
tebrae  are diseased, but little  can be done with
rational hopes of success beyond what has been
recommended above (§ 217, 220).   But in the
course of treatment,  the intercurrence of in-
flammation of the membranes, or even of the
chord itself, should  be guarded  against and
watched for, and  be  promptly opposed by the
means already indicated (§ 216, 221).
  233. D.  The association  of palsy with neural-
gia or rheumatism, or with  pains  resembling
these affections, should always lead to the sus-
picion of congestion, or inflammatory  action,
of or near to the  origins of the nerves which
are the seat of pain, or which supply the pained
parts; and when the  palsy is, moreover, com-
plicated  with spasms or cramps, the same le-
sions should be inferred, and a treatment based
upon  the inference be prescribed.
  234. E. I have  already  contended that the
association  of palsy with disease of the kidneys
and  urinary organs is most  frequent and im-
portant ; and that the latter morbid condition,
even when it is apparently the primary one, is
generally only the consequence of congestion
of the vertebral or spinal sinuses, causing press-
ure on the chord, or increased  effusion into
its  sheath  (§184, et seq.).   In these cases the
urinary functions may be disordered to  a most
serious extent, or  even for a long time, before
symptoms  of  paraplegia are  evinced,  or the
      III             4
movements of the limbs are materially affect-
ed.  When the spinal congestion interrupts or
otherwise  changes the functions of the kid-
neys, the consecutive excrementitious plethora
may occasion  either hemiplegia, or coma with
general palsy.  In some cases the congestion
of the spinal veins and sinuses is soon followed
by acute congestion, or inflammation of the kid-
neys, or by suppression or retention  of urine,
paralytic symptoms not appearing untifcthe re-
nal malady is far advanced.   In these circum-
stances the treatment is obvious.  Cupping on
the loins, or near the part of the spine  chiefly
affected, according to  the severity of the at-
tack and the habit and constitution of the pa-
tient, should always be directed, and afterward
terebinthinate embrocations ought to be applied
to the loins and spine.
  235.  F. The nature  of the occasional con-
nexion of palsy, especially paraplegia, with hys-
teria, has been  already  noticed  (§ 140, 188).
The irregularities often observed in the urina-
ry functions of hysterical patients  may often
be attributed to the irritation propagated from
the uterus  and ovaria, either directly by  the
ganglial nerves to the kidneys and bladder, or
indirectly to the spinal chord, and thence to the
urinary organs along the nerves communica-
ting between  them and the  chord.  In those
cases where the protracted  irritation  of  the
uterine  organs, in connexion with exhaustion
of nervous power, disorders not only  vascular
action  in these organs, but extends itself and
its effects upon the vascular system,  not only
to the spinal chord, but also to the urinary or-
gans, pain or aching in the loins, and even ten-
derness on  pressing the spinous processes of
the vertebrae,  are often observed ;  and if the
vascular disorder  consequent upon  the local
excitement or irritation advances far, so as to
occasion certain of its most prominent effects,
numbness,  cramps, or spasms of the lower  ex-
tremities ;  retention or suppression of urine,
sometimes alternating with an unusually large
secretion or flow of it; occasional nausea, vom-
iting, and irregularity of  the bowels  ; irregu-
larity, or difficulty, or suppression of the cata-
menia ;  and, ultimately, even more or less com-
plete paraplegia may result.   Several cases of
this kind have occurred to me, and have long
resisted  treatment until  they were submitted
to energetic courses of the alterative medicines
above advised (217), particularly the bichloride
of mercury, or the iodide of potassium, vari-
ously combined, aided by terebinthinate ene-
mata and embrocations, by the extract of nux
vomica, and by such of the remedies already
mentioned as were most appropriate to the pe-
culiarities of the case.   In the remarkably se-
vere and prolonged  instance  noticed  above
(§ 139), for which all the usual means had been
exhausted, in addition to several of the  means
now noticed, a pea-issue was made in the in-
side of each thigh, and kept freely discharging
until the amendment was complete.   The  re-
covery was rapid in this instance, and the lady
is now in the enjoyment of good health.
  236.  G.  I have met with several  instances
of palsy, and especially of hemiplegia, associated
with visceral disease.  The connexion between
organic disease of the heart and hemiplegia, as
that between the former and apoplexy,  is suf-
ficiently obvious ; and neither it nor the treat- 
50                           PARALYSIS—Treatment or.
ment of the complication requires much com-
ment,  inasmuch  as our  remedial  measures
should be directed primarily to the cardiac le-
sion, and subsequently or  collaterally to  the
paralytic affection ;  the states of these lesions,
in connexion with the age, habit of body, &o,
of the patient, controlling the plan of treatment
and the choice of means.
  237.  H. The complication of palsy with hepatic
disease*as  been observed by me on several oc-
casions, the palsy being generally hemiplegic,
and the right side being that affected in nearly
all the cases I have seen.  Although in some
cases the liver has appeared to have been  pri-
marily affected, still it  is  very probable that
the loss of power in the voluntary nerves and
muscles of the right  side  may have in some
degree affected the functions  and circulation
of the liver, and, in prolonged cases, ultimate-
ly induced disease of it.   In these associations
the principles of treatment and the choice of
medicines will readily suggest themselves to
those who have perused the foregoing remarks,
and what I have adduced  on the treatment of
diseases of the liver.
  238. Palsy may, moreover, be associated with
scorbutus, and it not unfrequently occurs in the
gouty or rheumatic diathesis, more especially af-
ter irregular, displaced, or suppressed gout.  In
these circumstances,  the treatment should be
varied according to  the diathesis.  In the gouty
association of the malady the usual means should
be employed to develop the gout in the lower
extremities.
   [Paraplegia not unfrequently occurs in  this
country in  the  course of continued  or remit-
tent fever,  perhaps  more often in chronic than
acute cases, and where repeated relapses have
occurred.   If not speedily fatal, it  is of diffi-
cult removal, and  generally obstinately pro-
tracted.  The most successful treatment con-
sists in rest, repeated applications of cups to
the spine, and mild purgatives during the pe-
riods of the disease, in which there is often
considerable febrile excitement, and afterward
moxas. The treatment is, therefore, essential-
ly the  same as that of inflammatory  affections
of the  medulla spinalis.   In the non-inflamma-
tory stages of the  disease, strychnine or gal-
vano-magnetism  will be found useful.  Suffi-
cient attention  is far from being paid to those
violent pains in the back,  indicative of spinal
congestion, in the commencement of our con-
gestive, and even our common continued fe-
vers.  External revulsives, cups, leeches, and
the warm bath may all be  brought into requisi-
tion with much advantage in a large proportion
of these cases]
   239. vii. The Appreciation and Appropria-
tion of Remedies for Palsy.—In  discussing
the treatment of the several forms of palsy, it
has been, as will be seen above, a principal ob-
ject to advise the use of such means as appear
the  best  calculated  to  remove  the  morbid
changes upon which these forms severally de-
pend ; and mention has been made chiefly of
those  remedies which seem to me most likely
to produce this effect, and of which I have had
more or less experience.  It is necessary, how-
ever, to a  full  exposition  of the  treatment  of
palsy, to review the application  of the  more
energetic means  to certain states of the dis-
ease and of the constitution, and to notice oth-
er medicines which have been favourably men-
tioned by writers of reputation.
  240 After devoting due consideration to the
seat  and nature of the lesion of which palsy is
the prominent and most manifest phenomenon,
it next is of importance to estimate correctly
the states  of vascular action and of nervous
and  vital power ; to ascertain, as  nearly as
may be, how far the affection may be consid-
ered, from  these states, in connexion with its
cause and  duration, to be acute or chronic, and
sthenic or  asthenic.  These terms, it is true,
are merely conventional; but they  neverthe-
less  assist  us materially in  our attempts at
briefly indicating the conditions  of the patient,
which powerfully influence the operation, and
which  should, therefore, guide  our  choice of
medicinal agents for this malady.
  241. a.  Of blood-letting, general and local, it
may be briefly stated that it is generally re-
quired  early in attack, especially in acute and
asthenic cases, and more particularly  in the
hemiplegic or sanguineous form of the disease.
In the paraplegic and partial states of the mal-
ady local blood-letting is commonly to be  pre-
ferred to general;  and in all cases the quantity,
as well  as  manner and repetition of  the deple-
tion, should depend upon its effects, the state
of the pulse, and habit of body of the patient,
as well  as  upon the predisposing and exciting
causes of the attack.   We must not, however,
inconsiderately prescribe either venesection or
cupping in all cases, even of hemiplegia, be-
cause we find  them to have  been advised by
Celsus, Zacutus Lusitanus, Home, Abercrom-
bie,  and many other  eminent writers.   The
most recent of these writers recommends it too
profusely,  too  generally, and  too  exclusively,
at least as regards the inhabitants of large cit-
ies and manufacturing  towns,  wherein the
causes  of  the  malady and the asthenic states
of a very  large proportion of those attacked
either admit not of depletions, or require  very
different or even opposite means of cure.  Dur-
ing the  treatment of both hemiplegic and para-
plegic palsy, intercurrent inflammatory action
may appear, and require, generally, depletions
by cupping or leeches; and the physician should
be alive to such an occurrence when he  has re-
course  to  stimulating medicines, in doubtful
circumstances, and in young persons.
   242. b. Of cvacuants, purgatives and diuretics
are the most appropriate; and of the former of
these, the  most active should be selected, and
such as influence most energetically the princi-
pal secreting viscera, as calomel, colocynth,
jalap, scammony, &c.  In paraplegia, and even
in hemiplegia, the bowels are very torpid, and
require repeated and full doses of these, and
even of still more energetic cathartics, as cro-
ton oil  or  elaterium,  in some obstinate cases.
In many, recourse should also be had to  pur-
gative enemata, particularly to those in which
the oleum  terebinthinae is an ingredient.  It is
not merely necessary regularly to evacuate fae-
cal matters by means of these, but to employ
them so as to derive from the  cerebro-spinal
axis any  increased flow of blood to it which
may have  occasioned or prolonged the  attack.
Indeed, with these conjoined  objects, they are
advised by Halle, Dalberg, Brodie, and oth-
ers who have insisted on their use.
   243.  The ancients advised a recourse to diu- 
PARALYSIS—Treatment of.
51
relks in palsy, and some of the medicines pre-
scribed  by modern physicians, and considered
by them to influence  the  disease  merely as
stimulants, owe no small  share of  their good
effects to their operation on  the kidneys.  Of
these, the most efficient are the tinctura lyttae,
the preparations of iodine, and spirits of tur-
pentine—substances of which  farther  notice
will be taken hereafter—which  require caution
in their use, and which  are  suited chiefly to
chronic and asthenic cases, and to the paraple-
gic states.
  214. c.  Of alteratives, the most beneficial and
most generally appropriate are mercurials, iodine,
and the iodides and sarsaparilla.—a. Mercurials,
employed so as to  affect the system, and chief-
ly by inunction, have  been recommended for
palsy by Schenck,  Schneider, Cavallini, and
J. P. Frank ;  and,  both internally and  exter-
nally, by Vallisneri, Burger,  and  many oth-
ers.  I have seen them of service, when judi-
ciously prescribed, in both hemiplegic and par-
aplegic  palsy.  J.  P. Frank prescribed  them
more especially for saturnine palsy, in  which
he has seen them  of great service.   In acute
and sthenic cases, calomel given with antimo-
ny, after blood-letting, until the pulse is suffi-
ciently reduced, should be preferred ;  afterward,
the milder mercurials may be substituted ; and,
in chronic and asthenic cases, the bichloride
may  be given in the decoction of bark until the
gums are slightly affected, especially in scrofu-
lous  and  rheumatic constitutions.    I  lately
attended a  patient in  hemiplegia (Mr. G., of
Watling-street), for whom I prescribed the bi-
chloride of mercury, in this combination, a fre-
quent recourse to  purgatives, and a  seton in
the nape of the neck, with the best results.
His right side  was affected,  and he now can
walk unaided, and writes letters and checks as
usual.
  245. (b) I have prescribed iodine and the io-
dides in several cases of the  various forms of
both partial and general palsy;  but  in no case
of the disease have I ventured to employ them
otherwise than in very small  doses  at first,
carefully watching their effects, and cautiously
increasing the doses.  Dr. Manson  was the
first  who published cases of palsy in which io-
dine had been employed ;  and these cases show
not only the good  effects of this substance in
certain states of palsy, but also its injurious in-
fluence  in the more  acute  and sthenic cases,
and when prescribed  in too large doses.  Dr.
Manson employed only the tincture of iodine;
but, both before and after the publication of his
cases, I had used  both this and the iodide of
potassium for this  disease, as well as for some
others, in public and private practice  ; and more
recently the iodides—the  iodide of potassium
and the iodides of mercury—more  frequently
than the pure iodine.   These preparations, es-
pecially the  last, are best suited  to the more
chronic and asthenic cases, or after depletions
and other evacuants have been pushed  suffi-
ciently far.   Even then the doses should at
first be small, and the effects upon the pulse be
carefully watched.  The occurrence  of head-
ache ought to cause an interruption  in the use
of these medicines.  The iodide of potassium
may be conjoined with liquor potassae and sar-
saparilla, commencing only with one or  two
grains, and  gradually increasing  it.  I  have
oven  given only one grain in the twenty-four
hours with advantage.
  246. d. Stimulants and tonics were employed
internally for palsy much more  frequently by
the older writers  than by physicians of the
present day, who are more  conversant than
they generally were with the true seat and na-
ture of the lesion causing the paralytic attack.
These substances  are contra-indicated  in  all
acute and sthenic cases of palsy, and whenever
there  is reason to infer the existence of inflam-
matory irritation, haemorrhage, or vascular ex-
travasation, or even of active congestion, while
they may be employed with reasonable hopes
of benefit in chronic  and asthenic  cases, and
when the disease has appeared after exposure
to cold or to other depressing  influences, or
has followed exhausting causes.
  247. (a) Of this class of medicines the resin-
ous extract of nux vomica and strychnine have
been more frequently employed than any other
in recent times.  Of the two  preparations, my
experience induces me to  prefer  the former as
more  manageable than the latter, and equally
efficacious.  I have usually prescribed it in con-
junction with purgative or aperient extracts.
It, as  well as other internal stimulants, should
never be given in palsy, especially hemiplegia,
when  the  pulsation of the  carotids or the tem-
perature of the scalp is at all increased ;  and
if the pulse become strong or frequent, or the
face flushed during its use, it should be discon-
tinued, and local depletions, with an antiphlo-
gistic treatment and regimen, instantly adopted.
It is most serviceable in paraplegia and in lead
palsy.
  248. (b)  The flower of the Arnica  monlana
was much praised,  and is still much  used in
Germany and Denmark for paralytic cases.  It
has received the commendations of Angeli, De
Meza, Conradi, Aaskow, and others ; but I am
not aware of any other British physician besides
Home who has given  it a trial, and his evidence
is not much in its favour.   The Rhus radicans,
or Toxicodendron, has been recommended in this
disease by Brer a, Desgranges, VanMons,Kok,
and Alderson ; but Zadig considers it  quite in-
efficacious.  A decoction of  the Chenopodium
ambrosioides has been advised  by  Rudolphi,
Baldinger, and Lentix ; serpenlaria and capsi-
cum by Falconer ; guaiacum by Fothergill
and Johnston ; ammoniacum by  Bourget ; jry-
rethrum, internally, by Oxley ; cajeput oil, both
internally and externally, by Pereboom  and
Thunberg; naphtha byRA.MizziNi; camphor dis-
solved in turpentine by Schumacher ; this sub-
stance dissolved in naphtha by Reichsanzei.;ki: ;
musk by Truener, Lceffler,  and others ;  cas-
tor by Pauli ; the tinctura lytta, internally, by
Vaughan, May, Brisbane,  &c. ; phosphorus dis-
solved in ether, internally and  externally, by
Brera and Gaultier-Claubry ; and the nitrous
oxydc gas  by Beddoes, Hill, and Pinel.  It  is
very probable  that these  may severally prove
of service when judiciously  prescribed, espe-
cially  in those circumstances  of  the disease to
which  I have above ($ 246) limited the use of
stimulants and tonics.  In the same category
aconite may also be  noticed, it having  been
recommended by Stohrck and Greding ;  also,
opium and belladonna, which have severally been
used by Stoll, Thomann, and others,  in palsy
from lead. [The ergot, or secale  cornutum, has 
 52                           PARALYSIS-

 been found very useful in the treatment of para-
 plegia.  It is believed to stimulate the lower
 portion of the spinal chord, to which,  perhaps,
 its influence over the bladder and uterus is ow-
 ing.   It may be given in daily doses  of from
 fifteen to  sixty grains.]
   249. The circumstances which admit  of the
 internal use of stimuli also allow a recourse to
 electromotive agencies  in the several forms in
 which they have been employed ; and in no dis-
 ease have they been more generally and more
 empirically resorted to than in this.  Electricity,
 in the form of shock, hath, sparks, &c., although
 chiefly prescribed by persons ignorant  of medi-
 cine, has received the eautious sanction of Van-
 der Belen, Hart, and  others, in the most
 chronic and asthenic cases.   Meyer, Bang, and
 Percival  advise  it chiefly  for paraplegia  and
 lead  palsy; and  they, with Stoll, De  Haen,
 Quarin, and  Falconer, doubt its efficacy in
 other circumstances.  The electro-galvanic in-
 fluence was first recommended by Volta  in this
 disease ; and it was soon afterward adopted by
 Walther, Halle, Marcus, and Grapengeisser
 for those  cases in which powerful stimulants
 seemed to be required.   [We have derived sig-
 nal benefit in  many cases of local palsy from
 the employment of electro,  or galvano-magnet-
 ism, applied to  the paralyzed muscles in cur-
 rents  of moderate intensity, and  gradually in-
 creased in force.  Although many cases  will
 not be  materially benefited  by it, there  are
 others which will at once yield to the  repeated
 and judicious application of this remedy.]
   250. e.  The numerous means which may be
 strictly called external, and which have been so
 generally  resorted to in this disease, operate
 either (1) by  rousing the circulation and exci-
 ting the nervous influence in the part, as simple
 or medicated friction ; (2) or by deriving irrita-
 tion or other morbid action from the  nervous
 centres to superficial parts, as issues, setons,
 &c. ;  (3) or by a  combination  of  these  modes
 of operation,  as blisters, sinapisms, urtication,
 &c.   These means are severally appropriate to
 most of the forms of  palsy ; and, when judici-
 ously selected, they may be safely used  in the
 various states and relations of the disease.
   251. (a) Frictions in a simple form,  although
 advised by Stoll and Hilscher,  are seldom
 employed  ; for some medicinal substance with
 which frictions may be used is requisite  to im-
 part confidence to the patients in their efficacy.
 However, they maybe advantageously employ-
 ed by means of the hair-glove, or of the khee-
 sha, or Indian glove.  Frictions of the palsied
 limbs with various stimulating substances, as
 with phosphorus dissolved in oil or ether; with
 camphor, soap, and turpentine;  with cajeput oil,
 camphor,  olive oil, &c, have been often ad-
 vised, and may in a few instances prove of
 service.
   [Dr. Graves recommends very highly a lini-
 ment of strong acetic acid,  jss.; spirit of  tur-
 pentine, f\\}.;  rose water, fijss.;  essential oil
 of lemons, x drops ; and a yolk of egg in  suf-
 ficient quantity to suspend the turpentine. This
 is to be applied by means of a sponge  ; after a
 few applications, it produces  an eruption  of
 small  pimples, and proves very efficacious.]
  252. (b) Issues and setons are, upon the whole,
the most efficacious modes of permanent exter-
nal derivation in palsy, and the most generally
-Treatment of.

 adopted, especiallv in  this country.   The for-
 mer may be made in the scalp itself, by incisions
 in or near the occiput, pease being afterward in-
 serted ; the latter may be worn in the nape of
 the  neck.   They  have been praised by Pott,
 Appleton, Latour, Schreoer, Prichard, and
 Loder ; and I have had  several occasions of
 witnessing their good effects.   Moxas, which
 have been for ages employed in the East as the
 usual mode of external derivation, have  been
 strongly insisted upon  by Larrey and others in
 this and other diseases, and have been much
 employed on the Continent of Europe ; but their
 superior efficacy to issues or  setons  is very
 doubtful.   [Moxa is a  remedy by no means to
 be  neglected in paralysis.  We have  known
 cases of general paralysis where moxa, applied
 on each side of the spine, near the second dor-
 sal vertebra, procured immediate benefit]  The
 actual  cautery, mentioned  by Paulus -Egineta,
 and others  of the ancients, has been  recom-
 mended, also, by Richter, Portal, and  J. P.
 Frank.  Neri Nerii, a Neapolitan physician of
 the sixteenth century,  directed it to  be applied
 to the occiput in hemiplegia.  Among the usual
 means of derivation, dry-cupping, mentioned by
 Celsus and others in  this disease, should not
 be overlooked.
  253. (c)  Blisters, kept discharging  for a con-
 siderable period, or frequently repeated, as ad-
 vised by Boerhaave, Fordyce, and  Dickson;
 or artificial eruptions, produced for a  longer or
 shorter period, by means  of tartarized antinio-
 nial ointment, or by croton oil, are also frequently
 of service both in acute and chronic cases; but
 in the former especially,  after  local depletions
 and evacuations have been  freely  practised.
 The same remark is  applicable to the  use of
 sinapisms, and to a frequent recourse to urtica-
 tion, which has been advised by Paulus Moi-
 neta, Muys, Home, Hufeland, and many others,
 or to embrocations containing capsicum, or its
 tincture, or pyrethrum, all which exert the dou-
 ble effect noticed above  (§ 250), when applied
 to the paralyzed limb, as they should generally
 be applied, unless in cases where the sensibil-
 ity and temperature of the paralyzed limb are
 morbidly  increased, as sometimes  observed;
 and then they may even prove  injurious, espe-
 cially in asthenic cases.  In these, also, blisters
 applied to the palsied limb may be followed by
 sloughing.
  254. /.  Simple,  and medicated, and  mineral
 warm baths have been  much praised in palsy;
 but it is obvious, from the nature and forms of
 the disease, that, although they may be of ser-
 vice in some instances, they may be injurious
 if inappropriately or indiscriminately employed.
 I have seen them of service in  chronic and as-
 thenic cases, and in those states of the disease
 caused by exposure to cold.  Medicated warm
 baths—with warm and aromatic substances-
 were most beneficial in a case of general palsy
 arising from this cause that came under my
 care.  J. P. Frank notices favourably simple
 and sulphureous warm baths, and states that
 those of Baden have  been of service in some
 obstinate  cases of chronic palsy.  In recent,
 acute,  or sthenic  cases, he justly dreads the
 use of warm baths, whether simple, mineral, or
 medicated, as he has  known  apoplexy super-
 vene where they have been injudiciously pre-
 scribed.  The  sulphureous  thermal baths  of 
PARALYSIS—Treatment of.
5«
 Baden were recommended by Stoll, chiefly in
 lead palsy, after electricity had been employed.
 It may be noticed, farther, that the warm min-
 eral springs of Bath, Toeplitz, &c, have been
 frequently resorted to by paralytic patients, and
 sometimes with more or less advantage, when
 neither general nor local plethora or conges-
 tion exists, or when opposite states of the vas-
 cular system obtain;  that sulphuieous warm
 baths have been favourably  noticed by Baker,
 Summers,  Tolberg,  Waitz, and Hufeland ;
 that aromatic and spiced warm baths were rec-
 ommended by Riedlin ; warm salt-water baths
 by Reil ;  and  even  warm  chalybeate-water
 baths by Graefe, in this malady.
   255. g. The diet and regimen in palsy should
 depend entirely upon  the peculiarities of the
 case.   In most cases of hemiplegia, in all acute
 and sthenic cases, or whenever  general or lo-
 cal plethora is inferred to  be present, both the
 diet and regimen should be strictly antiphlogis-
 tic ; a farinaceous and vegetable diet, with sim-
 ple diluents only, being  adopted.  In  chronic,
 asthenic, and  anaemic  cases, light, digestible
 animal food may be allowed ;  but in every  in-
 stance  the predisposing  and exciting  causes
 should be viewed in connexion with the patho-
 logical conditions, and all these should  be duly
 estimated before either  the treatment, or the
 diet, or the  regimen  is assigned.  The chief
 part of the regimen in all cases  is the careful
 avoidance of the causes  ($ 157, et seq.) of the
 disease.
   [The treatment of palsy in this country, as
 in every other, has been very generally empiri-
 cal, owing to the extreme difficulty of ascer-
 taining in all cases  its true  pathology.  Prof.
 Geddings, of Maryland, has  reported several
 highly interesting cases which yielded to the
 influence of strychnine.  The late Dr. Barton
 employed internally, with much success,  in
 the Pennsylvania Hospital,  mustard seed and
 horse radish. Dr. Delafield, of New-York, has
 recorded several very interesting cases of par-
 tial paralysis of the face, in  which cupping,
 leeching, and blistering over the region of the
 portio dura, mercurial purgatives, and a seton
 in  the  neck were instrumental in effecting a
 radical cure.—(N.  Y. Med.  and  Phys.  Journ.,
 Dee., 1824.)   We succeeded  in curing a chron-
 ic case of hemiplegia of several years' stand-
 ing, in an old lady of 60 years of age, by an al-
 terative  course of mercury, which produced
 very copious salivation.
  There is a form of paraplegia, not particular-
 ly noticed by our author, owing to ramollisse-
 ment of the  spinal marrow, from retrocession
 of gout, which, so far as we  have seen, is gen-
 erally incurable.  The symptoms come on very
 insidiously, and it is often  not until irremedia-
 ble disorganization has occurred  that the true
 pathology becomes clearly established.  We
 have derived most benefit in  these cases from
 an open issue on each side of the spine, with oc-
 casional aloetic and mercurial purges, with al-
 terative doses of the iodide of mercury.   Where
 local paralysis has occurred from  pressure on
 the nerves of the part,  as in the arm, from
 sleeping upon it, or carrying  a weight upon  it
 for  a considerable distance, of which we have
 seen several cases, we have derived most ben-
efit from  moxas, or stimulating embrocations
to the  limb,  with an occasional cathartic and
 regulated diet.  In the paraplegia supervening
 on visceral disease, we have found local rem-
 edies, as frictions, blisters, &o, to the legs and
 thighs, more beneficial than applications over
 the spine itself.  Great benefit will often result,
 both in hemiplegia and paraplegia, from the free
 internal  and external use of sulphur, especial-
 ly in  the form of the natural sulphur waters ol
 our country, as those of Avon, Richfield, and
 of Western Virginia.  Cases of paraplegia, fol-
 lowing the remittent gastric fever of children,
 are often unconnected with spinal disease, es-
 pecially in those of a scrofulous temperament,
 and as a general rule, they are very obstinate
 under the most judicious treatment.   In that
 form  of  paraplegia connected with disease  of
 the kidneys, our attention should be partly di-
 rected to the first link in the chain of morbid
 action, or we shall be disappointed in the re-
 sults  of  our remedial measures.   Dr.  Eberle
 reports two cases  of hemiplegia in which he
 employed, with unequivocal benefit, the satura-
 ted tincture of the Rhus toxicodendron (Prac. of
 Physic, vol. ii.).  Doctor  Calhoun, of Philadel-
 phia, has proposed  the use of the tourniquet for
 restoring the power of muscles debilitated by
 long-continued inactivity (Philad. Journ. of the.
 Med. and Phys. Sci., vol.  i., p.  131).  Dr. Det-
 mold, of New-York, has  recommended a pecu-
 liar apparatus  of  his own contrivance  for a
 paralysis  of the lower  extremity commonly
 called  " weak ankle," together with the ex-
 ternal  application  of a spirituous preparation
 of strychnine (N.  Y. Journal of Medicine, vol.
 iv., p.  305).  Dr. Zabriskie, of Queen's coun-
 ty, has published a well-written essay on pa-
 ralysis from visceral disorders (Am. Journ.  of
 Med. Science, vol.  ii., N.  S., p. 360), in which
 he recommends general  and  local bleeding to
 subdue the  phlogosis, followed by mercurials,
 when these symptoms abate, and counter-irri-
 tation, to divert the inflammation.  After the
 inflammatory symptoms  have  somewhat sub-
 sided, he enjoins the use of strychnine, which
 he thinks is most useful in that form of the
 disease which is symptomatic  of visceral  irri-
 tation.  Doctor B. F. Joslin, of New-York, has
 given a history of two cases of paralysis of the
 face  (American Journ. of Med.  Science, vol. iv.,
 N. S., p. 322), cured by the local application of
 strychnine  (3 grs.  to 5J.  alcohol) to the part
 three  times a day.   In the treatment of palsy
 we are always to be governed  by a due regard
 to its  causes, its pathology, and  those various
circumstances which modify therapeutical in-
dications.  In applying galvanism or electrici-
ty to the treatment of paralysis, " It is neces-
sary,"  says M. Matteucci, " to  bear in  mind
two electro-physiological facts.   The  first is,
that an electric current, if transmitted through
a nerve for a certain period of time, destroys
the sensibility of the nerve, or, in other words,
 paralyzes it. If allowed to remain in  repose,
the nerve, after a certain interval, recovers its
excitability."  It has been discovered,  howev-
er, by Matteucci, that the excitability may be
restored in a much shorter period by passing a
second current through the nerve in an oppo-
site direction.   The second fact to be borne in
 mind is, that if the nerves of a  living animal
be submitted to the passage of the electric cur-
rent, renewed at short intervals, tetanic con-
tractions are excited; and if the experiment 
54                        PARALYSIS—Bibliography and References.
be continued for some time,  the nerves entire-
ly lose their excitability.
   " These  are  the  facts,"  says   Matteucci,
" which, independently of all theory or hypoth-
esis, should guide us in therapeutical  applica-
tion of the electrical current to palsies.   We
may, in fact, admit,  that  in some  cases of pa-
ralysis the  nerves of the  affected limb  are in a
condition similar to  that  produced by the con-
tinued passage of an electric  current. We have
seen that, to restore the excitability to a nerve
which had  been deprived  of it by an  electric
current, it  is requisite to conduct  the current
in the  opposite  direction.   Hence, to cure the
paralysis, the current should be  passed  in  a
contrary direction  to that which has produced
it.   In  a paralysis of motion the  inverse cur-
rent should be employed ; while, on the contra-
ry, in a paralysis of sensation,  the direct  cur-
rent should be  used.   In  a  case  of complete
paralysis, that  is,  of  both motion and sensa-
tion, there  is no reason to  induce us to prefer
the  one current to the other.
   " Theory also teaches  us a rule in its appli-
cation,  never to continue  the  passage of the
current too long, lest we augment the disease
we  wish to cure.  The more intense  the cur-
rent, the shorter should  be  its  duration;  and
as we have seen that the passage of the  elec-
tric current in the nerves, repeated at  short in-
tervals of time, considerably enfeebles their sen-
sibility when continued  for  a long time, we
must take care  and not pass  from  one  extreme
to another.  Theory  advises  us  to apply the
electric  current of an intensity which should
vary with the degree  of the malady, and con-
tinue its passage for two or three minutes, at
intervals of some  seconds.   After these two
or three  minutes, during which we shall have
communicated  from twenty  to thirty shocks,
we  should  leave the patient at rest for  some
time, and then  renew the  treatment."—(Med.
Chirurg. Review, April, 1845.)   The same  prin-
ciples, doubtless, should  regulate  the applica-
tion of galvano-magnetism, as of ordinary elec-
tricity.]

  Biblioo. and Refer.—Celsus, L. iii., c. 27.—Pliny, L.
xxvni., c. 16.—Paulus Mgineta,  L. iii., c.  18.—Oribasius,
Synopsis, 1. viii., c. 14.—Avicenna, Canon., 1. iii., fen. ii.,
tract. i., c. 2.—Zacutus  Lusitanus,  Med. Pract.  Hist., 1. i.,
No.  45 ; et vii., obs. 13, 14, 15.—Morgagni, De Sed. et
Caus. Morb.,  Ep. ii., art.  11, 14 ; Ep. iii., passim.—J. Sum-
mers, A short Account of the Success of Warm  Bathing in
Paralytic Disorders, 8vo.   London,  1751.—B. Franklin, On
Electricity in  Paralytic  Cases, Phil. Trans.  Lond., 1757.
—G. Cavallihi, Storia d'una Paralisia curata con l'Unzione
Mercuriale, 4to. Venez., 1769.—R. Charlton, An Inquiry
into  the Efficacy of Warm Bathing in Palsies, 8vo.  Oxf.,
1770.—J. N. Marquet, Traite de  Apop. Paral., &c, 12mo.
Paris, 1770.—R. Charleton, Three Tracts on Bath Waters ;
2d. On Palsies, 8vo. London, 1775.—Holler's  Disput. ud
Morbos, <fcc,  vol. i., p. 17, 97, 115.—Pereboom, in Schlegel,
Thes. Patholog. Therap., vol. i., p. 243.—B. Chandler, An
Inquiry into the Theories and Methods of Cure of Apoplex-
ies and Palsies, 8vo. Cantar., 1784.—Hart, in Philns. Trans.,
vol.  xlviii., p. 786.—P. Pott, Remarks on Palsy of the Low-
er Limbs found to accompany Curvature of the Spine, &c,
8vo.  Lond., 1779;  and Farther Remarks on the same, 8vo.
Lond., 1782.—J. Jebb, Select Cases of the Disorders com-
monly called Paralysis  of the  Lower Extremities, 8vo.
London,  1782.— C.  Cramer, De Paralysi et Setaceorum ad-
versus earn eximio  usu ;  in Sandifort,  Thesaur. Dissertat.,
vol. i., p. 127.—Narrative of the Efficacy of Bath Waters in
various Paralytic Disorders, 8vo.  Lond., 1787.—J. Alder-
son, An Essay on Rhus Toxicodendron, showing its Efficacy
in Paralysis,  &c, 8vo.  Hull, 1793.—Vaughan, in Mem. of
the  Medical Society of London, vol. i., art. 28, 8vo.  Lond.
— Falconer, in Ibid., vol. ii., art. 20.—Fathergill, in Med
 Observat. and  Inquiries, vol.  v., p. 394.—T. Kirkland, A
 Comment on Apoplectic and Paralytic Affections, &c.,8vo.
 Lond., 1792.—Rahn, in Museum der  Heilkunde, b. iv., p.
397 -L V Brera, Riflessinni  sul' Uso  del Fosfoio mXT
Emipleg.a 8vo.  Pavia, VM.-Louyer Villermay  in Mea,
de li  Soc.ete Med  d'Emulation, t. v , p. 4M.-Latowr, ]u
Ibid., t. vi., p. 57: Memoire sur  a P««>y»"« *« Eitremr-
tes  Infeneures, Ac, 8vo.  Pans,  W*--f?."ft  Cou»
d-Anat. Med., t. i., p. 303 ; t. iv., p. 118-ReW, Memorab.
Clin., fasc. iv., No. 4.-/. P. Frank, De Cur. Horn. Morbis,
1. ii., p. 46 ; et 1. v., 2, p. 497 ; 1. vi., 1, p. 260 ; et Interp.
Clinicie, vol. i., p. 145.—PiW, Nosograph. Philc.snph., t. it,
p. 93.—Marcus, Mngazin fur Therapie und Klinik, b. i., p.
325.—F. Frank, Nuovo Giornale di Milano, t. iv.— Gaultier
de Claubry, in Joorn. Gen. de  Med., t. xvi., p. 18.—Hufe-
land, Journ. der Pr. Heilk., p. 78, 1811.—M. Baillie, Med.
Trans, of Roy. Coll. of Phys.  Lond., vol. yi.—R. Powell,
Observat. on some Cases of Paralytic Affection, 8vo.  Lon-
don, 1814.—T. Copeland, Observat. on the Symp. and Treat.
of the diseased Spine, Ac, with Remarks on the consequent
Palsy, 8vo. Lond.,  1815.—Mo/fte,, Recueil d'Observat. sui
1'Apop. et  la Paral.  gueris sans retour, <fec, 8vo.  Paris,
1816.—J. Parkinson, An Essay on the Shaking Palsy, 8vo.
Lond., 1817.—J. Copland, in Lond. Med.  Repos., vol. x\ii.,
p. 379 ; vol. xviii., p. 523.—Merat, Diet, des Sciences Med.,
t. xx., art. Hemiplegic—Chamberet, in  Ibid , t. xxiv., art.
Paralysie et Paraplegic—J. Cooke, A Treatise on  Nervous
Diseases, vol. ii. ; on Palsy, 8vo.  Lond., 1823.—V. A. G.
Richter, Die  Specielle  Therapie, <fcc, b. viii., p. 821.—
Rostan, Recherches sur Ramollisseinent du Cerveau, &c,
8vo.  Paris, 1823, passim.— Rochoux, Diet, de Med., t. xv.,
art. Paralysie.—Burder, in Lond Med. and Physical Journ.
for June, 1827.—Hufeland, in Journ. des Progres des Scien.
Medicales, t. iii., p. 254.—Leuret, in Ibid., t. xi., p. 187.—
Duges, Archives  Gener. de Med., t.  xx., p. 258.—Cazau-
vieilh, in Ibid., t. xiv., p. 5.—Pelletier, in Ibid., t.  xviii., p.
200.—Bayle, in Revue Med., t.  i., p 33 ; t. ii., p. 143, 1825 j
et t. ii.,  p. 247,  1826.—Calmeil, de la  Paralysie  chez les
Alienes, 8vo.  Paris, 1826.—Taliaferro, Am. Jour, of Med.
Sci., vol. vi., p. 99;  et Ibid., p. 227: et t. viii.,  p. 236.-^4/-
bers, in Johnson's Med. and Chirurg. Rev., No. 43,  p. 227.—
S. D. Broughton, Cases Must, of the Distinct Functions of
the Nerves, in Lond. Med. and Phys. Journ., vol. lvii., p.
413 ; Trans, of Prov. Med. Association, vol. ii., p. 300; and
Lancet, Oct. 1,1836, p. 34.—L. F. Calmeil, De la Paralysie,
consideree chez les  Alienes, 8vo.  Paris, 1826.—J. Abet-
crombie. Pathological and Practical Researches on Dis. of
the Brain and Spinal Chord,  3d edit.   Edinb., 1834.—2'.
Chevalier, in Trans, of Med. and Chirurg. Soc., vol. iii., p.
102.—Shaw, in Ibid., vol. xii., p. 105.—//. Earle,  in Ibid.,
vol. xiii, p. 516.—E. Stanley, in  Ibid., vol. xviii., p. 260.—
Seymour, Medical Gazette, Oct. 29, 1836, p. 151 ; and Dec.
24, 1836, p. 445.—R. Graves, in Ibid., May 20,  1837, p. 257.
—Chandler, Dublin Journ. of Med., March, 1837,  p. 164.-
Craigie, Edin. Med. and  Surg.  Journ.,  Oct.,  1836, p. 318.
—Todd, in Cycl. of Practical Med., vol. iii., p. 240.—B. C.
Brodie, On Injuries of the  Spinal Chord ; in Trans, of Med.
and Chirurg. Soc. of London,  vol.  xx., p. 118.— W. Budd,
in Ibid., vol. xxii., p. 153.—M Hall, in Ibid.,  vol. xxii., p.
191 ;  et vol.  xxiu., p. 121-182; and  vol. xxiv., p. 83— E.
Stanley,  in Ibid., vol. xxiii., p. 80.—C. Hawkins,  in  Ibid.,
vol. xxiv., p. 51.—J. Webster, in Ibid., vol. xxvi., p. \.—J.
R.  Bennett, in Lib. of Proct. Med., vol. ii., p. 274.
  Paralysis from Poisons.—Borellus, Cent, iv., obs 32.
— Hoffmann, De Nerv. Resolut., opp. iii., p. 203.— De Haen,
Ratio Medendi, vol. iii., p. 113.—Bang, in Acta  Reg. Sue.
Med.  Hann., vol. i., p. 102.—Stoll. Rat.  Medendi, part ii.,
p. 416.—Falconer, Mem. of Med. Society of Loud., vol. ii.,
p. 224.—Brandis, Ueber die Wirkung der Eisenmittel. <fcc,
p. 150.—Percival, Essays, vol. ii., p  290.—Murray, in Edin.
Med.  and Surg.  Journal, vol.  xviii., p. 167.—Bateman, in
Ibid., vol. viii., p. 376 ; and vol. ix., p. 180.—Berat, Bei-
trftge zur gerichtlichen Arzneikunde, b. iv., p. 221.—Bur-
ger, in Horn's N. Archiv., I>. ii., p.  340.—Merat, Traite de
la Colique Metallique, p. 275.—R. Bright, Reporis of Med-
ical Casi s, &c, 4to, vol. ii., p. 495.— R. Christison, A Trea-
tise on Poisons, <fcc, 3d edit., 8vo, p. 290, 386, 515.  Edin.,
1836.
  Paralysis of Infants and Children.— Cazavvieilk,
in Archives Gener. de Medicine, t. xiv.,p. 5, 349.—E. Ken-
nedy, in Dublin Medical Journ.. vol. x., p. 430.—R, Doner-
ty, in Ibid., vol. xxv., p. 82.— H. Kennedy, Dublin Medical
Press, Sept. 29, 1841.—M'Cormac, in Lancet, Mav 27.1813.
—C.  West, in Med. Gazette, vol. xxxii., p. h29i—Colmer,
in  Ibid.,  April 21,  1843.  (See, also, the Biblioo. ahb
Refer, to arts. Apoplexy, Brain, Structural Lesions of,
and Spinal Chord.)
   [Ad. Biblioo. and Refer.— Wm. T. Tohafero, Paraly-
sis successfully Treated  with Moxas,  in Am. Jour. Med.
 Sci.,  vol. vi., p. 99.—J. H. Miller, in Am. Jour. Med. Sci.,
 vol. xiv, p. 321, On Galvanism  in Paralysis.—W. E.Hor
 ner, A Treatise on  Pathological Anatomy.—J. R.  Lucas, in
 Am.  Med. Recorder, I8'26, p. 239 —Boston Med. and Surg.
 Jour., vol. xxviii., p. 362.- S.  B. Tobey, in Bost. Med. and
 Surg. Jour., vol. xxvn., p. 415 (Case of partial paralysi."  of
 the fare in a child cured by galvanism, applied by moans  of
 " Page's  Revolving Armature for Shocks").— VV. J. Barber,
  in  Bost. Med. and  Surg. Journ., vol. xviii., p. 263.— B  B-
  Strobel, in South. Med. and Surg. Jour., 1636.—H. Chctvt- 
PAROTID GLANDS—Functional Disorders of.                    55
for. in Bost. Med. and Surg. Jour., vol. xv., p. 91.—S. H.
Dickson, Essays on Pathology, Therapeutics. &c, 2 vols.
Charleston, 8vo, 1845.—R. Dunglison, The Practice of Med-
icine, 2 vols., 8vo.  Philad.. 1844.—W. P. Dewees, A Prac-
tice of Physic, dec, 8vo.   Philad., 1833.—//. .4. Potter, in
New-York Journ. Med. and  Collat. Sci., vol. iv., p. 174.—
W. P. Buel, in New-York Journal Med. and Collat. Sci.,
vol. ii., p. 34.— R.J. Graves, Clinical Lectures, with Notes,
by W. W. Gerhard. Phil., 1842, 8vo.—John Eberle, A Trea-
tise on the Practice of Medicine, 2 vols., 8vo.  Phil., 1835.
—J. Bell and IV. Stokes, Lectures on the Theory and Prac-
tice of Physic, 3d ed., 2 vols.  Philad., 1845, 8vo.—Samuel
Annan, in Am. Jour. Med Sci., vol. ii., N.  S., p. 99.-7. B.
Zabriskie, in Am. Jour. Med. Sci., vol. ii., N. S., p. 360.—
Detmold, in New-York Journ. of Med., vol. iv., p. 305.—S.
Calhoun, in Phil. Jour, of the Med. and Phys. Sci., vol. i.,
p. 131.— Edward Delafield, in New-York Med. and Phys.
Jour., Dec, 1824.—B. F. Joshn, in Am. Journ. Med. Sci.,
vol. iv., N. S., p. 322.— Alban Goldsmith, Case of paralysis
from  fracture, in which the spinous processes of two verte-
brae, half of the third and the whole of the  fourth, were re-
moved by an operation, with partial success, in Am. Med.
and Surg. Journ., 1829]

   PAROTID GLAND —Diseases of.—This
gland is often the seat of inflammation, of con-
gestion, of scrofulous enlargement and inflam-
mation, and of several other structural lesions.
It is liable to be variously  affected by  the in-
gesta, whether alimentary  or medicinal;  and
it is often the seat of symptomatic disease, par-
ticularly in the course of those maladies which
reduce vital  power or  contaminate the blood
The diseases of the parotid may be divided into,
1st.  The functional; 2d. The inflammatory ; and
3d. The structural.
I. Functional Disorders  of  the  Parotid
   Gland.
     Classif.—I.  Class,  I. Order (Author).
   1. These disorders have received  but little
attention from medical writers ; for, unless in
a few prominent cases, they seldom attract at-
tention, and  even in these they are generally
symptomatic of some more important malady to
which a primary and principal attention should
be paid.  The functional disorders of the parot-
id consist chiefly of excessive and diminished se-
cretion.  Doubtless, an alteration of the quality
as well as of the quantity of the secretion often
obtains, but the latter change is more obvious,
while the former can be inferred chiefly from
the  deposites formed from the salivary fluid,
either in the  ducts or upon  the teeth ;  or from
the action of chemical re-agents, which, accord-
ing to M. Donne, evince more or less of acidity
in inflammatory diseases, with an increase of
the animal elements.   (See art. Saliva.)
   2. i.  Deficient Secretion of the Parotids
arises from numerous circumstances and agents
affecting  the digestive organs or the constitu-
tional powers.  Great mental anxiety ;  heating
articles of  food, condiments, and beverages  ;
general vascular excitement; and morbid states
of the blood, may diminish or altogether arrest
the action of the parotids and  other salivary
glands.  Irritation or inflammation of the stom-
ach, or of other digestive organs, sometimes
has a similar effect;  and numerous stimulating,
astringent, and anodyne  medicines impair the
action of  these glands, although in a very un-
certain and capricious manner.  Deficiency of
the salivary secretion  also generally  attends
most fevers and inflammatory diseases, more
especially those  fevers in  which  the blood is
early contaminated  ; and  in the  more malig-
nant maladies, when the action of the parotids
is arrested, the glands themselves become swol-
len and tender.  The secretion of these glands
is generally  diminished  in  diabetes and  dis-
eases of the  kidneys.   (See  arts.  Saliva and
Salivation.
  3. ii. Increased Action of  the  Parotids
often arises from the ingestion of various arti-
cles of food, condiments, and medicines ; but
when it is caused by food or  condiments, it is
generally transient and slight.  It is often very
remarkable and prolonged when caused by med-
icine, especially by mercurials ; and it is usually
more moderate and  irregular when it is symp-
tomatic  of other diseases, as of affections of
the pancreas, or of  the stomach or duodenum,
&c.   Seeing, however, that the functions of the
parotid  are  generally affected  co-ordinately
with those of the other salivary glands, whether
quantitatively or qualitatively, they will be more
particularly considered in relation to diagnosis
and prognosis, under the heads Saliva and Sal-
ivation.
II.  Inflammation  of the Parotid Glands.
Synon.—Uapunc  (from irapa, near,  and ovc
  the ear), Galen.   Parotis, Vogel, Sauvages,
  Pinel.  Parotitis,  Darwin.   Cynanche Paro-
  tidaa, Cullen, Parr.   Angina externa, Russel.
  Empresma  parotitis,  Good.   Cauma  paroti-
  tis, Young.  Oreillons,  Parotide, Ourles, Fr.
  Entzundung der Ohrdruse,  Germ.   Parotite,
  Ital.   Mumps,  Branks, Inflammation  of the
  Parotid.
    Classif.—1st Class, 2d Order (Cullen).  3d
       Class, 2d Order (Good).  III.  Class, I.
      Order (Author).
  Defin.—Pain, tenderness, and swelling in the
situation of one or both parotids, with symptomat-
ic fever, occurring either sporadically, endemically,
or epidemically.
  5. i. Causes and  History.—A.  Parotitis  is
most frequently observed in children, and about
the period of puberty, and  but  rarely after
twenty-five or thirty years of age, in an acute
form, although it sometimes occurs in  advan-
ced life as a chronic  disease.  M. Begin thinks
that it is more frequent in children of the male
than of the female sex.  It  proceeds, sporadi-
cally,  from cold  conjoined with humidity, and
from currents of cold  air.  It is sometimes so
prevalent in  cold  and  humid localities, espe-
cially during the colder months,  as  to  be en-
demic ; and it is occasionally epidemic in  exten-
sive districts.   When thus prevalent, it has ap-
peared in many instances to have  been  propa-
gated by infection, particularly in  schools and
in ships, &c, where a single case has frequent-
ly been followed by  very many; but  in these
circumstances  the propagation  of the com-
plaint may be imputed  to exposure to the same
physical agents  and atmospherical states; al-
though the removal  of a boy from a school  in
which the disease prevailed to a locality where
it was unknown, and the subsequent infection
of other children by  the one  removed, militate
against these agents having  been the  cause,
and evince an infectious property.   I have seen
two instances of the disease appearing in nurs-
es while attending  on persons affected with
erysipelas of the face  and scalp, and in both
these the  adjacent  cellular tissue was much
implicated.  One or both glands may be  affect-
ed ; and when the disease is epidemic, the max-
illary glands are often similarly diseased.  The
accumulation of morbid secretions or of faecal
matters  in the prima via evidently favours or
predisposes to an attack of the complaint.  Ep- 
56                      PAROTID GLANDS—Inflammations of.
idemic parotitis very rarely attacks the same
individual a second time.  In scrofulous  per-
sons, simple or sporadic parotitis often assumes
a modified character, and becomes  chronic or
prolonged.   It not infrequently follows scarlet
fever and other exanthematous fevers, and then
assumes a very severe and troublesome form,
particularly after scarlatina, the inflammation
often extending far into the adjoining cellular
tissue and to the lymphatic glands of the neck
  6. B. Symptoms.—a. The invasion of the com-
plaint is usually indicated by irregular chills or
rigours, followed by lassitude ;  pain and tender-
ness, with stiffness in the neck ; frequency of
pulse ; heat of  skin ;  difficulty of mastication,
owing to swelling and  pain in the situation of
one or both parotids ;  occasionally a somewhat
increased flow  of saliva;  slight difficulty of
deglutition,  more or less increased when  the
adjoining glands are affected, and by the usual
attendants on symptomatic fever, as thirst, loss
of appetite, costiveness, headache, &c.
  7. In some cases the symptoms  are  even
milder than now stated.  The swelling, pain,
tenderness, and tension are slight; the pulse is
but little affected ; and the organic functions
are not materially disturbed.   From this state
of extreme mildness every grade of severity
occurs,  until the disease assumes much  more
intense characters, both  locally and  generally
In these latter the swelling is great, not mere-
ly in the situation of one or both parotids, but
extends to  the  sub-maxillary glands,  some-
times also to the tonsils, and to the adjoining
cellular tissue.   In these cases  there are gen-
erally much  heat and  sensibility of the parts,
often with  more or less  redness, and always
with difficult mastication and deglutition, ow-
ing to the great tumefaction.  There are also
acute symptomatic  fever, with urgent thirst,
loss of appetite, severe headache, flushed coun-
tenance, &c.
   8. b.  The duration of the complaint varies
much in the simple and sporadic form of the dis-
ease ; beginning to subside in four or five days
in some cases, and continuing to increase du-
ring a longer period, or passing into suppuration
in others.   When it follows the eruptive fevers,
especially scarlatina, or  when it occurs in the
scrofulous diathesis, as it frequently does, it  is
often of longer duration than in other circum-
stances, or when it appears epidemically ; and
it more readily passes into  suppuration  of  a
chronic kind, the matter being discharged ex-
ternally, and but rarely by the external meatus
auditorius.   In the  epidemic disease, perspira-
tion usually breaks out  on the fourth or  fifth
day, commencing and becoming more copious
 about the neck, breast, and head, but often ex-
tending more generally.  The pain, tension, and
 swelling of the parotids  afterward  diminish,
 and the affected parts return  to their natural
 state.
   9. c.  Suppuration, which is more frequent  in
 the simple, in the consecutive, and in the scrofulous
 states of the disease than in the epidemic, is
 commonly  indicated  by  a greater intensity of
 the local symptoms ; by marked redness of the
 more swollen part ; by a more central and cir-
 cumscribed elevation ; by the pain being less
 acute and  more throbbing ; by the more ele
 vated part of the tumour becoming softer, and
 ultimately betraying more or less evident fluc-
tuation.  The cellular tissue surrounding  he
gland or connecting its lobules is generally the
ieat of suppuration.   Bichat and others  have
supposed that the lymphatic glands surrounding
the parotids are more affected than the parotids
themselves ; and this  may be the  case, espe-
cially in the consecutive (y 11) and scrofulous va-
rieties of the disease.  Probably, also, in the
epidemic form, these parts, with the glands them-
selves, and  the  adjoining cellular  tissue, are
more or less implicated.
  10. d.  Metastasis of disease from the parotids
to the testes, mammae, or even  to the brain or
its membranes, has been often observed and no-
ticed by writers as one of the terminations of the
disease, especially when appearing epidemically.
When this occurrence takes place, the swelling
under the ears rapidly  subsides, and either the
testis or the mamma on the same side with the
affected parotid  becomes painful and swollen.
When both parotids have been affected, the
metastasis has in rare  instances taken place to
both testes or to both mammae.   I have not met
with a case in which suppuration has occurred
in these parts after metastasis from the parotids.
In  some instances the parotids have  become
again affected upon the subsidence of the en-
gorgement of the testicle   I have observed but
few instances in which the brain or its mem-
branes have been affected consecutively  upon
the sudden  disappearance of the disease of the
parotids ; and these recovered under the treat-
ment about to be noticed.
   11.  C.  The nature of inflammations of the
parotids, in their several modes of manifesta-
tion, requires more consideration than has hith-
erto been devoted to it.  That the epidemic slate
of the disease is different in many respects from
the primary and simple form is  shown by vari-
ous circumstances, to which I  will more par-
ticularly allude.—a. Simple parotitis, whether oc-
curring primarily from cold or any other cause,
or consecutively of eruptive fevers, or of  other
affections  implicating the throat or mouth, is
more distinctly an inflammatory disease, and is
more  strictly local than the epidemic  malady.
It is also more prone to assume all the  charac-
ters of inflammation of glandular parts, and to
pass into suppuration, than the latter form.
   12.  b. Epidemic parotitis is less strictly inflam-
matory, at least in a large proportion of cases,
and is more manifestly congestive ; consisting
rather in active  congestion, or an engorgement
of the parotids  and  adjoining glands, than the
simple form of the  disease.  It is also less a
local than a constitutional malady ; and this, as
 well as its more congestive character, is shown
 by its originating in  infection, by its disposition
 to metastasis, by  its definite course, and  by its
 frequently terminating by a distinct crisis.  The
 simple or sporadic  complaint  is attended by
 fever, which is merely symptomatic of the local
 inflammatory action ; while the  epedimic is char-
 acterized by fever, which is less a symptomatic
 than  a  primary or idiopathic  malady, and of
 which the swelling  of the salivary glands is an
 attendant or local  feature, consisting  of con-
 gestion or  engorgement of these glands rather
 than of actual inflammation   In the epidemic
 or specific  form  of the disease, the fever is
 rarely sthenically inflammatory, but generally
 is either mild, or partakes more of an adynamic
 or asthenic character, and requires a different 
PAROTID GLANDS—Inflammations/of.                       57
treatment from the truly inflammatory or sim-
ple form of the complaint.
  13. c. From this it will be seen that I consid-
er Parotitis, or inflammation of the parotid, to
consist of the following varieties and stales:
namely, 1st.  Simple or Common Inflammation,
occurring, a. primarily, or independently of pre-
existing disease ;  and, b. consecutively, or follow-
ing eruptive fevers and affections of the mouth
and throat, in both which states it usually pre-
sents an acute character;  2d.  Scrofulous In-
flammation of the parotids, or parotitis affecting
the strumous diathesis, and usually assuming
a chronic or indolent form ;  3d. Epidemic Paro-
titis, or that proceeding from a specific cause,
and presenting a  specific or distinct and regular
course.   Indeed, it is doubtful whether this
last should be arranged as a local inflammation,
or rather  as a specific form of fever caused
by infection, and  characterized  by  congestion
or engorgement  of the salivary glands, and a
tendency to metastasis  to  the testicles, and
thence to the brain.
  14.  ii. Treatment.—The treatment of in-
flammations of the parotid should vary  with
the  severity of the local symptoms, and  with
the character of the attendant fever.—a. In the
simple form of the disease, when primary and
slight, moderate warmth, sustained by the ap-
plication of flannel locally, and cooling aperi-
ents  and diaphoretics, are generally sufficient
to promote resolution.  I  do not believe that
cold  applications  are  beneficial  in this  com-
plaint ; they  may  even  prove  injurious.   In
more severe cases, where inflammatory action
is unequivocally  manifested in the gland and
its vicinity, blood  should be taken away locally,
and  a more strict and antiphlogistic treatment
and regimen adopted, as in other cases of in-
flammation.  If suppuration commence, it should
be promoted by the usual warm applications,
and  an early outlet be given to the matter
which is formed.
  15.  b.  In the consecutive form of parotitis, par-
ticularly that following the anginous states  of
eruptive fevers, even local  depletion should be
cautiously prescribed, and with strict reference
to its effects.  Diaphoretics, stomachic  aperi-
ents, warm baths, and diuretics are  generally
required  in these  circumstances;  and if the
swelling become  sub-acute or indolent,  small
doses of the  iodide of potassium, with  liquor
potassae, may be given in the compound decoc-
tion of sarsaparilla.  If suppuration take place,
the matter should be early evacuated, and the
iodide and solution of potash may  be given in
the decoction of cinchona,  &c, and change of
air, especially to  the seaside, advised.
  16.  c.  The scrofulous, sub-acute, and chronic
states of parotitis sometimes require the appli-
cation of a few leeches to the parts, or to their
vicinity,  and the  means just  recommended ($
15) firmly persisted in for a considerable peri-
od.   Brandish's  alkaline solution may be sub-
stituted,  in many cases, for the solution of pot-
ash   When there is some  degree of anaemia,
or when  the affection occurs in females  about
the period of puberty, with delayed or scanty
menstruation, the iodide of iron may be  taken
in the sirup of sarsaparilla,  and warm salt-wa-
ter bathing, or warm salt-water hip  baths re-
sorted to.
  17.  d.  The epidemic form of the complaint is
so slight in some cases as to require merely pro-
tection from cold and humidity, and attention to
the state of the secretions and excretions.   The
affected parts ought to be  kept  moderately
warm, and the excretions from the bowels and
skin  promoted.  When the local  affection is
more decidedly inflammatory, the  swelling of
the neck  being considerable, and  the surface
generally red,  febrile action being also great, a
number of leeches may be applied, and their op-
eration promoted by warm fomentations.  Cold
applications are especially hazardous  in  this
form of the complaint, as favouring metastasis
to the testes ;  and this risk may even be incur-
red by active purgatives.   Antimonial diapho-
retics and gentle aperients are the safest means
which can be employed in most cases of this af-
fection.  If metastasis to the testicles or to the
mammae occur, these are also the best reme-
dies, in connexion with the horizontal posture.
In these secondary states of disease, the appli-
cation of  leeches, followed by warm fomenta-
tions and poultices, is generally necessary.   An-
timonial emetics are often of service in inflam-
mation of the testes ; but  when this disease
occurs suddenly upon the disappearance  of
parotitis, the subsequent metastasis of the mal-
ady to the brain should be dreaded, as it some-
times takes place ;  and it may be favoured by
the active operation, and consequent perturba-
tion of emetics, and  by the application of cold
to the diseased testicles.
  18. It is possible  that parotitis, caused by
cold  and humidity,  may assume an endemic
form, or may affect  a number of persons who
are exposed to these causes, or exist in a par-
ticular locality.  It has thus affected a consid-
erable number of a ship's crew, and it has then
manifestly arisen from the  once  general prac-
tice of daily, and even more frequently, wash-
ing the  decks,  now  happily abandoned.  The
cold  and humidity produced in a confined space
by this practice were the sources of more mal-
adies, especially of rheumatism, erysipelas, fe-
vers, &c, than were recognised  in those days.
Mr. Noble, in  his account of parotitis endemic
in a  ship of war, states that  the swelling and
redness of the neck suddenly subsided on the
fourth and fifth days, and were  in all the ca-
ses rapidly followed by metastasis to the  tes-
tes, the epididymis and spermatic chord not be-
ing affected.  In two instances  a  second  me-
tastasis took place from the testes to the brain,
the cerebral symptoms being  well marked and
severe.  In no instance did the disease return
to the parotids.  This remarkable frequency of
metastasis was probably favoured  by the  per-
sistence of the cause originating the disease,
and by the use of cold applications and drastic
purgatives.
  19. e. In some instances, especially in aged
persons, or in  females about or  soon after the
change of life, the complaint assumes a chronic
state, obscure  inflammation extending to the
adjoining cellular tissue, and giving rise to the
formation  of matter, and even to  indolent ulcer-
ation, if a suitahle treatment  be not employed.
In these, a few leeches should be applied, and
sometimes repeated, and an antimonial emetic
exhibited.    Subsequently,  antimonial diapho-
retics may be  given, and,  if matter form, fo-
mentations, poultices, and an early outlet to the
matter are requisite.  If the disease hecomo 
PAROTID GLANDS—Inflammations of.
!>8

indolent, or if swelling and hardness remain,
the iodide  of potassium, with liquor  potassae
and sarsaparilla,  should be prescribed.  The
external application of a weak tincture of io-
dine or of the iodide of potassium, in the form
of ointment, may also be tried ;  but I have sel-
dom seen this  ointment beneficial unless the
proportion of iodide has been much smaller than
that usually prescribed.  Dr. Neumann (Edin^
Med. and Surg. Journ., No. 93, p. 452) applied
a plaster, consisting of eight parts of mercurial
ointment, and one of the iodide of potassium,
to the swollen gland with great success, during
an epidemic parotitis which prevailed in Silesia,
having  premised  an  emetic.   When parotitis,
either simple or epidemic, occurs about the pe-
riod of  puberty, and previous to menstruation,
it is apt to become obstinate and chronic, par-
ticularly in scrofulous habits.  In these cases,
the iodides combined according to the peculi-
arities  of the case ; local depletion, emmena-
gogues, horse exercise, warm salt-water bath-
ing, stomachic aperients,  &c,  are most ser-
viceable.
III. Organic Lesions of the Parotids.
     Classif.—IV. Class, I. Order (Author).
   20. Structural  lesions of these  glands, both
the consequences of  inflammation  and inde-
pendent of this state of disease, are sometimes
observed.   The most  frequent  and  important
of these are enlargements, scrofulous disease,
6cirrhus, and open carcinoma.   To these may
be added the congestions and asthenic inflam-
mation, sometimes terminating in sphacelation,
 occasionally observed  in malignant fevers, and
 frequently in the plague.
   21.  A. Chronic enlargement  of the parotid,
 without pain, heat, or any other indication of
 inflammatory action,  is sometimes  met with.
 In some cases the gland increases to three or
 four times its natural size.   It is difficult to
 determine  how  far hypertrophy  is owing to
 change in the lobular  structure, or minuter
 granules composing the gland, or to deposites
 of lymph in, or change in the nutrition of, the
 interlobular and surrounding cellular tissue.
 Most  probably both orders of structure, and
 even  the  surrounding  lymphatic glands,  are
 more or lees  implicated ; and  this seems the
 more likely, since the researches of Murat and
 others  have shown the granules and minute
 lobules of the gland to be affected in parotitis.
 A very remarkable case of chronic enlargement,
 first of one parotid, and afterward of the other,
 the first having  become much reduced after a
 considerable time, lately came under my care.
 The history of this case, as well as of others
 which I have seen, led me to infer that the en-
  largement was consequent upon obstruction or
  obliteration of the  canal of the duct.   After
 having had recourse to a variety of means, the
  enlargement was at last entirely removed by a
  prolonged course of the iodide of potassium in
  minute doses  with  coniurn.  In this  instance,
  from half a grain to a grain only of the iodide
  was given in the  twenty-four hours, a larger
  dose occasioning uneasiness and febrile excite-
  ment.
    22.  The symptomatic enlargements, conges-
  tions,  asthenic inflammations, softenings, and
  even gangrene,  sometimes  observed in malig-
  nant fevers and the plague, were imputed by
  Ujchat and others  rather to alterations in the
connecting and surrouna.ng cellular tissue and
lymphatic glands than to change  in the gran-
ules of the gland itself.   But the researches of
Murat and others have shown that these gran-
ules are affected  from the commencement of
simple parotitis, while those of Bulard and
Clot-Bey have evinced  that the  surrounding
lymphatic glands are more especially implica-
ted in the plague, and in  other sympathetic en-
largements in the region  of the parotids.
  23.  B. Tumours of various kinds are some-
times seated in the  parotid, and scirrhus and
open  cancer,  commencing either  superficially
or in the gland itself, or in the lymphatic glands
surrounding the parotids, are occasionally met
with.   These have  been the themes of pro-
longed surgical disquisitions, as  well  as the
subjects of surgical operation.  But in this last
resource the dexterity or daring of the opera-
tor has been oftener displayed than the pro-
priety and success of the undertaking.   Com-
paratively few cases admit of this procedure—
in very few ought it  to be attempted when the
disease is malignant; and  in none of a non-
malignant nature, without  having previously
duly tried the means already indicated both  in
this article and in those  on Scrofula and Tu-
mours.  (See arts. Saliva, Salivary Ducts, and
Salivation.)
   [It is very important,  in the treatment of tu-
mours situated in the parotid region,  as well
as other  parts of the body, to allay all mental
anxiety, as it is found that disquietude of mind
and perturbation of spirits are powerful causes
in promoting morbid growths.   As they gener-
ally have  their origin in  mal-assimilation, or
faulty secretion and excretion, it is of the first
importance to shape  our  remedies with these
 ends in view; for, without attending to these
 functions, local applications will be altogether
 useless ;  and even  should the tumour be  re-
 moved, similar deposites will take place in oth-
 er parts of the body.  If the healthy functions
 of the various secreting organs can be main-
 tained, there is  every probability  that morbid
 growths  will eventually disappear ; at any rate,
 they will rarely become malignant, or  call  for
 a surgical operation.   We  have for  several
 years been in the habit of treating tumours med-
 ically rather than surgically, and we  have met
 with but very few cases in which extirpation
 was  called for.  Where a tumour is so situated
 as seriously to  disturb  the functions of parts
 essential to life, as  over the trachea, or within
 the mouth and about the jaws, its removal be-
 comes not only justifiable, but  absolutely  ne-
 cessary.  It may be that the presence of the
 tumour,  although not malignant, is the cause
 of continual apprehension on the part of the pa-
 tient, which cannot be allayed except by its re-
 moval ; here  it will be  in vain  to attempt  to
 check its  growth  by  local or constitutional
 means, and  it may, therefore, with propriety
 be extirpated.   By strict attention to hygienic
 regulations,  air, food,  exercise,  and  bathing,
 with a mild, alterative course of iodine and sar-
 saparilla, we shall succeed, in a large majority
 of cases, in allaying the pains and checking the
 growth of tumours, if we do not  succeed in ef-
 fecting their entire removal by absorption.  We
 agree with our author that a surgical operation
  in the first resort is never advisable, except un-
  der  the circumstances above detailed]. 
PELLAGRA—Symptoms and History of.                        59
  Biblioo. and  Refer. — O. Valentini,  Discorso Med.
Chirurgico intorno alle Parotidi nelle Febbri. Perug., 1736.
—E. G. Schmidt, Abhaudl. von den Geschwulsten am Halse,
&c.  Brauus., 4to, 1755.—Rochard, in Journ.de Medecine,
t. vii., p. 379, 1754.—M. Stoll, Rat. Med., p. iv., p. 263 —
Mariotti, Delle Parotidi ne' Mali Acuti, 8vo.  Perug., 1785.
—R. Hamilton, Account of the Mumps, Trans, of Roy.
Soc. of Edin.,  vol. ii., 4to.  1790.—/. B. Siebold, Hist.
Systemaiis Salivalis Physiol,  et Pathologice considerati,
rfcc, 4lo.  Jena, 1797.—A. L. Murat, La Glande  Parotide
consid. sous ses Rapports Anatom., Physiolog., et Patho-
logiques, 8vo.  Paris, 1803.—/. Noble, in Edin. Med. and
Surg.  Journ., vol. iv., p. 304  (Endemic).—A. Duncan, in
Edin. Med. and Surg. Journ., vol. vii., p. 431 (Epidemic).
—Murat, in Diet,  des Sciences Med., t. xxxviii., art. Ore-
Won; ett. xxxix., art. Parotide.—E. Gendron, Mem. sur les
Fistulcs de Glande Parotide, 8vo.  Paris, 1820.—Hammers-
ley, in New-York  Medicul Repository, July, 1822, p. 443.—
Rochoux, Dict.de Med., t. xvi., art. Parotide.—Begin, Diet.
de Med. et Chir. Prat., art. Parotide.—W. Kerr, Cyclop, of
Pract. Med., vol. iii., p. 260.—A. Duplay, Observat.  de
Parotides survenus dans le Cholera, in Archives Gener. de
Med.,  t. xxix., p. 365.  1832.
  [For an account of American operations for the removal of
the parotid gland, see Reese's edition of Cooper's Sur-
gical Dictionary, p. 259].
PELLAGRA.  — Synon.   Dermatagria, Titius.
   Scorbutus  Alpinus, Frank.  Ichthyosis Pella-
   gra, Alibert.  Tuber  Pellagra, Parr.  Lepra
   Lombardica, Swediaur.  Elephantiasis Italica,
   Good.  Pellagre, Fr. Pellarella, Pelagra, Mai
   di  Miseria,  Malattia dclla  Miseria, Mai del
   Sole, Mai  Roso, Ital.
     Classif.—3d Class, Ath Order (Good).
       IV. Class, IV. Order  (Author).
   1.  Defin.—A  squamous eruption,  chiefly  on
those  parts of the body exposed to the sun  or air,
preceded and attended by disorder of the digestive
organs and  nervous  system ;  accompanied  with
general cachexia ; a sense of burning pains in the
trunk and limbs ; ennui and melancholy ; intermit-
ting at first,  afterward more continued; endemic
and hereditary.
   2. The antiquity of Pellagra has been  a sub-
ject of doubt.    Moscati  and  others consider
that the disease has  not been  known much be-
fore  the middle  of the  last century, while
Strambio, who was  physician and director of
the hospital established near Milan for the re-
ception of pellagrosi, states, in his treatises pub-
lished in 1784-7, that he had  seen  many pella-
grosi in the hospital, who assured him  that
their fathers and grandfathers had died of the
malady.  Dr. Holland adds,  that  F. Frapoli,
physician to the hospital  at Milan, in his trea-
tise on the disease, published in 1771, also con-
tends  for its antiquity, and supposes it to  be
the same disorder as the  one called Pellarella,
which is casually noticed in the records of the
Milan Hospital for the year 1578.   It is certain,
however, from the concurrent testimony of all
writers on the malady, that pellagra has been
rapidly increasing itself since the middle of the
last century.  Dr.  Holland, who has investi-
gated the disease more closely than any Eng-
lish writer,  remarks  that, at  the  time when
Strambio wrote (in 1784),  the pellagrosi form-
ed about one twentieth part of the population
in the districts principally suffering under the
disorder, namely, in  the Alto-Milanese,  where
the country rises towards  the Alps.  In these
districts, Dr. Holland believes,  at  the time
when he wrote (1817), the pellagrosi to be one
in every five or six of the  population.  He adds
that the disease prevails in some districts much
more  than in others; that it appeared  first  in
the higher parts of the Milanese territory, and
that its ravages there are  still greater than  in
any other part of Lombardy.  Some time elaps-
 ed before it was said to have appeared in the
 Venetian provinces and near the shores of the
 Adriatic Sea.   At the present time it is increas-
 ing in every part of  Lombardy, as well on the
 plains as among the  hills which rise on  their
 northern border towards the Alps.  It also ex-
 ists in the province of Friuli, the district inter-
 vening between the foot of the Carinthian Alps
 and the northern shore of the Adriatic*
   3.  I. Symptoms.—Pellagra is almost exclu-
 sively confined  to the lower orders, and chiefly
 to peasants, and those engaged in agricultural
 employments.—a. Its first distinct appearance
 is that of a local cutaneous eruption, generally
 preceded by languor, debility, and indications of
 constitutional disturbance and cachexia. The lo-
 cal symptoms usually first appear early in spring,
 when the midday heat is increasing, and  when
 the peasants are most actively engaged in the
 fields.  The patient first perceives on the backs
 of his hands, on his feet, and more rarely on oth-
 er parts of the body exposed to the sun, certain
 red spots or  blotches, which gradually extend
 themselves, with a slight elevation of the cu-
 ticle, and a shining surface,  not unlike that of
 lepra.  The colour of the eruption is  a  more
 obscure and dusky red than that of erysipelas :
 it is  attended  by no other  uneasy sensation
 than  a slight pricking or itching, and some ten-
 sion in the  part.  After a short time, small tu-
 bercles are  frequently observed in the inflamed
 surface.  The skin always  becomes  dry and
 scaly, forming rough  patches, which are exco-
 riated and  divided by furrows and rhagades.
 Desquamation takes place gradually, and leaves
 behind a shining, unhealthy state of the affect-
 ed surface.   Towards the close of the summer,
 or occasionally earlier, the parts have nearly
 resumed their natural appearances;  and but
 that the farther progress of the  malady  is fa-
 miliar to all, the patient might suppose that the
 mischief had disappeared.
  4.  With  this local  affection are connected
 from  the first,  general  debility, vague  and ir-
 regular pains of the trunk and limbs, especially
 in the course of the dorsal muscles and spine ;
 vertigo and headache;  irregular appetite and
 depression of spirits.   The bowels are usually
 relaxed, and continue so throughout  the dis-
 ease.  There are no febrile symptoms, and the
 catamenia of females are  generally continued
 without  irregularity ; but there  are fsequent ex-
 ceptions ; febrile symptoms occasionally ap-
 pearing, and menstruation being  more  or less
 obstructed from the commencement; but these
 occur chiefly in  the more advanced course of
 the malady.
  5. The patient obtains a remission, more par-
 ticularly of the  external eruption, during the
 autumn and winter of the first year ; but he al-
 most  always experiences a recurrence of the
 symptoms in the following spring under a  more
 severe form, and with much greater disorder
of the constitution.   The  cutaneous affection
spreads, yet still affecting  chiefly the hands,
 neck, feet, and legs, and other exposed parts.
The skin becomes callous and deeply furrowed ;
large  rhagades  appearing,  especially near the

  [* M. GjBERT considers the pellagra of Lombardy to  be
merely an ichthyosis dependant on a chronic affection of the
digestive organs.  As it is a disease to which the inhabi-
tants of our country are fortunately strangers, we shall add
 nothing to the very full and complete history of the diW«S»
given by our author,] 
60
PELLAGRA—Symptoms and History of.
articulations of the fingers.  The cutaneous af-
fection now resembles an  inveterate degree of
psoriasis, or of lepra vulgaris, and, in some re-
spects, ichthyosis,  with which  Alibert has
classed it.
  6. The  debility is greatly increased  in the
second year, often rendering the patient inca-
pable of pursuing his active labours, and ren-
dering him susceptible  of all changes of tem-
perature.   Partial sweats  break out, especially
on  any exertion.   Cramps, spasmodic  affec-
tions, and pains are frequently complained of;
and the mind is despondent and depressed. All
the symptoms are aggravated as the heat of
summer advances, especially in those most ex-
posed to the sun. They begin again to decline,
as in the  preceding year, towards the middle
or end of  autumn ;  but  the remission, as well
of the local affection as of the general disorder,
is much less complete than before ; and the pa-
tient continues to suffer during the winter from
debility and other constitutional symptoms.
  7. The  disease  may continue for several
years thus to  remit during winter, and to pre-
sent increasing or varying grades of exacerba-
tion during the spring and summer, but  gener-
ally in the  third year, or in the fourth or fifth,
in some instances, or even later, every  symp-
tom is renewed at an earlier  period of the
spring, and in  an aggravated degree.  The de-
bility now  becomes extreme ;  the patient  is
hardly able to support himself;  and he  is af-
fected with pains in his limbs.   All the consti-
tutional phenomena indicate universal cachexia
and lesion of the nervous and voluntary pow-
ers ; the general symptoms now have a close
analogy to those of scorbutus.   The diarrhoea
continues, and augments the debility; and ul-
timately it assumes much of a dysenteric char-
acter, particularly in the  latter  stages  of the
malady.   The  evacuations  are  offensive and
morbid, and   preceded  by  abdominal  pains.
Aphthae, thirst, pains  at the stomach, &c, are
also frequently complained of.   The odour of
the breath and of the perspiration is extremely
offensive.   The appetite and digestion are ir-
regular ; but they are often  less affected than
most of the other functions.  Dropsical effu-
sions frequently appear  at this stage, generally
in the form of anasarca,  occasionally of ascites.
Vertigo, tinnitus aurium, double vision, are now
usually present; and  all the senses are  much
impaired.   Spasmodic affections, irregular con-
vulsions, involuntary  movements of the head
and body forward, and even complete epileptic
attacks, often occur.
  8. b. The nervous system presents remarka-
ble disturbance, and the manifestations  of the
mind are more or less disordered.  The pella-
grosi complain of a sense of heat in the head
and spinal chord;  of tingling or darting pains
in the course  of the nerves ; of heat  in the
limbs, palms of the hands, and  particularly in
the soles of the  feet;  of great weakness of the
limbs, with trembling when attempting to stand ;
and  sometimes of  contractions of the  lower
limbs  Their  looks become sombre and mel-
ancholy.  Ennui, depression of spirits, and men-
tal imbecility increase with the progress of the
malady.   Dr  Holland states,  that pellagrosi
afford a melancholy spectacle of physical and
moral suffering at this period.  They seem un-
der the influence of an invincible despondency;
they seek to be alone ; scarcely answer ques-
tions put to them ; and often shed tears with-
out obvious cause.  Their faculties and senses
are impaired;  and the disease,  when it  does
not carry them off from exhaustion of the  vital
powers, generally leaves them incurable idiots,
or produces attacks of mania, soon passing into
utter imbecility or idiocy.   The public hospi-
tals of Lombardy are incapable of receiving vast
numbers of the pellagrosi; the greater propor-
tion  perishing in  their own  habitations, or lin-
gering there wretched subjects of fatuity and
decay.   Where extreme debility and cachexia
are the causes of death, as is usually the case,
they are attended with colliquative diarrhoea,
spasmodic affections, coma,  and extreme ema-
ciation.
  9.  c. Mania  and delirium, consequent upon
pellagra, are either acute or chronic.   The acute
state sometimes  proves  fatal in a  few days;
but the more chronic form seems to retard,  in
some degree, the progress of the malady, the
strength of the patient declining less  rapidly.
In this state there  is always loss of memory
and of the powers of attention.   Religious mel-
ancholy frequently characterizes  this form of
delirium, with a desire to commit suicide, and
usually by drowning.  Hence Strambio denom-
inated this morbid disposition by the name of
hydromania.
  10. d.  Although  the disease  has been de-
scribed above as proceeding in its course three
or four years, yet it is generally of longer dura-
tion.   Several intermissions,  or remissions,
usually occur in its progress.  It occasionally
remains stationary; and certain of its phe-
nomena sometimes predominate over the  oth-
ers at  one  time, and others at another time
Thus some relief of his  sufferings is experi-
enced by the patient from time to time, although
he can entertain little  hope  of ultimate recov-
ery.  Occasionally the cutaneous eruption forms
the principal indication of the complaint for sev-
eral  years, it being renewed every spring and
disappearing in the autumn.  The constitutional
symptoms may also continue for some years
comparatively slight;  and, if the patient be re-
moved to a different locality and to another
mode of life, the disease  may be farther pro-
tracted, or  altogether  arrested in its progress.
It is rarely,  however, that these  means can be
adopted ; and  the constitutional  malady is gen-
erally so firmly established in the third or fourth
year, that few hopes of benefiting the patient
by treatment or by change of climate and occu-
pation can be entertained.
  11. e. Some  cases of the disease assume  a
more acute  and more rapid form, particularly in
respect of the constitutional symptoms. In these
the disease proceeds  as rapidly as  above de-
scribed, with all the more severe symptoms;
and, although the pulse is often  very slow and
weak, especially in  the more chronic cases,  it
is sometimes  frequent and  hard in  the more
acute.   This, however, only  occurs when fever
takes place in the progress  of the malady.
This consecutive  fever is connected either with
a state of gastro-intestinal irritation, or of as-
thenic  inflammation, or with  predominant af-
fection of the  brain and  spinal  chord; and  is
generally attended, at first, by heat of skin and
irregular remissions, followed by offensive per-
spiration.   These states of  febrile excitement 
PELLAGRA—Symptoms and  History or.                      61
 generally hasten the fatal termination of the
 malady, usually with all the concomitant symp-
 toms of the last stage of adynamic fever.
   12. /. In infants and children  the symptoms
 of the malady are not materially different from
 those  characterizing it  in more advanced life.
 The cutaneous affection of the hands, arms,
 feet, and legs is the first to appear ; is renewed
 and augmented in successive years,  and at-
 tended by the various  symptoms indicative of
 a cachectic state of the body.   The malady, as
 in other cases, has in them a fatal termination,
 unless a  change of climate  be obtained in an
 early period of its progress.
   13. g. Some anomalies have been observed in
 the progress and  succession of the symptoms
 of pellagra.  During  its first appearance in
 Italy,  the disease was  remarkable  for the in-
 tensity of the cramps and spinal pains, and the
 trifling extent  of the cutaneous affection.  At
 a more recent  period this affection became  a
 prominent feature, while  disorder of the di-
 gestive organs and mania appeared chiefly as
 secondary  symptoms.    Different phenomena
 have also sometimes predominated ; in certain
 years  ptyalism, and in  others it has been dis-
 placed by aphthae, desquamation of the lips, &c.
 Very recently the various cramps, spinal pains,
 and convulsions, insisted on by former writers,
 have  been  less noticed than previously, while
 pellagrous mania  and  delirium are very com-
 mon, and gastro-intestinal affections  are gen-
 eral.
   14. h. Pellagra may be complicated with other
 diseases of the skin, such as lepra, psoriasis,
 erysipelas,  eczema, purpura,  syphilitic erup-
 tions,  &c. ; and with intermittent and remit-
 tent fever, scrofulous affections, phthisis, peri-
 tonitis, white swellings  of the joints, &c.
   15.  II.  Appearances on  Dissection.—Le-
 sions are found chiefly in the digestive canal,
 nervous system, and skin.—a. In the five bodies
 examined by M. Brierre de Boismont, the mu-
 cous membrane of the stomach was red, inter-
 sected  by  bluish or dark vessels, soft, pulta-
 ceous, and easily removed.  The redness was
 greatest at the large end of the stomach ;  the
 mucous membrane was thinner in some cases,
 and thicker than natural in others. The valves
 of the duodenum, and the mucous membrane
 of the small and large intestines, were of a light-
 er or deeper tint, in some approaching to brown.
 This membrane was generally softened and hy-
 pertrophied ; it was likewise studded  with ir-
 regular or round ulcers, surrounded by a  red-
 dened  base.  The subjacent cellular tissue and
 muscular  coat  were hypertrophied.   The  in-
 testines, in all  the cases, contained lumbrici.
 Dr. Carswell, in addition to the usual signs of
 chronic inflammation of the stomach and intes-
 tines,  found perforations of the stomach from
 softening in two cases.
   16. b. The membranes of the  brain, particu-
 larly the arachnoid and  pia mater, in these ca-
 ses, as well as in those  examined by Strambio,
 Fantonetti, and others, were injected, thick-
 ened, and  opalescent.   The pia mater adhered
 to the cerebral convolutions, which were slight-
 ly atrophied.  The substance of the brain was
 in some cases diminished, in others increased
 in consistence ; the gray substance was inject-
ed and  deeply coloured  ; the  white substance
dolled  with vascular points.  The cerebellum
 was slightly injected and somewhat softer than
 natural.  The arachnoid and pia mater of the
 spinal chord were also injected.   The gray sub-
 stance of the chord was somewhat indurated
 and injected.   The white substance was much
 softened.
   17.  c. The skin of the backs of the hands and
 feet was like leather, and, when examined with
 a lens, presented a number of irregular cracks,
 crossing  at acute angles, and  placed  closely,
 and sometimes implicating the whole thickness
 of the corion.   Small, thin, yellow crusts, and
 furfuraceous  lamellae  of a  dirty white,  inter-
 posed in some of these small fissures, and ad-
 hered firmly.   The epidermis was six or eight
 times thicker than natural, brownish, friable,
 and dry,  and  was firmly attached.  The sub-
 epidermic layers were much thickened.   The
 radial nerves  were softened, reddish, and infil-
 trated with serum.  The most frequent lesions
 to the above were the usual signs of recent or
 of old, general or partial peritonitis.  Indica-
 tions of bronchitis and pulmonary tubercles were
 also  often  observed.   Enlargements  of the
 spleen and of the  liver, in some cases also of
 the mesenteric  glands, and  effusion of serum
 in  the shut cavities, have  been occasionally
 noticed.
   18.  III. Asturian  Pellagra— La  Rosa—
 Mai de la Rosa — Asturian  Leprosy, Thierry,
 Sauvages, &c.—Elephantiasis Asturiensis, Good
 —is, according to the descriptions of Thierry
 and others, merely a  variety of pellagra, and,
 in its  local and  general characters, still  more
 nearly approaches the leprosy of the Middle Ages
 than the pellagra of Lombardy. Thierry states
 that this disease generally appears at the spring
 equinox,  on different parts  of the  body, with
 redness  and harshness of the skin.  It after-
 ward  degenerates  into  rough,  dry, blackish
 crusts, intersected by deep cracks and fissures.
 These dry and fall off in  summer, leaving red-
 dish, smooth, and  shining  marks,  devoid of
 hair, and depressed below the level of the sur-
 rounding  skin, resembling  the  cicatrices  of
 burns.  They  remain through  life.   In the
 spring of every year they  are  covered anew
 with  crusts, which become more  and  more
 painful, offensive, and disgusting to the sight.
 They often appear on the fore, or most exposed
 part of the neck, extending to the clavicles and
 top of the sternum.
   19.  To these eruptions are added a constant
 shaking  or  trembling of the head and upper
 parts of the body,  heat of the mouth, vesicles
 on the lips, foulness  of  the tongue, extreme
 weakness of the whole body, with a feeling of
 heaviness, and disorder of the digestive organs
 Through  the  night, burning heat,  insomnia,
 groaning without obvious reason, dejection of
 spirits, melancholy, &c, are  complained  of.
 Several suffer slight delirium or hebetude of
 the senses,  particularly  of  touch and smell.
 To these are  sometimes added slight mania,
 erysipelas, ulcers,  and irregular fever.   This
 malady is often attended, in  its advanced sta-
 ges, with  a tranquil state of mania  or melan-
 cholia.  The patient sinks  into  a state of de-
jection, in which he forsakes his home, seeks
 solitude, and is reduced to utter despair.   This
 mental depression usually  appears about the
 summer solstice, and  proves fatal sooner or
 later.  A  fatal issue is often, also, preceded by 
62                    PELLAGRA—Diagnosis—Prognosis—Causes.
 marasmus and  dropsical effusion.  The local
 and constitutional symptoms place this malady
 in a position intermediate between the pellagra
 of  Lombardy and  the  leprosy  of the Middle
 Ages, although more closely to the former than
 to the latter.
  20. IV.  Diagnosis.—Pellagra  is manifestly
 allied, in many of its features,  to the  leprosy
 of  the Middle  Ages on the  one hand, and to
 scurvy, with which, however, pellagra is some-
 times complicated, on  the  other hand.   But
 still, there is an alliance only in certain points.
 The resemblance, also, which it bears to  ery-
 sipelas, led Titius to define it as a chronic, pe-
 riodic, and nervous form of that disease ;  from
 which, however, it differs  widely in its whole
 history—in local and constitutional symptoms,
 in its nervous characters and terminations.
  21. M. Mayer observes that certain  epidem-
 ics  which have occurred in the north of Europe
 during the  last three or four  centuries,  and
 which have been generally attributed  to want
 and to the use of unripe, spurred, and damaged
 grain, closely resemble  pellagra.  The  resem-
 blance is certainly close in many features, but
 the difference is great  in others.  There  can
 be no doubt that local,  external, and constitu-
 tional diseases,  peculiar in kind or anomalous
 in character, yet varying in  numerous  modes,
 grades, and phases, appear in certain localities
 and at certain epochs, as the several  circum-
 stances  and  agents occasioning them  are dif-
 ferently  combined, in respect both of the num-
 ber, grade, and quality of these  agents ; for it
 is only  reasonable to  infer  that as  causes,
 agents, and influences are variously associated
 in number, intensity, and quantity, so  will the
 effects be  different, and hence  present inde-
 scribable forms, varieties,  states, and  phases,
 which admit not of distinct  or specific limita-
 tions as to  character, nor  of consistent, con-
 stant, and uniform manifestations.
  22. a. It will appear in the sequel (see Causes)
 that many of the circumstances in which the
 Italian and Asturian pellagra originate  are the
 same which gave rise to the leprosy of the Mid-
 dle  Ages, and to certain epidemics which have
 appeared in several countries during  the fif-
 teenth and sixteenth centuries.  Still,  the fea-
 tures of each vary, or even differ.  In the true
 leprosy, the face, roots of the hair, palate bones,
 nose, are more affected, and the cutaneous dis-
 ease is more decidedly tubercular ; the affec-
 tion of the skin, of the extremities and face, in-
 creasing with the  other symptoms, and  the
 mind  being  less disordered  than  in pellagra.
 In the Italian pellagra, the mental, nervous, and
 intestinal affections predominate with the prog-
 ress of the malady.
  23.  b.  In the Asturian malady; the affection
 of the skin is greater than  that of the  Italian,
and approaches more  nearly the severity of
leprosy ;  the affection of the mind is less acute
than that of  true pellagra, but the termination
of all these is nearly equally unfavourable, al-
though their duration is  very  variable, not only
in regard of the respective maladies, but as re-
spects individual cases of each.
  24.  c. The history of pellagra sufficiently dis-
 tinguishes it  from  other diseases of the skin.
Chronic  erythema is never attended by the se-
rious  nervous, mental, and  digestive disorders
characterizing pellagra ; and lepra and psoriasis
 are removed to an equally great distance from
 the Italian malady, even  without taking  into
 account the different characters and forms of
 the eruption in each, and the ultimately fatal
 issue of pellagra.
   25. d. M. Rayer attempts to establish a sim-
 ilarity between pellagra and the epidemic of
 Paris  and  its vicinity in  1828,  to  which the
 name acrodynia has been given.   But, although
 the season of the appearance of  the latter was
 the same  as  of the  former, and although the
 eruption on the extremities, the pains in the
 feet and difficulty  of walking, the disorders of
 the digestive  organs, closely resembled  the
 same phenomena at an early period of pellagra,
 yet the absence of the mental disorder, the non-
 recurrence of the  malady, and the general re-
 covery  of  the attacked, indicate  a total differ-
 ence between the  two maladies,  the points of
 resemblance being probably  the  results of a
 concurrence of certain causes contributing to
 the production of pellagra.
  26. V. Prognosis.—The circumstances which
 render the prognosis of pellagra particularly un-
 favourable are the unequivocal  operation of
 those causes  to which this  malady is attribn-
 ted ; the circumstance of one or other parent
 of  the patient having died of it;  an advanced
 period of its course ;  the poverty and agricul-
 tural occupation of the affected ;  previous dis-
 ease, and  the severity  of the   constitutional
 symptoms, particularly of  the disorder of the
 digestive organs; general cachexia; emacia-
 tion, and mental disturbance ; severity of the
 nervous symptoms, and especially the  occur-
 rence of mania, delirium, partial, or general pa-
 ralysis ; and, at an early stage, the impossibili-
 ty of removing the subjects of the malady to a
 different  climate,  or  to  other   occupations.
 Pregnancy and lactation  also exert an unfa-
 vourable influence on its course  and termina-
 tion.
  27. VI.  Causes.—The  hereditary tendency
 of pellagra is fully admitted by all writers who
 have observed the progress  or traced the ori-
 gin of  the malady.   There  can  be no doubt
 of  the  disease being continued  in succession
 through families,  even the children of pella-
 grosi becoming affected, when much exposed
 to  the  sun and air, or early occupied  in the
 fields.   Writers have differed as to the respect-
 ive liability of sex ; but there seems to be no
 difference in this respect beyond what may be
 imputed to occupation and  exposure.   That
 these latter circumstances are chiefly produc-
 tive of  the disease cannot  be disputed, inas-
 much as those only who are subjected to them
 are affected by it.   Doubtless, however, other
 causes  co-operate ; but the influences to which
persons  thus occupied are alone exposed should be
 viewed as the chief agencies in  developing the mal-
 ady.  Some writers have supposed the climate
 to be the chief cause ;  but if this were the case,
 other persons  besides agricultural labourrrs
 would become  affected.  This disease has also
 been attributed to the  use of maize ;  but we do
 not find that maize has  any  similar effect in
 other or similar climates,  where it is  exten-
 sively employed as food.   It  has likewise been
 imputed to a rice  diet ;  but  the  same remark
 applies  also to this opinion. The imperfect
 and sometimes unwholesome  nourishment;
 the want of animal food, and due proportion 
PELLAGRA—Treatment.                             63
 of condiments and stimuli; the insufficient use
 of salt and  other antiseptic  substances;  and
 the general  wretchedness, privations, and filth
 of the field labourers in this part of Europe, to
 all which the malady has been attributed,  may
 certainly concur, in some degree, in  develop-
 ing it; but  even  these conjoined cannot  rea-
 sonably be inferred to be the real exciting caus-
 es of it, inasmuch as these causes are equally
 influential, and concur in similar grades of ac-
 tivity in other localities, without pellagra being
 the result.
   28. After  considering the various causes and
 their combinations to which this malady has
 been imputed, I  infer that they may tend to
 aggravate its  severity or to increase  the  pre-
 disposition  to its appearance,  but that other
 peculiar and endemic agencies are chiefly  con-
 cerned in generating it.   What these agencies
 are has not been demonstrated, nor do they,
 perhaps, admit of precise demonstration, but
 they appear  to me to proceed from the soil and
 water of the locality.  The use of water filtra-
 ting through certain or peculiar geological for-
 mations, or  certain alluvial deposites;  the la-
 bours of the peasants in fields which are satu-
 rated with moisture, or which have been inun-
 dated during the preceding winter;  and the cir-
 cumstance of those parts  of the body which are
 most exposed, or most commonly  immersed in
 the water and soil or earth which these labour-
 ers cultivate, must readily suggest themselves
 to the minds of those who reflect on the sub-
 ject as the obvious exciting causes of the  dis-
 ease.   That the  influence of the sun  is neces-
 sary to develop the cutaneous  affection, may
 be admitted, and may be explained by the ef-
 fects produced by its rays, or  by the drying ef-
 fects of the  air upon the surfaces covered by
 the  moisture  of the soil  in which  the peas-
 ants are employed.  It has been objected,  par-
 ticularly by  Strambio, that, although  the  sun
 and free exposure to  the air tend to  develop
 more completely the  cutaneous affection,  still
 the  constitutional  symptoms  appear  and  pro-
 ceed their course, even when no such exposure
 is incurred, and when the  eruption is either im-
 perfectly or  not at all  developed.
   29.  Viewing, therefore, the nature of the  wa-
 ter of the  localities in which pellagra occurs,
 together with the state of the  soil and  the  wa-
 ter saturating or inundating  the  soil,  as  the
 chief causes  of the malady, it  may be admitted
 that the other  agencies, to which so much in-
 fluence has  been  imputed by  various writers,
 may in  some degree contribute to develop  and
 to aggravate  the disease, especially the use of
 unwholesome food, as of sour or diseased  rye
 bread, or of unripe maize or rice ; dirty and ill-
 ventilated apartments;  hereditary predisposi-
 tion ; the depressing passions; privations, mis-
 ery,  and exhausting indulgences.  M.  Spessa
 attributes considerable  influence to  the habit
 of the poorer inhabitants  of passing the even-
 ings, and even  parts of the day during winter,
 in the dirty and unhealthy  cow-houses and sta-
 bles, by way of escaping from the cold.  The
effluvium,  also, proceeding from the accumu-
lated  exuviee of the  inhabitants  and  cattle
at the commencement  of  spring and of warm
weather; and when these exuviae are exposed
and spread upon the  soil as manure,  and to
which the field  labourers are more particularly
 exposed, may not be without its influence, and
 even exceed that insisted upon by M. Spessa.
 But, seeing  that those persons who are alone
 affected with pellagra are those  only who are
 much exposed to the agencies  to which I have
 attributed the malady, the inference that these
 agencies are the principal causes of it becomes
 inevitable.
   30. It  may  be  further  added,  that similar
 causes to those which obtain in Lombardy ex-
 ist also in the Aslurias, where a similar  mala-
 dy prevails.  These are extreme poverty, with
 its attendants, bad and insufficient food ;  filth ;
 crowded  and  ill-ventilated apartments ;  and
 agricultural  pursuits in  the deep and swampy
 valleys of the country.
   31. That the malady should first appear, and
 be aggravated  during spring and summer, can
 be accounted for by the exposure of the sub-
 jects of it at this  season to its chief exciting
 causes, and to the influence of labour, conjoined
 with increased temperature, in exciting the cir-
 culation,  and in throwing out, by means of the
 cutaneous excretion, the morbid materials ac-
 cumulated in the blood, and disordering vascu-
 lar action in the digestive organs, in  the ner-
 vous centres, as well as in parts of the  cuta-
 neous surface.
   32. VII. Treatment.—It is obvious that the
 chief means  of remedying, or even of checking
 the progress of this malady, are change of the
 habits and occupations of those who have be-
 come subjects of it;  change of climate, and re-
 moval of  the several causes and influences to
 which it has been  imputed, and particularly of
 those upon which I have above insisted on.  The
 circumstances  in which  those are placed  who
 become the subjects of pellagra very generally
 preclude the adoption of these measures, which,
 however,  can be but  of little avail at an advan-
 ced stage and confirmed state  of the malady.
 When the nervous and constitutional symptoms
 are fully developed ;  when the cutaneous  erup-
 tion is constant, extensive, and severe, and is
 attended  by a peculiar, offensive  effluvium or
 perspiration ; when affections resembling or ap-
 proaching to those  of either chorea, convul-
 sions, tetanus, epilepsy, palsy,  mania, or mel-
 ancholia appear ; or  when severe diarrhoea, or
 dysentery, or marasmus, or dropsy, or  pulmo-
 nary disease occur, then  removal  or change of
 occupation, or medical treatment, is very rarely
 of avail;  and even at an early stage medicines
 can produce but little benefit while the patient
 continues to be subjected to the several circum-
 stances and influences originating the  malady.
 In addition to wholesome and nutritious  food,
 alterative, tonic, and antiseptic  articles should
 be prescribed, aided  by warm bathing  and di-
 aphoretics.  The alkaline carbonates taken in
 tonic infusions, or  in demulcent and bitter de-
 coctions, or with emollient and narcotic sub-
 stances, are generally of service  ; but the treat-
 ment should vary according to the various prom-
 inent  affections which complicate the advanced
 stages of the disease.
  33.  For the affections  of the  digestive  canal
the decoction of Iceland moss ;  various emoll-
 ients, with or without opiates or Dover's  pow-
der ;  fomentations and embrocations on the
abdomen, and emollient and anodyne injections
are requisite.
  34.  Affections of the brain and  nervous sys- 
04                             PEMPHIGUS—Description of.
 tern, during the progress of this malady, admit
 not of a recourse to lowering means.   In but
 few cases can local depletions even be prescri-
 bed  with advantage ;  but, while tonics, anti-
 spasmodics, and  alteratives,  conjoined  with
 anodynes,  as circumstances may suggest, are
 administered, blisters may be applied to, or is-
 sues or setons inserted in, the nape of the neck ;
 or even small bleedings in the more acute ca-
 ses may be directed from this situation  or be-
 hind the ears.   In most of the nervous affec-
 tions appearing in the course of pellagra, the
 preparations of opium, taken with camphor, or
 ammonia and aromatics, are of essential  ser-
 vice, but chiefly as palliatives.
   35. For the cachectic habit of body and  cu-
 taneous affection, alkalies and alkaline carbon-
 ates with sarsaparilla, particularly the compound
 decoction,  in large quantity, or with  antimo-
 nials ; sulphureous warm baths, followed by
 frictions ; milk diet, and attention to the  sev-
 eral secretions and  excretions, using  those
 means which are most serviceable in improving
 and  promoting them, are the measures which
 promise the greatest amount of benefit, which,
 however, can rarely be attained without the re-
 moval of the causes which occasion the disease.
 Even in an early stage of the disease, while
 these continue to operate,  and at an advanced
 stage even, when these are  removed, medical
 treatment is generally of little or only of tem-
 porary avail, at least as far as it has been  em-
 ployed by the Italian physicians.
  Biblioo. and Refek.—F. Frapoli, Animadversiones in
 Murlmm vulgo Pellagram appell., 8vo.  Medio].,  1771.—
 Odoardi, D' una Spezie particolare  di Scorbuto, <fec, 4to.
 Venet., 1776.—M. Gherardini, Delia Pellagra Descrizione,
 8vo.  Milano,  1780— G. M. Albera, Traltato delle Malattie
 dell' insolato di Primnvera, volgarmente dette della Pella-
 gra, 8vo.  Varese, 1781—C. Strambio, De Pellagra,  Ob-
 servat. in Nosocoinio Pellagrosorum facta;, 4to.  Med., 1785 ;
 et Dissertazione sulla Pellagra, 8vo.  Milan, 1794.—Jansen,
 in Frank, Delect. Opusc, t. ix.—F. Fanzago, Memoria so-
 pra la Pellag. del Tcrrit. Padovatio.  Padov., 8vo, 1789 —
 /. Videmar, De quadam Impetiginis Specie, vulgo Pell, nun-
 cupate 8vo.  Med., 1790.—P. Dellabona, Discorso Compar-
 ative sopra la  Pellagra,  l'Elefantiasi, e lo  Scorbuto, 8vo.
 Venet., 1791.—L. Soler,  Osservazioni che formano la Sto-
 ria estatadi Pellagra, 8vo.  Venet., 1791.—.If. Thierry, Ob-
 servations de  Physique et  de Medecine en Espagne, 8vo.
 Paris, 1791.—S. C. Titius, Oratio de Pell. Pathologia, in
 Frank, Del. Opusc, t. xii.—C. Allioni, Ragionamento sopra
 la Pellagra, 8vo. Turin, 1795.—Leraches de la Freutrie,
 Recherches sur la Pellagre, 8vo. Paris, 1805.—G. Cerri,
 Trattato della Pellagra, 8vo.  Milano, 1807. — /. H. G.
 Schlegel, Briefe einiger Aertze in Italien, ueber das Pella-
 gra, 8vo.  Jena, 1807.—G. B. Marzari, Saggio Medico-po-
 litico sulla Pellagra, 4to.  Venez., 1810; et Lettere al Dr.
 Thierre sulla  Pellagra, 4to.  Treviso,  1812.—A. Boerio,
 Storia della Pellagra nei  Carnovesc, 8vo. Torino, 1811.—
 G. Cerri, Osservazioni intorno all' Saggio sulla Pellagra di
 Marsari, 8vo.   Milano, 1811.— V. Chiarugi, Saggio de Ri-
 cerche  sulla Pellagra, 8vo.  Firenz., 1814.—F. Fanzago,
 Memorie sulla Pellagra, 8vo.  Pad., 1815;  et Istrusione
 Catechistica sulla Pellagra, 4to.  Venez., 1819.—H.  Hol-
 land, in Transact, of Med. and Chirurg. Society of Lond.,
vol. viii., p. 317.—G. .V. Zechinelh, Alcnne Rifle6sioni sullo
 Statodello Pell., <tc , 8vo.  Pad., 1818.—G.Di Filippi, Me-
moria sulla Pell., 8vo.   Nap.. 1819.—Jourdan, Diet, des Sci-
ences Medicales, t. xl., art. Pellagre.—G. B. Marsari, Della
Pell, e della  Maniera di estirp.  in Italia, 4to.  Venez.,
1819.—J. C. Strambio, Natura, Sede, e Cagioni della Pell.,
8vo.  Milano,  1820.—Lagneau, Diet, de Med., t. xvi., art.
Pellagre.—A.  A. Spessa, in Annali di Omodei, t. lxiv.—/.
Johnson, Change of Air in pursuit of Health.  An Excursion
through France, Switzerland, and Italy, in 1829, &.C., 8vo.
Lond., 1831, p. 75 —Briere de Boismont, De la Pellagre at
de la F.die Pellagreuse, 8vo.  Paris, 1834.— W. Kerr, Cy-
clop, of Pract. Med., vol. iii., p. 262.—Rayer, Diet, de Med.
et Chirurg. Prat., t. xii., art. Pellagre; and  Theoret. and
Pract  Treatise on the Dis. of the Skin.  Trans, by R.  Wil-
lis, 8\u. Lond., 1835, p. 1162.
  [Am. Bibliog. and Refer.—American editions of Caz-
enave, Rayer, and Plumbe ;  also, Worcester on Diseases of
the Skin.J
 PEMPHIGUS.—Synov.  Tleptju^,  nefidjtyog  (a
   small blister  or bubble), nvperoc irep.o}iyu6ec,
   Hippocrates and Galen.   Pemphigus, Sauva-
   ges.  Fcbris Bullosa, Vogel.   Bulla, Bullosa
   Febris,  Morton.  Hidroa,  Piso.   Pompholyx
   (UopdjoXv^), Willan  and Bateman.   Typhus
   vesicularis,  Young.   Emphlysis  Pemphigus,
   Good.  Fcbris  vesicularis, Febris Pemphigoi-
   des, Auct.   Fievre Bulleuse, F. vesiculate, Fr.
   Wassenblasen,  Blasenfieber, Germ.   Pcnfigo,
   Ital.  Vesicular Fever.
     Classif.—3d Class, 3d Order (Good).   4th
        Order (Willan).   IV. Class, IV. Order
        (Author).
   1.  Defin —An eruption of transparent  or yel-
 lowish bulla of considerable size appearing in cir-
 cular  or oval erythematous patches, nearly corre-
 sponding in diameter with their  bases; termina-
 ting by effusion of the fluid they  contain, and by
 the formation of lamellar incrustations, or by exco-
 riations.
   2.  I.  Description.—The various appearan-
 ces assumed by this eruption have led to vari-
 ous divisions and denominations of it, according
 to the mode of its eruption (Pemphigus simul-
 taneus, P. successivus)—to the  number of the
 bullae  (P. solitarius, P.  confluens)—to the great-
 er or less  rapidity of their course (P. acutus, P.
 chronicus)—to the existence or absence  of fe-
 ver (P. pyreticus, P. apyreticus)—and to the age
 of the patient (P. congenitus, P. infantilis).  I
 agree, however, with  Rayer, Cazenave,  and
 Wilson, in the  propriety  of considering this
 eruption under  the  two  heads of acute  and
 chronic.
  3. i. Acute  Pemphigus.—P.  acutus, Febris
 bullosa, F. Pemphigoides, F. Synocha cum vesic-
 ulis, Auct.—This  is a rare disease.  The bullae
 almost  always  stand  apart,  or  are distinct.
 They are rarely confluent, and they usually ap-
 pear  in succession.  They may be partial or
 more  or less  general,  and  may occur on  any
 part of the  body, but  most commonly on the
 lower extremities ;  occasionally, however, also
 on the arms,  the trunk, and the  face;  most
 rarely on the soles of the feet, hairy scalp, and
 genitals.
  4. a.  The constitutional symptoms vary from
 a  slight  degree  of languor  and  listlessness,
 sometimes of sickness  and general uneasiness,
 followed by quick pulse and mild  fever (Pom-
pholyx benignus of Willan), to chilliness or rig-
ours followed  by  a dry and hot skin with pru-
 ritus, by pains in  the head and limbs, nausea,
thirst, anorexia, tenderness at the  epigastrium,
very rapid pulse, sore  throat, and even  slight
delirium.  In some cases the fever is attended
by irritation of the mucous surface of the di-
gestive, respiratory, or genito-urinary organs.
  5.  b. The eruption usually appears the second
or third day  from the commencement of the
constitutional  disorder, or even  later, in the
form of small red  spots, preceded and attended
by pruritus, and a parched and  hot sensation.
The spots  increase to circular or oval erythema-
tous patches, varying in redness from a pale to
a vivid or  dusky tint.   In  the course  of a few
hours  a vesicle arises  in  the middle  of each
patch, and becomes rapidly distended  by a lim-
pid serum, and increases to the size of a hazel-
nut, or even of a large  walnut.  The  bullae, or
blebs, which thus arise  are usually circular oi
oval,  and  slightly flattened at their summits. 
PEMPHIGUS—Description op.
65
They generally correspond with the breadth of
the patches on which they appear, and thus
conceal them ;  or they are somewhat smaller
than the patches, which thus show around them
as a narrow zone, more  rarely as a complete
areola.  The bullae usually break  in  a day or
two, and expose an excoriated surface, secre-
ting for a few days longer a serous fluid, which
concretes into  a  thin, yellowish scab, and  be-
comes gradually  browner and dark;  but they
sometimes do not burst, and in this  case  the
serum contained  in the bullae assumes an am-
ber or yellowish  tint, subsequently turbid and
opaque, diminishing in quantity by evaporation,
shrivelling and  drying up, in the course of a few
days, into  a  thin, dark scab.  The rupture of
the bullae, and the time when it occurs, depend
upon the situation of their eruption.   In about
three weeks the scabs fall off, leaving the skin
beneath of a dusky red hue, but sound.
   6. Bullae are occasionally imperfectly devel-
oped, and appear  in the form of circular or oval
patches, slightly red and prominent.   On pass-
ing the finger over their  surface, the cuticle is
felt loosened by a slight effusion of serum  be-
tween it  and the dermis.  The cuticle is  de-
tached after a  few days, exposing a  red spot,
covered by a thin and shining epidermic layer.
   7. The duration of the disease depends upon
the mode  of eruption ; if this takes place at
once, it is  no longer  than just stated, or from
seven to fourteen days ; but if the bullae appear
successively, it is longer accordingly, or from
three  to  four  weeks.  Mr. Wilson  remarks
that, in the progress of the cutaneous eruption,
vesicles are not  unfrequently observed on  the
mucous membrane of the mouth.
   8. When the disease is confluent, two or more
of the bullae unite and form a bleb as large as
a hen or a goose  egg.  In these  cases the con-
stitutional symptoms  are more severe, and  are
sometimes attended by irritation of most of  the
mucous surfaces.
   9. c. This disease sometimes affects children
—Pemphigus infantilis—P. gangrenosus of some
writers—and sometimes  assumes a very seri-
ous or even fatal  appearance.  But this severe
form occurs chiefly in lying-in hospitals, or in the
crowded, dirty, and ill-ventilated dwellings of the
poor.  In the cases which I have  seen in infants
the bullae  were numerous, more frequently dis-
tinct than  confluent,  and, in a few instances,
presenting many  of the characters of rupia es-
charotica, but assuming much more acute fea-
tures, and  even terminating fatally in four or
five  days.  When it  occurs in lying-in hospi-
tals, it may present a  mild form in some cases,
and a  very acute and dangerous form in oth-
ers, even in the  same ward and at  the  same
time.  It then  manifestly proceeds  from local
causes: from the states  of the beds and bed-
clothes, and the air of the wards.
   10. d. Solitary  Pemphigus—P. solitarius  of
Willan—is very  rare.  I have seen only one
case of it.  The  bulla rapidly attains the size
of an orange.   It is  preceded by disagreeable
sensations of tingling and smarting.   The bul-
la  breaks in about forty-eight hours, and is suc-
ceeded by a superficial excoriation, passing into
slight ulceration.   One or two days after the
disappearance of  the  first bulla another arises
in  its vicinity, and pursues the same course as
the preceding.  In this way,  two, three,  or
     III              5
even  more may appear in succession, the dis-
ease being prolonged to several days' duration.
Will an says that this variety very rarely oc-
curs,  and seems only  to affect women.  The
case I saw was  in a man, and occurred on the
lower  extremity.  Biett and Cazenave men-
tion a chronic state of this variety.
   11.  e. Acute Pemphigus may occur as a com-
plication or sequela of eruptive fevers, or be as-
sociated with other eruptions, as with herpes,
and more rarely with prurigo.  Mr. Wilson re-
marks that the small bullae of pemphigus bear
considerable  resemblance  to the  vesicles  of
herpes phlyctenodes ; and the likeness to her-
pes is  still farther increased by the occasional
appearance of the smaller bullae of pemphigus
in the form of rings.
   [The following case  of pemphigus, from Gi-
bert,  gives a very correct idea of the  acute
and accidental form of the  disease :
   " A man of sanguineous  temperament,  21
years of age, in the habitual enjoyment of good
health, went out hunting on the 8th of Septem-
ber, 1811, in  the marshes  of Bresse, and got,
several times, up to his knees in water, being
exceedingly fatigued, and  in a state of great
perspiration.   On the following evening a gen-
eral heat manifested itself, preceded by shiver-
ing, and accompanied by pain in the head, and
thirst, increasing towards  night.  The second
day, after a remission in the morning, the fever
became greater towards the afternoon.   The
third  day the face was more highly coloured,
the skin burning hot,  the  pulse  hard, quick,
and incompressible.  Pricking and itching sen-
sations in the inferior extremities, which ap-
peared slightly swollen, and of a deeper colour
than the rest of the body.   During the night,
restlessness,  extreme agitation, heat, and lan-
cinating pains  in the  legs.  The  fourth day,
the inferior  extremities,   swollen  from  the
knees  to the toes, were covered with red patch-
es, upon which were raised vesicles (bullae),
transparent, of a yellowish white, full of serum,
some the size of nuts,  others that of almonds,
and many merely that of pease, unequally scat-
tered, smaller and more numerous on the feet
and malleoli, larger and fewer upon the  upper
part of the legs.  All the red  patches are not
yet covered with vesicles ; on some the epider-
mis is scarcely,  or not at all, raised.   They
formed a slight prominence, their colour  not
disappearing  on pressure.  Those which had
vesicles in their centre were surrounded  by a
red areola, which became narrower as the ves-
icle extended itself.  Between each of these
patches the skin preserved  its natural colour.
The pulse, full  and  incompressible,  beat less
quickly than  the previous  evening;  the eyes
became painful, slightly red  and watery ; the
tongue dry and whitish ; the bowels costive ;
the urine high-coloured, and scalding.   The
other  functions  were unimpaired.  Passed  a
comfortable night, and slightly perspired.  The
fifth day  many  of the vesicles increased  in
size ;  some on the calves  of the legs became
confluent.  The sixth  day, the larger eleva-
tions became less full; the epidermis shrivel-
led, and the fluid which they contained  accu-
mulated  in the most depending part, when it
dried  up on  their spontaneous or accidental
rupture.  During the seventh and  eighth days,
most  of the vesicles,  faded  and shrivelled, 
66                           PEMPHIGUS—Description op.
spontaneously opened, and poured out a quan-
tity of yellow, inodorous, limpid serum, leav-
ing their bases  exposed, which formed large,
red, and painful excoriations, and continued to
ooze out a serous fluid for some period.  The
smaller  vesicles did not break,  but faded and
dried  up,  becoming white and  opaque.  The
red areola, at the same time, became obscure,
and at length disappeared.  From the eighth
to the tenth  day all the scales dried up, and
were  replaced, some by large, thin, yellowish
scales, others (those  which were  not evacu-
ated)  by more thickened crusts.  On the falling
off of these concretions, which took place in
two or three days, there  remained upon the
skin  bright,  shining,  wine-coloured  patches,
but without any depth of cicatrix.   The se-
verity of the fever was arrested after the de-
velopment  of the eruption ;  it then became
very  slight, and returned  no more after  the
sixth  day.  The urine then became turbid and
deposited a considerable  sediment.   On the
seventh  day the  bowels were relaxed,  the
stools being thin and frequent;  they soon,
however, became natural.   For the  first six
days  the patient did not leave his bed ; on the
seventh he left  it, and made a good meal with-
out any inconvenience resulting therefrom."]
   12. ii. Chronic  Pemphigus.—Pompholyx  di-
utinus, Willan — Phlyclenoide confluente,  Ali-
bert—is met with much more frequently than
the acute, and  appears much oftener in adults
and aged males than  in females.   It is either
limited to a small surface, or spreads more or
less over the body.  It is painful and tedious
in its course, always successive in its appear-
ance, and affects chiefly persons  advanced in
age and  of debilitated  constitutions.   It often
continues for many months or even years, and
in some cases  appears at a particular season
for several successive years ; for instance, in
the autumn and winter, and declining in the
spring.
   13. a.  The constitutional symptoms of chronic
pemphigus are  slight  compared with those of
the acute ; some degree of sickness and lassi-
tude, with pains in the head, back,  or limbs,
precede the eruption during several days ; and
these symptoms generally vary in degree with
the severity or extent of the eruption.  The
cutaneous disease is often  associated  with
considerable gastro-intestinal  irritation ;  and
in aged  persons, and  in cachetic  habits, it is
sometimes attended by dysuria or haematuria.
   14. b.  The eruption appears first in the form
of small red spots, attended by slight itching
The  epidermis soon becomes elevated in the
centre of each  patch.  The base of the eleva-
tion of'the cuticle gradually extends ; and of-
ten in a few hours an irregularly shaped bullae,
the size of a filbert, or even of a walnut, is thus
 formed.   Sometimes the bullae attain the size
of an egg.  At the end of three or  four days
some of the bulla? burst,  discharge their con-
tents, and leave an angry-looking excoriation
 of the dermis.   In others of them, the serum
 becomes reddish and turbid,  decreases, and
dries up, forming a dark scab covered by the
 shrivelled epidermis.   As one crop of bullae is
 thus changed, another is produced near to the
 first; and the disorder thus may be seen in all
 its stages  at the same time, and be prolonged,
 by successive eruptions,  almost  indefinitely.
The bulte are occasionally confluent, especially
when they appear on the face ; but this seldom
occurs.   They  sometimes attain the size of
the palm of the hand, the epidermis peeling off
and exposing an unhealthy-looking excoriated
surface, which seems difficult to heal, or which
heals in two or three days, new bullae forming
and pursuing the same course as the former.
In some severe cases the patient is confined to
bed, but there is rarely any fever.
  15. c. Chronic pemphigus may be complicated
with prurigo—Pompholyx prurigenosus of Wil-
lan—and with various chronic diseases of the
viscera, and in such cases may terminate fa-
tally.  It sometimes supervenes on chronic in-
flammation of  the  digestive organs, and on
partial or general dropsy.  When complicated
with prurigo, it is often a most distressing af-
fection, and  in old persons  especially  may
hasten a fatal termination, particularly  if vis-
ceral disease be also present, as commonly ob-
served.
  [The following case from Gibert was called
eczema in the first edition of his work, on the
" Special  Diseases of the Skin ;" it is a good
example of pemphigus diutinus, or the chronic
variety of the disease :
  " On the 26th of August,  1818, a woman 33
years of age was entered at the Hopital St.
Louis, tainted with a general cutaneous  mala-
dy, which developed itself without any appre-
ciable cause,  and had  lasted for 19 months.
The commencement of this disease had been
characterized by a bullous eruption,  accom-
panied  with  itching; but for some time pre-
vious to  her admission it had resembled the
form of squamous dartre, herpes squamosus ma-
didans of M.  Alibert.  The patient, whose
skin  constantly exhaled a  fluid which  pene-
trated and stained her linen, experienced no
pain in a  state of repose, except in the parts
on  which the weight of the body rested; but
walking was impossible on account of the pain-
ful friction  which  it  occasioned.   For  many
months past the catamenia had not appeared.
The  whole surface of the body, with  the ex-
ception of the palms of the hands and the soles
of  the feet,  was  covered with large,  round,
yellowish squamae, under which the skin was
rose-coloured, or even of a bright red.   There
was  an  abundant secretion of a slightly yel-
lowish fluid under the squamae, in many points.
The hairy scalp was the seat of a desquama-
tion  which  formed  drier and more delicate
scales ;  the  sub-cutaneous  cellular tissue of
the neck was swollen, the skin  being red,
cracked, and shrivelled ; the eyelids were red
and deprived of their lashes.  The  mouth was
dry, the tongue very red ; it presented in the
centre a slight coat of yellowish brown ; nev-
ertheless, the appetite and the digestive func-
tions  appeared unaffected.   The  pulse was
slightly accelerated, the patient felt very  weak,
and had a slight cough.  Laxative  drinks hav-
 ing been exhibited for some days, gave rise to
 a slight purging;  fever broke out,  though in a
 very slight degree ; the marasmus and  weak-
 ness gradually increasing, the  patient  sank
 into an adynamic state, after 19 days of treat-
 ment and about 20 months of disease.
   " On opening the body we found old adhesions
 in the chest, and some miliary tubercles in the
 two lungs (in other respects sound); a secre- 
PEMPHIGUS—Diagnosis and Prognosis of.
67
tion of calcareous matter in some of the bron-
chial glands.   Two pints of a citron-coloured
serum were effused into the peritoneal cavity,
which, besides, presented some old filamentous
adhesions, between the parietal and visceral
portions of the membrane.  The external sur-
face of the large intestines, near their concave
border, was studded  with  miliary tubercles.
The  internal  surface  of the intestinal  canal
was, generally, sound, with  the  exception of
some slightly vascular injections in the  stom-
ach and colon.  There was a quantity of yel-
lowish-white fluid contained in the intestines,
and particularly in the colon.  The whole ca-
nal  was shrunk and  contracted, and  the liver
had assumed  the fatty appearance: the gall-
bladder contained  a  very small quantity of
scarcely-coloured bile.  The skin, covered with
whitish squamae,  had quite  lost its  redness.
This discoloration had already much dimin-
ished during life, since the intestinal affection
and general debility had made so marked a
progress.'"]
   16. d. The contagious variety of pemphigus
mentioned  by Willan — P.  contagiosus — is
merely the symptomatic occurrence  of  bullae
in certain epidemic and endemic  maladies  de-
scribed by  authors.  Its endemic occurrence
has been observed by me on two occasions
among infants in  a lying-in hospital,  on each
occasion nearly all the infants in the  institu-
tion becoming affected ; but this prevalence
was attributable  to local causes,  and not to
contagion.
   [M. Alibert has given, under the name of
dartre phlyctenoide, the  following description of
chronic pemphigus:
   "There  was, at the  Hopital  St. Louis, a
commissioner,  named  Pierre Roger, about 60
years of age.   He was  attacked with a dartre
phlyctenoide.  It showed itself under the  form
of scattered pustules (bulla) of the size of a
nut, upon  the  trunk,  also upon  the  anterior
and posterior parts of the right  shoulder, as
though a scarf had been worn.   The  inner
side of the  arm  was  equally affected ; the
neck also, and the hairy scalp.  These  vesi-
cles, filled with  a transparent  fluid, shrank,
shrivelled  up,  and  spontaneously broke,  leav-
ing  the reticular tissue exposed.  Some days
after the  drying  up of the  eruption the skin
presented red patches, as if it had been burned
with fire or with concentrated nitric acid.  The
itching was not very urgent, but there was a
most uncomfortable  feeling of tension over
the whole  skin.  I noticed that all this super-
vened on a discharge of blood from  the rec-
tum.  This man had  been for a long time ex-
posed to the vicissitudes of the season, and
had  been unable, owing to his distress, to pro-
cure himself even the necessaries of life.
  " The same author has described under the
same name a fatal case of pompholix diulinus.
  "Anne Brundomy, 57 years of age, presented
herself at the H6pital St. Louis for treatment.
She  had suffered violent grief at the loss of
her husband.   One day, after having experi-
enced  some  digestive  disturbance,  she was
attacked with  a  spontaneous  vesicular  (bul-
lous) eruption, which gradually extended  over
the whole surface of the integuments.  These
ve&icles (bullae) were oval,  and multiplied so
rapidly that they soon became confluent:  they
 were not surrounded by any inflammatory are-
 ola. The eruption was accompanied by a gen-
 eral feeling of intolerable smarting and burn-
 ing, which became less after it assumed a fa-
 tal aspect.  Phlyctana formed on the mucous
 membrane of the mouth, aesophagus, and whole
 intestinal tube.   The patient had a sensation
 of burning  coals moving about in the intes-
 tines : she remained in this wretched state  for
 19 months, and at last sank, presenting for the
 last 15 days of her life all the symptoms of
 continued adynamic fever."]
   17. e.  The morbid appearances found in fatal
 cases are entirely those constituting the com-
 plications, and usually causing the fatal issue
 of this  affection.    M. Biett and Cazenave
 have often met with fatty liver in  their exam-
 inations  of these cases, with effusion of serum
 into the  chest and other shut cavities.
   [It has been stated that blebs, or bullae, have
 been met with on the mucous membranes, and
 particularly  on  that  of the  pharynx of those
 persons  who have died of this  affection, but
 this is of very rare occurrence.   On the con-
 trary, these membranes will be generally found
 pale.]
   18. II. Diagnosis.—The bullae  which occa-
 sionally appear during the progress of erysip-
 elas are accidental, and are to be distinguished
 from those  of acute  pemphigus by the latter
 being distinct, the surfaces between  them be-
 ing neither  tumid, nor red, nor painful.  The
 isolated  form of the  bullae and the laminated
 crusts  which they form generally distinguish
 pemphigus from other eruptions.  The bullae
 of rupia simplex are  exceedingly few, and ter-
 minate in ulcerations and in thick prominent
 scabs.   In ecthyma the epidermis is sometimes
 raised  by puriform fluid to a certain extent ;
 but the purulent nature of the contained mat-
 ter, the  brownish appearance of the apex of
 the elevations, and the presence of pustules of
 ecthyma at  an  earlier stage, will sufficiently
 distinguish the eruption.  In herpes the vesicles
 are always formed in groups upon a red and
 inflamed surface ; while the bullae of pemphi-
 gus are generally isolated, and free from sur-
 rounding inflammation.  Even when the bul-
 lae of pemphigus are small and confluent, so as
 somewhat to resemble herpes phlyctenodes, they
 are always larger than those  of herpes, and
 some of  them present their distinctive charac-
 ters.
   [It is generally easy to recognise pemphigus,
 if we except the chronic  form of the disease,
 which  somewhat  resembles chronic impetigo,
 or even pityriasis, in its foliaceous desquama-
 tion.  When it is chronic, and the bulla?  are
 imperfectly developed, and particularly  when
 there  are nothing but squamous vestiges,  or
even consecutive stains, to establish a diagno-
 sis, it  requires some care and experience  to
distinguish the disease.   In some instances it
 has even been simulated by placing small quan-
 tities of powdered cantharides on the limbs. J
   19.  III. The Prognosis of acute pemphigus,
 when occurring in adults, and without any com-
 plication, is always  favourable.   When met
 with in infants, in the circumstances above no-
ticed (v  9), it is often a serious or even dan-
gerous disease.  The prognosis of chronic pem-
phigus should depend upon the constitution  of
the patient, and upon the existence of visceral 
68
PEMPHIGUS—Causes—Treatment or.
disease.  When it is extensive or frequently
developed, and affects those debilitated by dis-
sipation or poverty, or when it is complicated
with visceral disease, an unfavourable opinion
of the result should be entertained.   Its sever-
ity usually corresponds with the cachectic state
of the body affected by it.   M. Rayer adduces
a case in which chronic pemphigus of the legs,
following attacks of haemoptysis, appeared to
exert a salutary influence.  Where there is ob-
vious visceral  disease complicated  with this
eruption, the cure  of  the latter will aggravate
and  increase the danger of the former.   Mr.
Wilson remarks that he has seen several ca-
ses which have induced him to " believe that
this eruption is an effort of the system to rid
itself of some morbid disposition."  I may add,
that  I have hardly seen a case in which there
was  not reason to  infer, what I have elsewhere
so much insisted  on. a more  or less morbid
state of the circulating fluids,  owing either to
impaired elimination  and  excretion, or to im-
perfect assimilation.
  20. IV. Causes.—Acute pemphigus attacks
infants, children, and  young persons most fre-
quently.  It has been said to be congenital and
hereditary.   It  is  most prevalent in the  sum-
mer, and in  those exposed to the sun's rays.
I have often seen it in sailors  who have exert-
ed themselves  under  a tropical sun without
any covering to the upper parts  of the body.
It is usually referred to teething; to improper
or unwholesome food  ; to gastric and intestinal
irritation; to over-feeding; to mental emotions ;
and to amenorrhcea and dysmenorrhea.  It has
sometimes resulted from the constitutional ir-
ritation caused by vaccination.  The endemic
sources to which infants are sometimes expo-
sed have been already noticed (§ 9).  The symp-
tomatic appearance of pemphigus, in connexion
with various fevers, has been  occasionally ob-
served.
  21. Chronic pemphigus occurs chiefly in aged
persons whose systems are debilitated or ca-
chectic, and appears most frequently in autumn
and winter.   It is  usually caused by intemper-
ate habits, by excesses, unwholesome food, by
fatigue ; anxiety of mind; low, damp situations;
living in cellars and  ill-ventilated apartments ;
exposure to cold ;  and by chronic irritation  of
the digestive, mucous, and genito-urinary or-
gans.  It is  more rarely a sequela of the ex-
anthematous fevers.   It may follow disease of
any of the secreting and excreting viscera, and
thus be complicated  with it, the morbid ele-
ments not being eliminated from the circulation,
but irritating and inflaming the cutaneous sur-
face in  the particular mode constituting pem-
phigus ;  and often affecting, also, the mucous
surfaces.
  22. V. Treatment.—A. In the mild cases of
acute pemphigus, but little more is requisite than
to exhibit diluents,  gentle aperients,  warm
baths, and diaphoretics, thereby to promote the
functions of the several emunctories.  When
the symptoms are more acute, and the patient
is plethoric, a few ounces  of blood may be ta-
ken  away, and purgatives,  with the rest of the
antiphlogistic regimen, prescribed.  In infants,
and  in  cases attended  by debility or sympto-
matic of low fever, the infusion or decoction of
bark, with  muriatic  acid, or with the alkaline
carbonates, if the urine be very acid, is gener-
ally beneficial;  and when any complication ex-
ists, especial attention should be directed to it.
  23.  B.  Chronic pemphigus often  withstands
the use of very active means ; but it is neces-
sary, previously to determining upon the meth-
od of cure, to  ascertain as nearly as  possible
the states of the secretions and excretions, and
of the several emunctories.  The urine should
be carefully tested, and the alvine evacuations
daily examined.  When  the biliary and intes-
tinal functions are disordered, means appropri-
ate to  such disorder, as blue  pill, or hydrarg.
cum creta, with ipecacuanha or opium, or with
Dover's powder, should be exhibited.   In most
cases,  warm baths, either simple or alkaline,
are of essential service.  When the  liver is
torpid, after a  recourse  to calomel or milder
mercurials, the nitric or nitro-hydrochloric acids
may be given with the infusion or decoction of
cinchona, or the decoctions of sarsaparilla.  If
the urine be acid, the liquor potassae, with the
preparations of sarsa, are generally beneficial;
and, if the digestive mucous surface be exempt
from marked irritation, small doses of the io-
dide of potassium may be added with great ad-
vantage.  When there is marked disorder of
the digestive organs, warm baths,  alteratives,
ipecacuanha, and anodynes are generally requi-
site.  When the evacuations  are offensive,  as
well as frequent, care should  be  taken not  to
confine the bowels  by opiates, but rather  to
correct the secretions by alteratives, by the al-
kaline  carbonates and salts, and by a spare, far-
inaceous, and  milk diet.  If, however, the in-
testinal irritation be severe, and the symptoms
present a dysenteric character, ipecacuanha or
Dover's powder, in frequent doses, may be ex-
hibited, and emollient enemata  administered;
and, when restlessness and pain are complain-
ed of, these means, aided by warm baths, will
be still more requisite.
   24. When the menstrual discharge is sup-
pressed or interrupted, these measures should
be directed to its restoration ; but these meas-
ures should be chosen according to the pecu-
liarities  of the case.  In most cases  of men-
strual  obstruction connected with  cutaneous
eruption, the  iodide of potassium  with liquor
potassae, and tonic infusions, will prove benefi-
cial, if the bowels be duly regulated by means
of suitable aperients; and the biborate  of soda,
conjoined with any of the preparations  of aloes,
will often be of use in similar circumstances.
M. Rayer has had recourse to the arseniate of
soda in obstinate cases of pemphigus; and  in
these Donovan's solution of the iodide of arse-
nic and mercury may be employed with some
hopes of advantage, as I have seen benefit de-
rived from it in one case of this kind for whicli
I lately prescribed it.
   25.  The observation made above respecting
the pathological relations of pemphigus (y 19,
21) should be borne in mind during the treatment
of this eruption, and especially of the  chronic
states  and complications of it;  for a morbid
condition of the circulating fluids, arising ei-
ther from insufficient elimination or excretion,
or from imperfect assimilation, as fully shown
in the articles Blood and Disease, generally
more or less obtains, not only in this, but also
in most other cutaneous diseases.   This posi-
tion being unassailable, it should form the ba-
sis of our therapeutical operations  and all our 
PERIOSTEUM—Inflammation of the.
69
efforts ought to be directed to the restoration
of the excreting functions to  the removal  of
all obstructions to the discharge of these func-
tions, and especially of the cutaneous functions.
  26.  C.  The topical treatment  of chronic pem-
phigus is often of much importance.  As a gen-
eral principle,  the serum effused in the bullae
should, as soon as they are fully developed, be
let out by puncturing them, for even the partial
absorption of it tends to  perpetuate the morbid
condition of the circulating fluids on which the
complaint  chiefly depends, while the  early re-
moval of  the  morbid secretion  prevents  not
only this contingency, but also  the excoriations
and sores which often result from leaving the
bullae uninterfered with.   After puncturing the
bullae, warm baths, warm bread and water poul-
tices, or emollient  fomentations may be em-
ployed, and, subsequently, gently astringent lo-
tions,  or  absorbent powders, or  healing oint-
ments may be applied, according to the circum-
stances of the case.
  [Dr. Bulkley thinks that,  as a general rule,
the bullae should not be opened, and that warm
and moist applications to them  should be avoid-
ed.   Should they burst, either spontaneously
or by accident, some soothing application must
be made to allay the irritation, and especially to
protect the excoriated surface  from the air.—
Am. ed. of Cazenave, p. 118.]
  27. D. The diet in this, as in many other cu-
taneous  affections, should  consist chiefly  of
milk and farinaceous articles ;  animal food, of
easy digestion, should be taken sparingly ;  but
veal,  pork, shell-fish,  and dried or highly-sea-
soned articles ought  to  be avoided.   In cases
requiring  tonics, a  more  generous diet,  and
good  wine in moderate  quantity, may be  al-
lowed, particularly if due exercise in  the open
air be also taken.

  Biblioo. and Refer. — Delius, Amoenitates Medics,
cas. 9, p. 71.—C. Lepois,  De Morbis a Serosa  Colluvie et
Diluvie ortis, Obs. 149.—C. Seliger, Ephemer. Nat. Curi-
os., dec. 1, aim. viii., Obser. 56. — Langhans, in Acta  Hel-
vet., vol. ii., p. 260.—Hoffmann, De Affectu raro Scorbutico
Pustulari, supp. ii., p. 2.—Gilibert, Adversar. Med. Pract.
Lugd.,  1773,  p.  183.—Dickson, Observat. on  Pemph. in
Trans,  of Irish  Academy, 1787,  p. 47.—D. Stewart, in
Med. and Phys. Comment, by a Soc, &c.  Edin., vol. vi.,
p. 79.—Finke, De Morbis Biliosis Anomalis, &c, p. 118.—
Macbride, Method. Introduct. to  Medicine, 4to.  Dubl.,
1772.—/. P. Frank, De Curandis Morbis Hominum, 1. iii.,
p. 258.— Wichmann, Beytrage zur Kenutnissdes Pemphigus,
Erfurt, 1790. — C. G. C. Braune, Versuch ueber den Pem-
phigus und das Blasenfieber, 8vo.  Leipz., 1793. — L. Rit-
ter von Brann, Ueber die Erkenntniss  und Behandlung der
Pemphigus, 12mo. Erft., 1823.—Ozanam, Hist, des Malad.
Epideimques, t. v., p. 208.—Lobstein,  Journ. Complement.
des  Sciences Medicales,  t. vi. — Robert, Journ. dc Med.
Chirurg. et Pharmac, t. xxiii., p. 227. — Savory, in Ibid.,
t. xxii., p. 203. —Jacquemin, in Journ. Gener. de  Med., t.
xxx., p. 264. — Martius, Ueber den Blasenausschlag oder
Pemphigus,  8vo.  Berlin, 1829. — Bateman, Synopsis of
Cut. Diseases, 1829, p. 197; and Delineations,  <fec, pi. 33,
fig. 2. — Hinzt, Sur le Pemphigus des Nouveau-nes ; in
Bullet, des Sc. Med. de Ferussac, t. xi., p. i~.—Bidault de
Villiars, Recherches  et Observat.  sur le Pemphigus; in
Recueil Period, de la Soc. de Med.de  Paris, t. liv., p. 1.—
Asdrubali, Archives G6ner. de Medecine, t. xvii., p. 601.
—Btett, Journ. Hebdom. de Med., t. viii. p. 46.—P. Rayer,
Theoret. and Pract. Treatise on the Diseases of the Skin,
trans, by R. Willis, 8vo.   Lond., p. 208. — Cazenave  and
Schedel, Manual of Dis. of the Skin, trans, by T. H. Bur-
 ?ess, 8vo.  London, 1842, p.  106. —Erasmus  Wilson, A
 ract. and Theoret. Treat, on the  Diseases of the  Skin,
8vo.  Lond., 1842, p. 137.
  [Am.  Biblioo.  and Refer. — Am.  Ed. of Cazenave,
Plumbe, and Rayer. — Wilson on Healthy Skin. — Good's
Study of Medicine, by Doane.—Worcester on the Skin, &c]

  PBRICARDIUM.   See art. Heart and Per-
   PERIOSTEUM. — HepiooTiov—Perioste, Fr.
—Die Knockenhaut, Beinhaut, Germ.—The dis-
eases of the periosteum have been noticed in the
articles Brain — Membranes of, Cranium, Fi-
brous Tissue,  and Osseous  System.   When
thus treating, in their respective relations, of
certain portions of the periosteum, and when
viewing them  in connexion with the bones
which  they form and  support,  the several al-
terations of structure  observed  in the perios-
teum were fully noticed.  It  now only remains
for me to  consider inflammations of the  perios-
teum and their consequences.
   1. Inflammation of the Periosteum.—Syn-
on. — Inflammatio periostei, periosteals, periosti-
tis ; Periostite, Fr.  Die  Entzundung der Bein-
haut,  Germ.
    Classif.—III. Class, I. Order (Author).
   2. Defin.—Pain, more or less acute,  referred
to the surface of one or more bones, with  tender-
ness on pressure ; deep-seated swelling, at first ob-
scure,  but  afterward  more manifest, sometimes
with redness in the parts covering the more super-
ficial  and  prominent bones; more or less symp-
tomatic fever.
   3. The  conventional division of periostitis
into acute and chronic is useful,  although every
grade of activity  and duration obtains in this
as well as in  other  diseases.   Periostitis is
also simple and primary, or consecutive  or con-
stitutional.  In this latter case it generally pro-
ceeds from previous disease, and is character-
ized  by a  certain diathesis, or  is  the  conse-
quence of a specific cause.   Thus, periostitis
may be scrofulous, gouty, scorbutic, or rheumatic,
and present certain modifications in its  course
and consequences as it occurs in constitutions
thus characterized.   It may, moreover, be spe-
cific, or be caused by certain specific causes, as
by syphilis and the excessive use of mercury.
Due regard to  these several states of the dis-
ease is requisite in practice, inasmuch as each
of them requires a modified treatment.
   4.  i. Symptoms.—A. Acute and sub-acute pe-
riostitis often commences in  an insidious man-
ner,  but  it  sometimes  declares itself  very
acutely.  In the  former case there are gener-
ally neither chills nor rigours, and the accompa-
nying fever may be slight; in  the latter case,
chills or rigours are often experienced, with in-
tense   pain,  complete insomnia,  and 'severe
symptomatic fever.  The progress  of the dis-
ease in the one is generally  slow, in the other
much more rapid : it is often difficult to deter-
mine whether  or not the inflammation  is seat-
ed in the periosteum or in  the  bone itself.
Most frequently, I believe the bone is affected
nearly as  soon as the periosteum, more espe-
cially  in the scrofulous and syphilitic states of
the disease.  If the bone be superficial  and the
inflammation severe, swelling, at first hard or
resisting,  subsequently more superficially soft
or doughy as it increases, may  be detected in
the course of the bone.
   5. a. The symptoms are much more  obscure
where the periosteum of deep-seated bones is
affected.  In these cases, the attending swelling
may be obscure or hardly felt, and the existence
of the disease  can be only  inferred from the
pain being fixed in or limited to  some  part of
the skeleton, and from the nature of the pre-
disposing  and exciting causes.  It is  difficult
to determine whether the disease commences 
70                       PERIOSTEUM-Inflammation  of thk.
 in the exterior or in the interior surface of the
 periosteum, unless under  particular circum-
 stances, as when the periostitis is caused by
 certain external injuries, by ulceration, or the
 extension of inflammation from parts covering
 the periosteum.   In such cases, and when the
 inflammation extends from the periosteum to
 the soft  parts  covering or surrounding it,  it
 may be inferred that the external surface of
 the periosteum is chiefly affected, and the bone
 underneath either slightly or not at all.  And
 this condition may be also inferred  where the
 disease  attacks the rheumatic and  gouty diath-
 eses ; and in  these  cases,  particularly where
 the periosteum  in the vicinity of joints is im-
 plicated, serum or fluid lymph often accumu-
 lates in the sheaths of tendons, or even within
 or around the capsules; similar changes, in
 these situations, have also been observed by
 me in  several  cases of syphilitic  periostitis,
 complete recovery taking place without any in-
 dication of disease of the bones.
   6. b.  In the more  acute cases of periostitis,
 suppuration is not an infrequent result.   If the
 external surface of the  periosteum be  chiefly
 affected, the swelling becomes more and more
 manifest, softer, and circumscribed.  The tis-
 sues external to the primary swelling become
 somewhat cedematous, or even reddened, and
 fluctuation, at first obscure, may be detected.
 In scrofulous constitutions, and when the peri-
 osteum of the long bones is affected, especially
 near articulations, oedema of the joints, or se-
 rous effusion under  the capsules,  or  in the
 sheaths  of tendons,  is  often  observed ;  but
 these changes may also take place independ-
 ently of suppuration, as in the rheumatic diath-
 esis, but more frequently in connexion with it,
 in the scrofulous.
   7. c.  In the more acute cases of periostitis,
 when there is reason to  mfer the extension of
 inflammation  to the  bone  itself, suppuration
 may likewise occur, and may detach the peri-
 osteum from  the  bone ; but,  in the  more in-
 tense cases, and in cachetic or scorbutic habits,
 the morbid action in the periosteum may give
 rise to the effusion of a  turbid serum between
 the  periosteum  and the  bone, detaching  the
 one from the other to a considerable extent,
 even before suppuration  takes  place, and to
gangrene of the periosteum and necrosis of the
 bone.  This result may take place in acute pe-
 riostitis of any of the more superficial bones,
 and not infrequently in periostitis of the bones
 of the cranium and face ; but suppuration is a
more frequent occurrence.  (See articles Cra-
 nium (t) 4), and Osseous System.—Osteitis.)
  8. B.  Chronic periostitis usually commences
slowly and  insidiously,  and presents similar
constitutional  and specific relations  to those
above alluded to (v 3).    It is more frequently
observed than  the acute, and is sometimes
connected with ulceration, tumours,  or other
organic changes of the parts  external to the
periosteum;  and is attended  by  slight pain
only, which is  often  aggravated  during the
night by more or less tenderness, especially in
superficial situations ; and by varying or slight
symptomatic fever and  constitutional symp-
toms.  Chronic inflammation, when limited to
a very small extent of  the periosteum, may
produce various local changes, according to
the grade of morbid action, and to the charac-
 ter of the secretion  infiltrating the inflamed
 part and contiguous tissues;  it may occasion
 simple thickening and induration, or even thick-
 ening with softening; it  may give rise  to the
 accumulation of a glairy, soft, or gelatinous or
 semifluid matter, chiefly external to  the peri-
 osteum ; or to a grayish, homogeneous matter
 resembling soft  cheese ;  or to a fibrous, carti-
 laginous, or osseous substance.  These even
 may form apparently between the periosteum
 and the bone, or in the fibrous structure of the
 former.
   9. In the rheumatic form of chronic periosti-
 tis, thickening, or fibrous, cartilaginous, or even
 osseous transformation of parts of the perios-
 teum sometimes takes place, particularly in the
 vicinity of articulations ; occasioning stiffness,
 or even complete immobility of the joint or
 joints.   In  trie gouty state of the  disease,  a
 calcareous or chalky deposite, similar to that
 which  forms  around the  articular ligaments,
 and consisting chiefly  of  the urate of  soda,
 sometimes takes place in the structure of the
 periosteum, or between it and the bone.  In
 addition to these changes, various others are
 met with in the bones  and in the periosteum,
 consecutively  of chronic   periostitis; but  I
 must refer the reader to the notice  taken of
 them in the articles mentioned above (y 7).
   10. The terminations and consequences of pe-
 riostitis are in every respect the same  as those
 shown  to follow osteitis, and are attended by
 the same symptoms as accompany them.  (See
 Osseous System, v 12-22.)
   11. ii. Associations of  Periostitis.—The
 periosteum is very rarely inflamed without an
 extension of the  morbid action, in a greater or
 less degree, to the bone  itself.  Hence it is
 difficult to determine  how far the bone  is af-
 fected until the disease in it has made consid-
 erable progress.   Much depends upon the di-
 athesis and age of the  patient, and the nature
 of the exciting causes ;  but when the pain re-
 ferred to the bone whose periosteum is affect-
 ed is increased, as in  the  case of any of the
 long bones, by sustaining  a weight or stand-
 ing on it, inflammation of  the bone itself may
 be inferred.  The association of osteitis  with
 periostitis is most frequent in young persons,
 children, and the scrofulous diathesis ; and the
 least so in the gouty and rheumatic.
   12. When periostitis is seated  in any of the
 vertebrae, or in the sacrum, or, indeed, in any
 of the bones either incasing parts of the ner-
 vous  masses  or furnishing outlets  to  the
 nerves, the consequent swelling of the  peri-
 osteum and effusion of lymph may so affect
 the parts of the nervous system contiguous to
 it, or the nerves as they  pass through  their
 respective foramina or outlets, as to interrupt
 their functions, and to occasion paralysis more
 or less complete.   I have  seen  several cases
 of paraplegia thus produced, and very recent-
 ly attended one with Dr. Johnson and Mr. Lis-
 ton where this complication existed.  In these
 cases the bladder is often  affected, indeed al-
 ways when  paraplegia is present.  Periostitis
 may be  also associated  with neuralgia,  and in
 this case the former is usually the cause of the
 latter, which not infrequently in these  circum-
 stances passes into palsy.
   13. When periostitis affects the head, a*s the
pericranium, of which I have seen two or three 
PERIOSTEUM—Diagnosis—Causes.
71
cases, one of them that of a physician in this
city, the symptoms are often distressing.  The
disease  may  be either acute  or  chronic, and
proceed simply and favourably, as in the  case
just alluded  to ;  but  it also, owing to the ex-
tension  of the inflammation to the inner table
of the skull, or to the  effect  produced upon the
nerves  in the  vicinity, may  be complicated
with epilepsy, as in a case recorded by Dr.
Graves.  Indeed, epilepsy is  not infrequently
caused by inflammatory and other changes  in
the dura mater;  and we know that inflamma-
tion may be propagated from the pericranium,
through the  tables of the  skull to  this mem-
brane, especially  after injuries.
   14. The complication of periostitis with  gout
or rheumatism need hardly be mentioned, since
the latter are more commonly causes than com-
plications of this malady; and this remark  is
still more  applicable  to  syphilitic  periostitis.
Still they should  be viewed also  as complica-
tions requiring a modified  and even peculiar
mode of treatment.
   15. iii.  The changes found in the periosteum
during  the  several periods of periostitis are
briefly  these :  In the simple and early state
of the disease, the membrane is red and in-
jected,  without any remarkable thickening  or
softening.  The adjoining cellular tissue is also
injected.  At a somewhat more advanced pe-
riod the injection increases  and extends to the
bone, the  adhesion between which and the pe-
riosteum  is  now  somewhat impaired.   At a
still later stage this membrane is redder, thick-
er, and  somewhat softer, owing to  some  infil-
tration  of lymph or  serum;  and it is much
more easily detached from the bone ; and the
bone itself is often more discoloured.  In the
more chronic states of the  disease, the mem-
brane is less red, but  it is  more  thickened,  is
more dense,  and more closely adherent to the
bone.   In  scrofulous persons, small abscesses
or scrofulous suppuration  may take  place  in
the periosteum,  and  extend  outwardly,  with
or without a more or less serious lesion  of
the bone.
   16. When the disease goes on to suppura-
tion, which may  occur in either the acute, the
sub-acute, or  chronic  state,  particularly the
latter in scrofulous persons, the  periosteum is
still more thickened, softened,  villous at  its
surface, or even fungous.  Suppuration  most
frequently occurs in  the outer surface of the
membrane, and proceeds externally; but some-
times it takes place from the internal surface,
particularly when  the bone is much affected.
In this latter case it detaches the periosteum
from the bone, causing considerable changes in
both, often with perforation of the former, with
extension  of the abscess  externally through
the soft parts, and with the death of the bone
underneath.   In  cases of injury of the  peri-
cranium,  purulent matter is not infrequently
collected  between this part and the bone, and
the inflammation having  extended  through
both tables,  advances to  the  dura  mater, be-
tween which and the inner table matter  often
also collects, so that, before the abscess breaks
externally,  fatal  lesions may be  produced un-
derneath  the bone.  In some cases abscess
forms externally to  the periosteum, and this
membrane is thickened, opposing for a time a
barrier between the abscess and  the bone; but
this is at last overcome, and the bone is more
or less destroyed.  In this case, periostitis and
osteitis are consequent upon the inflammation
of the adjoining parts.  The other changes ob-
served after periostitis are  the same as those
found after osteitis,  and are described in the
article on the Osseous System (y 12-22).
  17. iv. The Diagnosis of periostitis is gen-
erally easy when  the periosteum of superficial
bones is affected ; but  in other circumstances
it is extremely difficult.  The history of the
case, and  the  relation which  the  symptoms
have with the causes which seem to have pro-
duced them, will generally aid in the formation
of a correct opinion.  When an acute or ach-
ing pain is felt in  the situation of a bone, and
is increased on firm pressure, and  during the
night; and more  particularly when there  is a
fixed  and deep-seated  swelling which is  con-
tinuous with the surface of the bone, it  may
safely be inferred that  either periostitis or os-
teitis is present, or both ; and,  although it  may
be impossible to  determine which of the two
structures may be chiefly affected, the circum-
stance is the less important, inasmuch as the
treatment is the same, or very nearly the same,
for  both.   It  is  often  much  more important
to ascertain the  existence of certain of the
consequences  of  the disease, particularly of
suppuration, or of caries,  or the death of the
bone.  When the former occurs, redness is of-
ten observed at the surface, unless  the perios-
teum be  deep-seated, and there is  also some
degree of oedema of the adjoining parts, fol-
lowed by more or less distinct fluctuation, par-
ticularly when suppuration commences in the
external  surface  of  the periosteum.  The ex-
istence  of caries  is  to be inferred  from  what
has been stated on the subject under the head
Osseous System (y 16-20).
  18. v.  The  Causes  of  periostitis are alto-
gether the same as those which produce ostei-
tis.  They are  constitutional or intrinsic, or ex-
ternal or extrinsic.—a. Many of the  former are
chiefly predisposing causes, as the  scrofulous,
gouty, and rheumatic diathesis ; but syphilis is
not only a predisposing, but also an energetic
exciting cause ; and when it affects  the scrofu-
lous diathesis, not only periostitis, but osteitis
also,  often supervenes.  Periostitis may also
follow fevers, especially exanthematous fevers
of a malignant character.   It is not  infrequent-
ly caused  by scurvy, and  by  various  chronic
cutaneous  affections, when neglected or allow-
ed to proceed to  ulceration, particularly in the
extremities.  All debilitating agents, unwhole-
some food, exhausting excesses, and the abuse
of mercury, also predispose to periostitis.
   19. b.  The exciting causes are chiefly contu-
sions and  local injuries  of all kinds;  chronic
ulcers near or over superficial bones ; the irri-
tation of abscesses, of tumours, or of tuber-
cles in the vicinity of the periosteum ;  excess-
ive muscular exertion, sprains, &c.; exposure
to excessive cold or  heat; and a prolonged  or
unsuitable exhibition of mercury, especially for
syphilis affecting the scrofulous diathesis.  Ma-
ny of the cases of periostitis, osteitis, and con-
sequent caries of the  bones of the skull and  face,
which were formerly  so  frequent, and which
are still occasionally met with, are more attrib-
utable to the excessive use of mercurials than
to the disease for which they were prescribed. 
72                             PERIOSTEUM—Treatment.
  20. vi. Treatment.—A. In the acute or early
state of this malady, the antiphlogistic  treat-
ment and regimen are requisite, particularly in
young,  robust, or  plethoric persons.   Even
when we have cause of suspecting  the peri-
osteum only to be affected,  the intimate con-
nexion between it and the bone should induce
us to employ decided and prompt means.  Lo-
cal depletions are always requisite, particularly
in the simple form of the disease, occurring in
a previously healthy person, and they ought to
be large or repeated, or be  preceded  by gen-
eral blood-letting, especially  in robust or pleth-
oric habits.  After depletion, calomel should be
freely exhibited with antimonials until the gums
be affected, and  I  agree with Dr. Graves in
thinking that the calomel is especially required
when the pericranium and bones  of the head
are implicated ; taking care, however, not to
prescribe calomel so as to risk an injurious ef-
fect  from it.  When  the  periosteum  of the
more superficial bones is affected, as those of
the head, face, or extremities,  the practice of
making incisions down to the  inflamed  struc-
ture, even before suppuration has commenced,
and  with the view of preventing this conse-
quence of the inflammation, seems judicious,
and is advocated by  Crampton, Velpeau, Be-
eard, and others.  These incisions not only un-
load the vessels of the inflamed and adjoining
tissues, but tend to determine the suppurative
process, if this should occur, externally in the
direction of the excisions, and thereby to  pro-
tect the bone.  When the inflamed periosteum
is, however, deep-seated, such  early incisions
can hardly be  practised, or  only may be ven-
tured on when suppuration has advanced.  Af-
ter'local depletions, or even when they cannot
be prescribed, as in those sub-acute attacks
which  sometimes  occur in  debilitated,  ex-
hausted, or broken-down constitutions, blisters,
other issues, or the tartarized antimonial oint-
ment, or other means which will produce vesi-
cation or irritation, with a copious or prolonged
discharge from the  cutaneous surface over the
inflamed periosteum, will often prove extreme-
ly beneficial;  but, as soon  as  vesication or a
discharge is obtained, it should  be favoufed by
warm poultices, and such other means as the
peculiarities of the case will suggest, and per-
petuated for  a  considerable period, so as to
fully determine its effects.   After  these an-
tiphlogistic  means have  been  employed, the
treatment about to be advised for the chronic
states, if the disease still continues,  should be
employed.
  21. B. In the chronic states of periostitis, the
treatment  should be nearly the same as  that
recommended for  osteitis ;  for in  this state
the bone generally  partakes  more  or  less in
the morbid action.  Such, however, may not
be the case to any extent in the rheumatic or
gouty states of the disease, even when assu-
ming more of an acute than of a chronic charac-
ter ; but, in the scrofulous form of the malady,
the  probable  extension  of  the  morbid  action
to  the  bones requires  more  especially  the
treatment advised  for  osteitis;  namely, re-
course  to the iodide of potassium, with liquor
polassa, or Brandish's alkaline solution, in ei-
ther of the preparations  of sarsaparilla, or in
hitter infusions.   In  the rheumatic  and gouty
states these means are equally beneficial; and
occasionally the mistura guataci may be advan-
tageously made the vehicle of the other medi-
cines.   In these states also, some one of the
preparations  of colchicum  may  be added to
those just named; and a small quantity of
sulphur  with magnesia may be taken at bed-
time for a considerable period, or until conva-
lescence is far advanced.
  22. C. If  suppuration, either externally to
the periosteum, or between it and the bone,
should take place, an early exit  ought  to  be
given to the matter, and  the  local treatment
proceeded with according  to the circumstan-
ces of the case.   The iodide of potassium and
liquor polassa, with sarsa  and tonics, should,
however, be  persisted in,  if no urgent reason
exist to contra-indicate them ;  as they gener-
ally enable the system to repair whatever local
mischief may  have been  done.   In many  of
these cases,  a full dose  of some one of the
preparations  of opium will be conjoined with
the above, or given at bedtime with benefit.
  23. D.  In  the  other states of organic lesion
occurring in the  periosteum, the means now
mentioned are generally most efficacious, even
when associated  with caries of the bone.  I
state this from experience; but  I should also
add, that I have likewise seen the bichloride of
mercury prescribed in the compound  tincture of
bark, with tincture of capsicum, almost equally
beneficial with the iodide,  both in the simple
and in the advanced and complicated states of
periostitis.   In cases  of  syphilitic periostitis
this  salt, either in simple solution or prescri-
bed with sarsa, is  the chief remedy upon which
we should confide, particularly if it be  taken
according to Van  Swieten's method, and soon
after a  meal.   In cases where mercury has not
previously been given, or in those where it has
been given in inadequate quantity  or  ineffi-
cient form, this mode  of treating syphilitic pe-
riostitis should not be overlooked.   Where,
however, mercury has been  resorted  to  in
this complicated state of  the disease, without
marked benefit, the preparations of iodine should
be  preferred  and sufficiently tried.  As far
back as 1824  I employed  these  preparations
with decided  success in  both syphilitic and
scrofulous periostitis ; and about this period I
prescribed them for  a gentleman whose case
presented this complication,  and had become
remarkable  for the  persistence and conse-
quences of this disease,  and the number of
medical means and measures he had had re-
course  to.   They proved efficacious in his
case, as well as in others, and he is now alive
and well.  (See Osseous System, v 23-25.)
  Biblioo. and Refer.— Voigtel, Handbuch der Patho-
log. Anatomie, b. i., p. 127.— Gaudet, in Journ. de Medi-
cine, t. vi., p. 220.— Wilson, Lectures on the Struct, and
Physiol, of the Parts composing  the Skeleton, and on the
Diseases  of the Bones and Joints, 8vo. Lond., 1820 —
Rayer, in Archives Gener. de Med.  Mars et AvTil, 1823.
—A. Btrard, in Diet, de Med., art. Perioste, Maladies,
&c.—P.t. Blandin, in Diet, de  Med. et Chirurg. Prat.,
art. Periostite.—Cruveilhier, Anatomie Pathologique, liv-
rais.  xxxv., pi. v. (Extravasation of Blood between the
Periosteum and Bone.)—Parsons, in  New-England Med.
Review and Journ. ; and in Journ des Progres des Sci-
ences Med., t.  xv., p. 54.— Roche et Sanson. Nouv. Ele-
mens de  Palhologie, Ac.  Brux., 1834, p. 238.—/. Hamil-
ton, Dublin Journ. of  Med. Sciences, vol. ix., p. 255.—R.
Graves,  System of Clinical Medicine, 8vo.  Dubl , 1843.
See,  also, Biblioo.  and. Refer, to articles Fibrous
Tissue and Osseous System.)
PERIPNEUMONIA.-S^Lungs-Inflamju-
   TION  of. 
PERITONEUM—Acute Inflammation of—Description.
73
  PERITONEUM—Diseases of—The perito-
neum (nepiToveiov,  from irepiTEivu, to extend
around) was not recognised, until a compar-
atively recent  period  of medical history,  as
being often  the seat of disease, independently
of the parts which it envelops ; and, as will
be  shown in  the  sequel,  the most serious
changes to which it is liable were, until mod-
ern times, often confounded with other  mala-
dies.  The greater  precision imparted to path-
ological research since the appearance of the
writings of Morgagni,  and  more recently  of
those of C. Smith, Bichat, Baron, and others,
and the more accurate connexion of lesions of
this membrane with the phenomena or symp-
toms by which they are indicated, furnished
by numerous modern writers,  more especially
by those referred to at the conclusion of this
article, have combined to place our knowledge
of the nature, symptoms,  and treatment  of
diseases of the peritoneum greatly in advance
of the progress it presented at  the close of the
last century, or even at the commencement of
the present.   In this article I shall, first, con-
sider the  several states of inflammation  of  the
peritoneum, and their consequences ; and, second-
ly,  the structural changes found in this  mem-
brane independently of inflammation.
   1.  Inflammation of  the  Peritoneum.—
Synon.  Peritonitis,  Vogel,  Cullen, &c.  Phleg-
mone Peritonei, Phlegmone Mesenterii, Prosper
Alpinus.   Epiploitis, Sagar, Sauvages.  Omen-
titis,  Vogel.  Inflammalio  Omenti, Boerhaave.
Mesenteritis,  Enteritis Mesentcrica, Sauvages.
Inflammatio Mesenterii, Hoffmann.  Febris Me-
sentcrica,  Darwin.   Enteritis  epiploitis,  Parr.
Cauma Peritonitis, Young.   Empresma peritoni-
tis,  Good.  Inflammatio  Peritonei;  Peritonite,
Inflammation du peritoine, Fr.   Darmfellentzun-
dung, Bauchfellentzundung, Germ.
     Classif. — 1st Class, 2d  Order  (Cullen).
      3d  Class, 2d Order (Good).  III. Class,
      I.  Order (Author).
  2.  Defin.  — Nosolog.  Defin. Tenderness,
pain, heat, and tumefaction of the abdomen, icith
symptomatic fever;  the patient always preserving
a supine posture, with the knees drawn up; and
the pain being aggravated by pressure, or by  ac-
tions of the abdominal and respiratory muscles.
  3.  Patholog. Defin.—Increased vascularity,
softening,  or thickening of the  peritoneal mem-
brane, with effusion of coagulable lymph, or  of
a sero-albuminous, or sero-puriform, or sero-sanr
guineous fluid; sometimes with  organized adhe-
sions, dj-c.
  4. Inflammation of the peritoneum may  af-
fect persons of any age, of any temperament,
and of any habit of body;  it may attack  sud-
denly and acutely,  or slowly, insidiously, and
chronically;  it may be general or limited,  or
at first partial,  and  afterward more or less ex-
tended ; and it may be primary or idiopathic,
and  consecutive or symptomatic.   It  may,
moreover, be characterized  by either of those
states of vital diathesis  which I endeavoured
to establish as  important pathological distinc-
tions, when treating of inflammation, and which
I ascribed to the nature of the exciting  caus-
es, and to the states of vital or constitutional
power, and  of  the  circulating  fluids.  Hence
peritonitis may also be either sthenic or asthenic
as regards the local action and the  accompa-
nying fever.
  5. I.  Acute  Peritonitis. — Acute peritonitis
in a sthenic form often commences in a part only
of the peritoneum, but extends  more or less to
other portions of it.  It is comparatively rare,
in this state of the malady, that the peritoneal
surface is at first extensively  affected ; but I
have seen many cases of the puerperal and ery-
sipelatous states of the disease, of the asthenic
form,  in  which this membrane was more  or
less extensively implicated at an early period,
and more particularly in  the puerperal states
of peritonitis associated with, or  even arising
from, contamination of the circulating fluids.
  6. True or primary peritonitis commences in,
and is chiefly confined to, the peritoneum ; and,
when thus originating, the inflammation more
rarely extends  to the organs which are envel
opsd by this membrane.   As I  have shown on
several occasions, the inflammation does not
so rapidly spread over the surface of the per-
itoneum as  was generally supposed, unless  in
the asthenic forms of the disease, although the
lymph thrown out from the surface of the part
first affected rapidly irritates and inflames the
opposite  surface,  or that coming in  contact
with it;  so that it may be confidently asserted
that sthenic acute peritonitis extends rapidly
and chiefly by contiguity of situation, and but
slowly and  less remarkably by continuity of
surface.   I  have often observed  the opposite
surfaces,  or those in more immediate contact,
intensely  inflamed, while large  portions of the
surface continuously interposed  between the
inflamed parts were unaffected.
  7. This limitation of the inflammation  to
opposite surfaces is equally remarkable when
the peritonitis is consecutive of inflammation of
a subjacent tissue or organ ; unless, indeed, the
circulating  fluids have  become contaminated
and constitutional power  much depressed, cir-
cumstances tending remarkably and rapidly  to
spread the  morbid  action continuously over
the  surface.  In this latter case coagulable
lymph is  not formed, but  a turbid and irrita-
ting serum  is abundantly  thrown out, as will
be more fully noticed when I consider certain
asthenic and complicated  states of the disease.
  8. i. Symptoms  of Acute Sthenic Perito-
nitis. — The symptoms  of  acute peritonitis
vary with the  causes which produce  it  and
with the  portion of the  membrane primarily
and chiefly affected.  As  this form of the uis-
ease often originates in,  and is limited to,  a
part only of the peritoneum,  although often
extending more or less rapidly and generally,
I shall first describe, the symptoms of the more
partial slates of peritonitis, and  next those of
general peritonitis.
  9. A. Partial Peritonitis is most frequent-
ly observed  after surgical operations, in connex-
ion with  incarcerated or strangulated  hemia>
and  consecutively of inflammation of the ap-
pendix cad, as shown in  the article Cjecum,
and of metritis, ovaritis, and cystitis.  It is of-
ten, also, consequent upon, or associated with,
splenitis, hepatitis, enteritis, and dysentery, and
upon chronic ulceration and perforation  of the
stomach or of an intestine.   Indeed, partial per-
itonitis  is often consecutive of inflammation
of parts enveloped by this membrane, the dis-
ease proceeding no farther, when  occurring in
a previously healthy state of the  frame, than
in the production of coagulable  lymph, and the 
74               PERITONEUM—Acute Inflammation of—Description.
affection and agglutination thereby of the op-
posite surface, terminating in adhesions which,
as will  be  shown hereafter, time will modify
or alter.
   10. a. Partial peritonitis, consequent  upon
local injury, surgical  operations, or occurring
without any very obvious cause,  Peritonitis
partiaria traumatica  et  spontanea,  generally
commences with pain confined  to  a  particu-
lar part of the abdomen ; often with rigours or
chills,  but  sometimes without  either;  with
tenderness on pressure, and  with  slight ful-
ness.  To  these soon succeed  the usual at-
tendants of symptomatic fever ; increased or
more constant pain and tenderness ;  a some-
what swollen, hard, and hot state of the  most
painful part;  nausea, vomitings, and  an  anx-
ious expression of the  countenance, in the
most severe cases.   The bowels are confined,
but stools are  usually procured by active pur-
gatives and enemata.  The pulse is frequent,
small, hard, or constricted. In some instances
the complaint proceeds no farther, and either"
gradually subsides or is followed by indications
of circumscribed effusion, or more rarely of
purulent collection.   In other cases  the dis-
ease extends, and  assumes, with greater or
less rapidity, all the characters of general per-
itonitis (v 19).
   11. b. Peritonitis  connected with  incarcer-
ated or strangulated hernia — P. Hernialis — P.
ex Strangulatione—presents similar features to
the above,  being only more intense and  rapid
in its course.   The symptoms of partial  peri-
tonitis may exist, in  cases of hernia, without
any appearance of hernial tumours, and  with-
out  the bowels being  obstructed.   In  these
cases, most probably only a small  portion of
one side of the bowel is strangulated, the ca-
nal not being thereby obstructed.   A very in-
teresting case  of  this  kind  occurred  many
years  ago  in  a cook in my family, who had
been subject to femoral hernia.  She  was re-
moved  to Guy's hospital, where she remained
for a very  considerable period under  the care
of Sir  A.  Cooper and  Mr.   Galloway, who
agreed with the author in considering the case
to be one of partial peritonitis from the  stran-
gulation of a  small portion of one side of the
sigmoid flexure  of the colon.   No tumour
could  be detected in the  seat of the hernia.
She ultimately recovered without an operation.
Partial peritonitis, arising from internal  stran-
gulation, or even from the strangulation caus-
ed by the  adhesions or bridles formed  by an
old partial peritonitis or omentitis, or from the
operation of  hernia or other local causes, pre-
sents  the  same symptoms as  have  been al-
ready noticed, and usually pursues a most unfa-
vourable course, the inflammation extending
with greater or less rapidity, with obstruction
of the bowels and its consequences.
   12.  c. Inflammation  not infrequently  com-
mences in that portion of the peritoneum cover-
ing the appendix vermiformis and cacum—Peri-
tonitis partiaria caci — and is either more  or
less limited to it,  or extended much farther.
In most of these cases the disease arises, as I
have shown  in the  article Cjecum,  from in-
flammation of the appendix caused by the pas-
 sage into it of hard substances, as the stones
 of fruit, gall-stones,  &c.  The symptoms are
 chiefly acute pain in the caecal region, with
distention, great tenderness, fulness or swell-
ing, tormina, costiveness,  nausea, and  occa-
sionally  vomiting with symptomatic  fever.
The inflammation may continue limited to this
portion of the peritoneum and the more imme-
diate  vicinity, terminating  either  in  suppura-
tion or in gangrene of the appendix, or it may
extend much farther over the peritoneum, and
ultimately become general.   Several cases il-
lustrative of these states and terminations of
this form of partial peritonitis have come be-
fore me, and some of them are fully noticed in
the article Caecum.
  13.  d.  Inflammation of the peritoneum reflect-
ed over the abdominal muscles—Peritonitis super-
ficiaria—P. antica—P.  externa—was first no-
ticed  by J. P. Frank, and afterward by Hil-
denbrand.   They considered that this variety
might be distinguished from  inflammation of
the visceral peritoneum. They remark, that it
is attended by extreme tenderness of the ab-
domen, particularly  at  the umbilical region ;
by an extension of the  inflammatory action to
the cellular tissue connecting this membrane
with  the muscles; and often by  the effusion
of lymph into the sheaths  of these  muscles,
causing extreme tension, hardness, and swell-
ing.   This  variety usually  commences with
rigours,  chills, and  irregular heats,  preceded
and  attended by a  fixed acute and  burning
pain,  remarkably increased by  coughing, and
by motions of the trunk.  There  are marked
heat  of  the abdomen ;  swelling and hardness,
particularly in the course of the  recti muscles;
occasionally  distinct  and  circumscribed tu-
mours ;  intolerance  of the  touch  of the bed-
clothes,  and of the  slightest contractions of
the abdominal  muscles; and symptomatic in-
flammatory fever, with its  usual  attendants.
The  vomiting  and obstinate costiveness ac-
companying  some other states of peritonitis
are not usually  remarkable  in this.   These
symptoms  may, however,  be present, and be
attended by anxiety,  nausea, and  dyspnoea, as
the inflammation becomes  more extended, and
by singultus, laboured  respiration, &c, when
it mounts to the diaphragm, as  it  usually does
in the most severe and unfavourable cases.
   14. e. If the inflammation be seated in the
peritoneum covering the psoa and iliac muscles—
Peritonitis psoitica—P.  partiaria postica—many
of the symptoms already mentioned, with others
which are proper to  this seat, are complained
of. Some of these occasionally resemble those
attending hepatitis.   Pain  is felt  in the back,
sometimes obtuse, more frequently very acute.
It is  often referred to either flank, or to some
part  above  the  bladder on  one side.  An ob-
tuse  pain, occasionally with numbness, passes
through the  groin to the thigh, which the pa-
tient cannot stretch out without an  increase
of suffering.  The urinary  functions a^e not
 disturbed,  and the bowels  are not obstructed.
 There is more or less tenderness  on pressure,
 according to the situation  and severity  of the
 inflammation.
   15. /. Dorsal Peritonitis and Mesenteritis—
 Peritonitis dorsualis — P. mesenterica — are the
 most obscure of the  several varieties of peri-
 tonitis ; but it is very rare to observe inflam-
 mation  of the  peritoneum covering the dorsal
 and  lumbar  spine without  the  mesentery and
 intestines   being more or  less implicated. 
PERITONEUM—Acute  Inflammation of—Description.               75
When the disease originates in this situation,
acute pain is  felt along the spine, which is
much increased upon  extending or straighten-
ing the  trunk, or upon drawing  it upward or
backward upon extending the limbs, and upon
firm pressure  of the abdomen.  The febrile
symptoms are most severe, with marked affec-
tion of the stomach and bowels.   (See  article
Mesentery—Inflammation of.)
  16. g.  The  omentum may  be  the principal
seat of the inflammation—Peritonitis omcntalis
—Epiploitis—Epiploite, Fr.—but it is extreme-
ly difficult to distinguish this state of the  dis-
ease from that which is more or less extended.
Indeed, general peritonitis commonly implicates
the omentum ; and this is more  particularly
the case in the asthenic  and puerperal  states
of the disease.  Or, if peritonitis commences
in this situation, it rapidly extends, in  the way
already  indicated, to  all the parts coming in
contact  with  the  inflamed  omentum.  J. P.
Frank states that, in  true epiploitis, the epip-
loon is  generally greatly  thickened, and that
he  has  seen it  in  several  instances upward
of an inch in  thickness.   Omentitis is usually
attended by acute burning pain of the  anterior
part of the abdomen, above and below the  um-
bilicus, but chiefly between the epigastrium and
umbilicus, with extreme tenderness, a sense of
tension, slight hardness, and marked swelling,
and by  acute  symptomatic  fever;  but  these
symptoms are also present in most cases of
general  peritonitis, of which, however, omen-
titis is often a more or less considerable part.
  17. Omentitis may be associated with inflam-
mation of one or more of the contiguous  vis-
cera, as of the liver, stomach, colon, or small
intestines, and by the symptoms  more espe-
cially belonging to such complication.  Indeed,
simple omentitis rarely occurs, unless in con-
nexion  with some cases of hernia,  it  being
usually  associated with inflammation of con-
tiguous  portions of the peritoneum.  It should
also be recollected that the most severe cases
only of  omentitis present the acute symptoms
just mentioned, and  that slighter or sub-acute
cases sometimes occur, in which the symptoms
are milder, but more  insidious and equivocal.
I have  even met with  omentitis in a chronic
state, and nearly limited to the omentum, with
the exception of some adhesions to contiguous
parts of the peritoneum, covering portions of
the  bowels  and  abdominal parietes.    These
cases have  been  generally in  females  some-
what advanced  in life,  and chiefly in  those
who have been  subject  to umbilical hernia.
The adhesions  consequent upon omentitis, and
the extension  of the inflammation to  contigu-
ous portions of the peritoneum, may  become,
even at  a remote period after the recovery of
the patient, the cause of internal strangulation
of a portion of intestine.  Many  instances of
this occurrence  might be adduced, if it were
necessary.
  18. Omentitis,  in a very acute form, often
extending to contiguous parts of the perito-
neum, is frequently observed in the course, or
as  a  consequence, of hernia;  and when the
hernia consists of a portion  of omentum and
becomes strangulated, the inflammation thus
induced often  terminates in  gangrene,  which
is either limited to a part of the omentum, or
is extended to parts of the peritoneum and in-
testines.   Omentitis may likewise, in either
an acute  or sub-acute state, terminate in sup-
puration.   In this case the matter may find its
way, by perforation, into the bowels, or exter-
nally through the parietes of the abdomen.  J.
P. Frank states that he has met with instan-
ces of this kind, but they are very rare.
  19.  B. General  Peritonitis.—The  more
general states  of peritonitis,  occurring in a
person of good  constitution,  or in a  sthenic
form, usually commence with rigours or chills,
more or less severe and prolonged, with acute
pain, soreness, and tenderness  in the abdomen,
and aching in the back or limbs. The abdom-
inal pain soon  becomes the chief symptom,
is sharp, burning, pungent, or cutting, and is
attended  by a sense of tension, or of heat and
distressing  distention.   It is  aggravated by
pressure, by efforts to vomit, or to pass a stool,
or to pass  the urine, or even by the slightest
movement in bed.  The patient cannot endure
the weight  of the bed-clothes,  or of a foment-
ation.  He  lies  on  his  back,  with his knees
drawn  upward,  thereby favouring relaxation
of the  abdominal muscles, and removing a
part of the pressure of the bed-clothes  from
the abdomen.  In some cases the pain is less
acute,  or remits  somewhat for a short time,
and returns with much severity.  In others it
is felt chiefly on pressure, or upon any effort;
and more acutely after intervals, or when flatus
is passing through or distending portions of
the intestines.   The pain  is usually most se-
vere about  the umbilicus, or between  this
place and the hypogastrium ;  but it continues
most acute at the part where  it commenced,
even when it extends most rapidly over  the
abdomen, which is hot, distended, and flatulent.
  20. As the disease advances and is  extend-
ed,  the pain is increased by respiration, which
soon becomes  short and  superficial.  There
are also  nausea, frequent retchings, and vom-
iting of the fluids taken, with mucous matters,
and sometimes with bile, more or less thirst,
and generally constipation.  The tension of the
abdomen is at first attended by a marked con-
traction of  the abdominal  muscles, under  the
hand of the physician, owing to the increased
sensibility being  attended by augmented  sus-
ceptibility,  and disposition of  the muscles to
contract energetically, when the sensibility is
excited.  Subsequently, or after a day or two,
seldom later, but often after a  few hours only,
the feeling of tension is attended by much dis-
tention, which  varies in amount,  and in  the
rapidity of appearance, with the intensity, and
the general diffusion of the inflammation.  The
circumstances proper to the patient, however,
modify the distention considerably ; it is great-
est  in females of a relaxed habit of body, and
soon after parturition  ; and least in males of
a spare habit of body,  with  strong or rigid
muscles.   In this state or form of peritonitis
the abdominal distention is equal throughout;
any irregularity  which may  be felt  arising
chiefly  from muscular contractions under  the
hand of the examiner.
  21. Percussion can hardly he endured ;  but
at an early period,  the clear  sound which is
emitted evinces that the distention is owing to
the accumulation of flatus ; but this sound be-
comes  more dull as the disease advances, par-
ticularly  in more depending parts of the abdo- 
76
PERITONEUM—Acute Inflammation  of—Description.
men, owing to the collection of serum, while
it  still  continues  clear,  or even  more so,
around  or above the umbilicus.  The ear or
stethescope applied  in different parts of the
abdomen sometimes detect  a rubbing or fric-
tion-sound, similar to that often heard in peri-
carditis or pleuritis ; and this sound is caused
by the motions of the  opposite inflamed sur-
faces during respiration.
  22.  The countenance is pale, expressive of
anxiety and  suffering, and the features are
sharpened and sunk.  The  patient continues
motionless on his back, the least inclination to
either side increasing his suffering ; and  he is
afraid of quenching his thirst, lest vomiting
should ensue and augment his distress.   Res-
piration becomes more short, frequent, inter-
rupted, and shallow,the action of thediaphragm
increasing  the pain.  The pulse is frequent,
small, constricted, or hard.  The  skin is hot
and dry ; the urine  scanty, high-coloured, and
often turbid.
  23.  The course of general sthenic peritonitis
is  usually rapid, and characterized by a pro-
gressive aggravation of the symptoms ; espe-
cially  of the tenderness, tension, and swelling
of the abdomen ; and of the sickness and vom-
itings.   The pain and tenderness become more
general, and diffused  through  the abdomen,
extending to  the back and loins;  the  face
paler  and  more sunk;  the anxiety and  dis-
tress greater;  and  the  pulse  and respiration
smaller and  quicker.  Having reached its ac-
me, the disease may continue for one, two, or
three  days, or  even longer, nearly stationary,
but with  irregular  exacerbations  and remis-
sions.  Having, however, become general, and
thus far advanced, it most frequently is not
the less  fatal, even when prolonged, as  it
sometimes is, to seven or eight days.   Gen-
eral peritonitis, however, often runs its course
in a much shorter period;  in three or four
days, or even in less time ;  but this rapid ter-
mination occurs most frequently in  the asthenic
and puerperal states of the malady.
  24.  II. Acute peritonitis presents  certain
varieties or modifications requiring particu-
lar notice.   The most remarkable of these oc-
cur in the puerperal states—Puerperal Peritoni-
tis—but as they present so many peculiarities,
and are so often complicated with other affec-
tions connected with these states,  I shall treat
of the puerperal forms of peritonitis in connex-
ion with those maladies with which they are
so often associated, under the general head of
Puerperal Diseases.
  25.  Some authors have noticed  what they
have denominated bilious and nervous forms of
peritonitis ; but these require merely a passing
notice.  The former of these is merely perito-
nitis occurring in connexion with  an accumu-
lation of bile in the biliary organs, and  its dis-
charge, chiefly by vomiting, during the course
of the disease.  The latter is characterized by
a more than  usual  predominance of nervous
symptoms;  of acute pain, of low  delirium or
of convulsions, of restlessness, and, lastly, of
coma,  with subsultus  of the- tendons.  It is
obvious that these modifications are dependant
upon  previous disorder and temperament, and
may appear in either the  sthenic  or asthenic
forms of the malady.
  28.  i.  Asthenic  general  Peritonitis —
Erythematic or Erysipelatous peritonitis — most
frequently occurs in the puerperal states, and
will receive due  attention in connexion with
these states.—a.  But it sometimes occurs in-
dependently of these, in debilitated  and  bro-
ken-down constitutions ; in cachectic habits ;
in connexion with erysipelas, or with morbid
states of the circulating fluids; in the course
of exanthematous, adynamic, or other fevers ;
after  spontaneous perforation of the stomach
or intestines, or even of any portion of the per-
itoneum ;  and after the operation of paracente-
sis abdominis.  Under these diverse circum-
stances asthenic peritonitis presents varied
phenomena, as respects  both the  local  and
the constitutional symptoms.   Still it exhibits
many, and  these  the most characteristic, that
are common to all circumstances ; and chiefly
the appearance of symptoms diagnostic of it
after previous disorder, or during a state of ill
health; its often sudden accession  and rapid
progress, and frequently  without  previous or
concomitant rigours or chills ; the greater soft-
ness,  rapidity, smallness, and weakness of the
pulse ; the cachectic or even livid hue of the
countenance  and  general surface, as when  it
occurs in the progress  of fever; the almost
sudden distention of the abdomen, and indica-
tion of serous effusion into the peritoneal cav-
ity ; the more profound prostration; and the
rapid  supervention of singultus, with frequent
regurgitation of the contents of the stomach,
coldness and dampness of the extremities, and
other fatal symptoms.
   [This form of peritonitis is a very frequent
disease in those places where  epidemic ery-
sipelas prevails, and  is extremely fatal.   We
have  met with several cases  of it,  some of
which ran their course with great rapidity, and
one resulted in death in 48  hours.  It gener-
ally comes on with  great gastric  disturbance
and vomiting, tenderness at the epigastrium,
extreme prostration, coldness of the surface,
small and frequent pulse, &c.  It is most apt
to attack females who  have recently been ly-
ing-in ;  but it is not confined to them : in some
instances, although comparatively rare, it seiz-
es upon males.  For a more particular account
of this affection, see article Epidemic Erysipe-
las.]
   27. b. When the  peritonitis results  from
spontaneous perforation of any portion of the di-
gestive canal (see Digestive Canal, y 42), or
from  perforation of this membrane  covering
any of the  abdominal  viscera,  by tubercular
softening,  disease, or rupture of vessels, or
other lesions affecting the organs over which
it is reflected, it is usually excited by the es-
cape  of faecal,  morbid, or other matters  into
the peritoneal cavity; and, although these mat-
ters  may  not extend much beyond the place
through which they passed, yet they excite a
spreading or asthenic inflammation^ attended
by a copious, turbid, serous, orsero-albuminous
effusion, the constitutional powers being inca-
pable of forming  coagulable lymph, or such as
can  agglutinate  the  opposing  surfaces,  and
thereby limit  the extension  of the  inflamma-
tion or prevent the diffusion of the  matters
passed through the perforation over  the peri-
toneum.  In all these cases, the pain and ten-
derness are first  referred to the seat of perfo-
ration, which is most frequently in or near the 
PERITONEUM—Acute Infi
right  iliac region;  but  they rapidly  extend,
and are  followed by all  the symptoms  just
mentioned,  which  always  terminate  fatally,
sometimes within twenty-four hours, and sel-
dom later than two or three days.
  28.  c. Peritonitis from paracentesis abdominis
usually presents  similar characters, and  pur-
sues the same course as that just noticed.   It
is one of the most frequent varieties of as-
thenic peritonitis, and is  almost  uniformly fa-
tal.   It is very closely allied in its symptoms
and progress to that state of the disease which
has been denominated erysipelatous peritonitis
by  some pathologists,  from the  connexion
sometimes subsisting between erysipelas and
asthenic peritonitis.  Indeed, the connexion is
sometimes obvious, as when erysipelas attacks
the parts punctured in paracentesis, as it some-
times does, particularly when it is prevalent in
a hospital, or is epidemic in the  locality.   In
rare cases, also, asthenic  peritonitis occurs on
the subsidence  of  erysipelas  from  external
parts of  the body.   I  have met with an in-
stance of it consequent upon the  disappear-
ance  of erysipelas from one of the lower ex-
tremities, and Dr. Abercrombie mentions an-
other.  In these, the patients complained of
acute pain through the abdomen, with tender-
ness  on pressure, great anxiety,  and  restless-
ness,  death  taking  place  within  thirty-six
hours.   On  dissection, the  appearances were
nearly the same in  both instances; the intes-
tines  were all distended by flatus ; the perito-
neal surface was of a dark  red,  passing to a
dull  leaden colour,  and the cavity contained
much turbid serum, somewhat reddened, or of.
a sanious hue.
  29. ii. Hamorrhagic peritonitis  has been no-
ticed  by Broussais and others, but it is ex-
tremely rare.  It is not, however, to peritoni-
tis consequent upon rupture of a  blood-vessel,
or of a viscus, as of the  spleen or liver,  that
this  term has been applied ; but to  asthenic
peritonitis occurring in the haemorrhagic diath-
esis,  and attended  by an exudation  of blood
from  the capillaries of the peritoneum,  without
rupture.   I  have  never met with a case of this
form  of peritonitis ;  but Broussais states that
the symptoms are  inflammatory at  the com-
mencement, and  rapidly pass  into those indi-
cating great depression of the powers of life ;
the pulse soon becoming rapid, small, and soft,
and  death quickly  supervening,  with  convul-
sions, cold and damp extremities and surface,
and the  other symptoms attending  the fatal
sinking of the asthenic and other states of the
malady.   The effused blood remains  fluid, is
mixed with  serum, and  the peritoneum ap-
pears generally affected.
  30.  iii.  Latent peritonitis occurs sufficiently
often  to deserve notice at this place, although
less frequently than  is supposed  by some wri-
ters.  Indeed, it is very rarely that the disease
remains latent when it occurs primarily, and
perhaps never when it affects a robust or  pre-
viously healthy person.  It is chiefly when per-
itonitis  attacks persons  who are exhausted,
cachectic, or otherwise diseased, or who are
labouring under some other malady which at-
tracts the chief attention, or who are maniac-
ally or otherwise  insane, that the characteris-
tic symptoms are either imperfectly developed
or overlooked from their  slight or mild form,
lammation of—Description.               77

 and from the more prominent affection of a
 distant part.  It is chiefly from the absence of
 pain, tenderness,  and pyrexia, and  from the
 insidious progress of the disease, that the na-
 ture of it is unsuspected.  The appearance and
 expression  of the features ;  an attentive ex-
 amination of the abdomen by pressure, percus-
 sion, &c.;  and the  position  of the patient in
 bed,  will generally  disclose, without  much
 doubt, the  nature  of the malady.
   31.  iv. The  Terminations of  acute general
 peritonitis are much influenced by the predis-
 posing  and  the exciting causes ; by the state
 of the  patient  at  the time  of attack;  by the
 particular form the disease may assume ; and
 by the several circumstances and influences to
 which the patient  has been or is  subjected.—
 a. Resolution of the inflammatory  action some-
 times occurs,  and chiefly when the disease is
 of the sthenic form, is of a mild character, or
 less intense than  that described  above (§ 19);
 or, although equally severe with it, if the symp-
 toms become ameliorated by treatment.  A
 diminution  of pain, tension,  and  tenderness ;
 less frequent retchings ; an improved state of
 the pulse and of respiration, and a more natu-
 ral expression of countenance, are favourable
 indications, especially if they are  accompanied
 by perspiration, a more copious  secretion of
 urine, and freer alvine evacuations.
   32. b. In  many instances  of  resolution of
 sthenic peritonitis, evidence  of adhesions hav-
 ing formed between parts of the contiguous sur-
 faces is furnished in the continued tenderness
 or pain, increased by pressure, or accidental
 shocks, or quick motion, or by turning in bed,
 that is  felt  in one or even  more parts  of the
 abdomen, although the  patient may  apparent-
 ly have nearly, or even altogether, recovered.
 That these symptoms result from  adhesion has
 been proved by the subsequent history of some
 cases of this kind; these  adhesions  becoming
 the cause of internal strangulation of a portion
 of intestine, of partial peritonitis, and  of the
 patient's death.   In other  instances the  in-
 flammation, instead  of being completely re-
 solved, is only abated, the symptoms gradually
 subsiding in severity, without recovery  taking
 place.  In  these  the acute  passes  into the
 chronic  disease (v 36).
   33. c. Effusion of serum, or of sero-albumi-
 nous, or even  of sero-sanguineous or sero-pu-
 riform matter, more rarely the latter, into the
 peritoneal cavity, is rather a consequence than
 termination of the disease.  At an early stage
 the effusion  is slight, but at an advanced period,
 and as the powers sink, it becomes more and
 more copious.  The abdominal pain and ten-
 sion then subside or altogether cease ; the ab-
 domen  being soft,  relaxed, but tumid, and dull
 on percussion, excepting at its most elevated
 part, where the sound emitted indicates flatu-
 lent distention of  the intestines.  Fluctuation
 is sometimes remarked, but occasionally it is
 obscure, or  not evident, owing to the effusion
 being either traversed by adhesions, or exist-
 ing  between the  folds  of the mesentery and
 convolutions of the  intestines, or gravitating
 to the iliac and pelvic regions.
   34. d. Gangrene very rarely occurs in gen-
 eral peritonitis, even when it is most asthenic
 in its nature.  It appears chiefly when the dis-
 ease commences  partially, as in  the appendix 
78              PERITONEUM—Chronic  Inflammation of—Description.
of the caecum, or from strangulation or local
injury.   Its occurrence is indicated by sudden
cessation of the pain and tension of the abdo-
men ; by hiccough, and by coldness and clam-
miness of the extremities and general surface;
by rapid, weak,  small, thready, and intermit-
tent pulse;  and sunk, dark,  and  Hippocratic
countenance.
  35. e. A fatal issue may be the consequence
of effusion and its effect upon the system, in
connexion with  the extent of lesion, and, in
rare cases, of incipient gangrene.  But it most
probably chiefly  results from the shock  or in-
fluence produced upon the vitality of the frame
by the  great extent  of the  inflammation and
consequent lesions ; and  this is especially the
case when the disease is  intense, and the per-
itoneal surface extensively affected at its com-
mencement, for  in these cases the powers of
life  most rapidly  sink, especially  when  the
malady presents an asthenic character. Where
effusion is not extensive, and consists  chiefly
of serum, or of a sero-albuminous fluid, it does
not  necessarily occasion death,  the patient
sometimes recovering ; the fluid being absorb-
ed, and partial adhesions still remaining, or the
disease passing into the chronic form.
  36. A fatal issue  occurs  chiefly when  the
more intense cases of the sthenic form of the
disease have  been neglected at  their com-
mencement, and the  more unfavourable con-
sequences  of inflammation have  supervened
before the treatment has commenced. In these,
this issue usually takes place at periods vary-
ing from two or three to eight or  nine days.
In the several varieties of asthenic  peritonitis
noticed above, this issue generally  occurs, un-
less in a few instances, where  the  disease is
judiciously treated  at its commencement, in
from one to two or three days. This termination
is preceded  and indicated by increased altera-
tion of the countenance ; by greater rapidity,
weakness, and smallness, or irregularity of the
pulse; by coldness and dampness  of the  ex-
tremities ;  and  by more frequent  vomitings,
the  contents of the  stomach being rejected
without retchings or effort,  and by mere re-
gurgitation.   On the accession  of  these unfa-
vourable symptoms, the  state of the respira-
tion and the occurrence  of singultus indicate
the extension of the disease to the diaphrag-
matic peritoneum.  The  patient is now some-
times restless  or  oppressed, and  the breath-
ing is laboured or thoracic ;  but he still lies on
the back, and makes no  effort to move, even
when fluids are regurgitated  from the stomach,
these being thrown over his person and the bed-
clothes.  The matters thus  ejected are fluid,
with some mucus and green bile.   He soon af-
terward  either  sinks into  a state of  coma,
quickly terminating in dissolution,  or he is at-
tacked by convulsive movements, with difficult
or  laboured respiration,  spasms  of the dia-
phragm, and asphyxia, or he  sinks with all the
indications of vital exhaustion.
  37. III. Chronic Peritonitis.—This form of
the  disease was not duly recognised and  in-
vestigated  until the  commencement  of the
present century.  Bichat was the first who
distinctly and  correctly  noticed  it, and  Dr.
Pemberton subsequently described one of its
forms.  Soon afterwards  Dr. Baron fully illus-
trated the tubercular variety of chronic  perito-
nitis ;  and about  the  same  time Broussais,
Montfalcon, Gasc, and  the author, further
investigated the disease.  Although overlook-
ed as  an idiopathic and distinct malady by
writers of the seventeenth and eighteenth cen-
turies,  still cases illustrative  of its nature are
to be found in the works of many of them, as
shown in a  memoir  published by me many
years ago, containing the history of some ca-
ses of  it which had occurred in my  practice.
The  writings of Columbus,  Fantonius,  Fer-
nelius, Ballonius, Tulpius, Lomius, Bone-
tus,  Tissot,  Hoffmann, Burserius,  and Mor-
gagni,  at the places mentioned  in the Bibliog-
raphy,  furnish some interesting cases and re-
marks, illustrating the history of chronic peri-
tonitis, and showing how frequently this mal-
ady was confounded with colic and mesenteric
disease.
  38. i. The History of our pathological knowl-
edge of chronic peritonitis must nevertheless be
considered as very limited.  Although the med-
ical writers of the last two  centuries furnish
no accurate  description of this highly danger-
ous  disease,  yet their  writings are not alto-
gether deficient in proofs of a partial acquaint-
ance with its nature ;  but they  failed in recog-
nising  the lesions found on dissection of fatal
cases as the results of chronic inflammation.
Columbus (De Re Anat., lib.  xv.)  describes
" Conglomerationem intestinorum, natam vide-
licet ex  ultimis ilei partibus una  complicatis,
tumoremque in hypogastrioexhibentibus."  And
Morgagni adduces several cases (Epist. Ana-
torn.  Med., 39, sect. 24-32) in which he found
the  intestines agglutinated in  one mass, and
their coats possessed of an almost cartilaginous
firmness.  One of these cases occurred after
ascites, and  sufficiently marks the acute na-
ture of the dropsical affection.   Tulpius  (Ob-
servationes, lib. iv., p.  348) mentions a similar
instance in a female  who had been affected
from an early age with ascites:  upon dissec-
tion, the peritoneal coverings were everywhere
thickened to  such a degree as to equal that of
the ring finger.
  39. Morgagni, when adducing the cases just
referred  to,  mentions  others from preceding
writers, which  are, as  well as those seen by
himself, illustrations of chronic peritonitis oc-
curring without tubercular formations.  He de-
scribes these cases as unfavourable results.of
prolonged or repeated attacks of colic and of
ascites;  and he  describes others as forming
varieties of abdominal tumours, owing to the
thickening and induration of the peritoneal coat,
and  the agglutination  of the intestines to each
other and to  one or more of the other abdom-
inal  viscera.
  40.  It is singular, however, that Morgagni,
with all his  pathological knowledge, did not
attribute the  changes in the peritoneum, which
he has so fully and even frequently described,
and  with which he occupies  nearly the whole
of his thirty-ninth epistle, to inflammation  He
is very much puzzled to account for the  chan-
ges, now universally ascribed to chronic in-
flammatory action, and enters upon a some-
what  lengthy disquisition (sect. 31)  in expla-
nation of it.   He ascribes the pain to flatulent
distention of the  bowels ; and the  agglutina-
tion of the opposite surfaces to the pain and
distention, which he considers to  have caused 
PERITONEUM—Chronic  Inflammation of—Description.               79
 an exudation of a glutinous matter from these
 surfaces.   The thickened and indurated state
 of the peritoneum, often found in connexion
 with more or less serous effusion,  he imputes
 to the effect produced upon this membrane by
 its prolonged maceration in an acrid or morbid
 serum.   When adverting to the symptoms, he
 remarks,  " Pulsus humilis et debilis potius, et
 qui,  si bene attendas, sibi obscure, dissimilis
 sit:  abdomen autem tensum, et durum, et cum
 dolore quodam ; facies denique insoliti aliquid,
 sed in aliis aliud, ostendens," &c.
   41.  Hoffmann, after  describing  the  more
 acute affections of the intestinal  tube  which
 terminate either fatally or in health, in a very
 short time, mentions those of a chronic  char-
 acter, which he denominates "dolores chroni-
 ci, vel colicae diuturnae."   He describes  them
 as continuing during many weeks, and even
 for the  space of a twelvemonth, with various
 intermissions and exacerbations.   On dissec-
 tion, "the intestines are found constricted,
 their coats thickened, callous, and scirrhous,"
 &c.   (De Inteslinorum Doloribus, sect, ii., cap.
 v., p. 180.)
   42. Other instances could be  also adduced,
 from Bonetus (sect, xxi.,  Observat. 3-8), from
 Fantonius (Observations, Epist. 4), and from
 the Acta  Academ. Nat. Cur. (torn i., Observat.
 87; et torn, vi., Observat. 124), in all of which
 the intestines, omentum, and mesentery were
 accreted into one mass.  Burserius mentions
 similar  cases, which he considered as arising
 from an  " arthritica, rheumatica, herpetica,
 scorbutica, vel scabiosa materies, retropulsa."
 Speaking of these diseases, which he denomi-
 nates " intestinorum conglomerationes," he re-
 marks,  " Similem  (conglomerationem) vidi in
 muliere colica chronica jamdiu afflicta, et  de-
 mum marasmo confecta."  (Institutiones Med-
 icina, vol. iv., p. 362, et seq.)
   43 Jodocus Lomius furnishes some remarks
 which may be referred to this  disease.   " I
 find  it observed," he  says, " by some learned
 men  that the  peritoneum, or  at  least those
 membranes  which  cover the abdomen  and
 parts of the belly, are likewise  afflicted with
 very grievous  pains.  These pains, although
 they in nowise belong to  the colic, yet they
 are  equally violent.  And these, as they  are
 very  severe, so likewise are they very long,
 and yield to none of those  remedies which  are
 proper in  the  colic, whether  medicines,  fo-
 mentations, and clysters ; but generally suc-
 ceed  long fevers, and those kinds of bilious
 diseases which are not easily solved, and have
 been often observed to terminate, as it  were
 critically, continued fevers, as well as tertians
 and  quartans.  The mesentery may also be
 seized with an inflammation ; at this time there
 is an inward weight, but no manifest pain; a
 fever arises, but  this is  moderate," &c. (Ob-
 servat., p. 316, et seq.)
  41 It is not, however, to the scanty details fur-
 nished by the earlier writers in modern medi-
 cine that we are to attribute the progress made
 in our knowledge of the pathology  of chronic
peritonitis ; but to the researches of Bichat,
Pkmbertox, Baron,  Broussais,  Montfalcon,
 Gendrin,  Gasc, Scouttettin,  and  Hodgkin,
that we are chiefly indebted.   Up to the time
of the earliest of those  writers, this disease
was  confounded, as  I have now shown, with
 colic, mesenteric affections, or tumours of the
 omentum.  And it is very probable  that the
 varieties  of  colic, particularized by many of
 the  older writers under  the appellations ar-
 thritica, rheumatica, scorbutica, metastica, in-
 flammatoria, symptomatica, diuturna, chronica,
 endemica, &c,  were actually chronic inflam-
 mations of this membrane, the disease occur-
 ring in  the manner indicated by those specific
 names. In addition to this catalogue of names,
 others  from  the same and different authors
 may be mentioned, as constituting  varieties
 of colic, as  colica herpetica,  C. ex  scabiosa
 materie retropulsa ; C. ex perspiratione reten-
 ta, atque  ad  intestina translata ; C. mesenter-
 ica,  &c, which, most likely, were truly affec-
 tions of a slow inflammatory nature, attacking
 this  membrane, and either simple or  primary,
 or associated with tubercles.   Fernelius ap-
 pears to have been of this opinion ; he says :
 " Ab acri vero erodentique humore, aut etiam
 ab inflammatione, quisquis ortus fuerit, dolor
 colicus  fixus etiam est, sed cum febricula, ar-
 dore, siti  et vigiliis ; irritatur esculentis potu-
 lentisque  calidioribus, a quibus  etiam sumpsit
 originem."  And again, " Alii insuper crucia-
 tus quadam similitudine et vehementia colici
 nuncupantur, quibus tamen non in colo intesti-
 no sedes  est; sed vel in peritonaeum vel in
 membranis quae abdomini ventrisque  partibus
 obtenduntur.   Hi sane gravissimi sunt,  et ad-
 modum diuturni, ac neque clysteribus, neque
 medicamentis, neque fomentis, neque iis reme-
 diis quibus qui vere sunt colici dolores, deliniri
 solet."  (Fernel., Pathol., lib. vi., c. vi., p. 159.)
 Although  Willis did not consider colic to be
 an inflammatory disease, he believed  the part
 primarily  affected by  it to be the mesentery,
 "which is highly sensible," he adds,  "and
 through which a morbific  matter is conveyed,
 not by means of the arteries, but by the nerves,
 and its  seat  is not the proper coats of the in-
 testines." (Pathol., p. 11,  c. xv.)  Many a case
 of chronic peritoneal inflammation probably is,
 even in the present day,  taken for colic, but
 more especially for diseased mesenteric glands;
 the size of the abdomen, its irregular hardness,
 with the hectic,  emaciated limbs, and dry, foul
 surface, being symptoms, which may readily be
 mistaken, if not carefully inquired into, for
 those of the  latter affection. Indeed, disease
 of the mesenteric glands  may  be induced by
 continued irritation, existing primarily  in the
 serous membrane ; and, in the tubercular form
 of chronic peritonitis,  I have shown  that tu-
 bercular disease of these  glands is often also
 present.  It  may be also granted that disease
 sometimes takes place in these glands coetane-
 ously with morbid action in either of the mu-
 cous or serous membranes, in consequence of,
 and  depending  upon,  the nervous  influence
 supplying  the capillary vessels distributed to
 those textures, and upon the state of the cir-
culating fluids;  chronic  inflammation  with
 tubercular productions resulting therefrom in
scrofulous constitutions.
  45. Chronic peritonitis not unusually super-
venes on continued exanthematous and  remit-
tent  fevers.   I have met  with several instan-
ces of this connexion.  Tissot  (in his disser-
 tation De  Febribus Biliosis, p. 143) mentions an
affection following fever which  continued for
 many months.  He gives the following charac- 
80
PERITONEUM—Chronic  Inflammation  of—Description.
teristic symptoms : " Accessit diarrhoea saepe
recurrens, tumet  frequenter tympanitice abdo-
men, et fere semper dolet, ita ut minimam ves-
tium constrictionem fere nequeat; deletur pror-
sus  appetitus; urget seepe  sitis; parvus est
somnus ; urinae paucae, turbidae."  This case
evidently puzzled Tissot ; for he asks, " Quae-
nam causa morbi 1" He adds, "Tabes succedat,
tympanitis, ascitis, icterus, mors."  He makes
no mention  of any dissection.  Chronic peri-
tonitis may follow acute  dysentery; and even
during the continuance of the chronic form of
that disease, from an extension of the inflam-
matory action to the serous membrane. I have
met with several  instances  of this occurrence
in the  course of practice ; and  they are often
seen in climates where dysentery is endemic;
and many cases are recorded by writers in the
last century that  illustrate this succession.
  46. Although chronic peritonitis sometimes
occurs as a secondary affection, and is compli-
cated in the manner just alluded to, it appears
also as a primary disease. This independence
of inflammation of the peritoneum of disease
of the contiguous  structures did not escape the
penetrating  mind  of John  Hunter.   " If the
peritoneum," he says, " which lines the cavity
of the abdomen, inflames,   its  inflammation
does not affect the parietes of  the abdomen ;
or if the peritoneum covering any of the vis-
cera is inflamed, it does not affect the viscera.
Thus,  the peritoneum shall  be  universally  in-
flamed, as in the  puerperal fever, yet the pari-
etes  of the abdomen, and the proper coats  of
the intestines, shall  not  be  affected.   On the
other hand, if the parietes of the  abdomen, or
the proper coats of the intestines are inflamed,
the peritoneum shall not  be affected."  (On the
Blood  and Inflammation,  p. 244.)  Bichat re-
marks : " L'affection d'un organe  n'est  point
une  consequence  necessaire de  celle  de  sa
membrane sereuse, et reciproquement, souvent
l'organe s'aff'ecte sans que la membrane devi-
enne malade," &c.  (Anat.  Generate, vol. i., p.
551.)  And Sprengel observes, " Neque facile
ad reliquas intestinorum  tunicas transit adfec-
tus hujus externi velamenti, unde peritonaei
inflammationes saepius observamus  sine ulla
inflammatione tunicarum musculosarum et ner-
vearum."   (Institut.  Physiol., t. i., p. 343.)
  47. ii.  Description.—Chronic peritonitis ap-
pears in two distinct forms: 1st.  It occurs pri-
marily, and  then  generally  gradually and  in-
sidiously,  and most frequently  in connexion
with tubercular formations ; 2d. It appears con-
secutively, or succeeds to  the acute form of the
disease,  or  to  inflammation of some  viscus
that  has extended to the peritoneal covering.
As in the acute form, so  in this, the inflamma-
tion  may be  either partial  or general.   It  is
most frequently the  former  when it proceeds
from local  injury, or from inflammation of a
subjacent viscus, and it is often general when
it is granular or  tubercular, or is associated
with serous or dropsical effusion ; but  the gen-
eral, as well as the partial state of the malady,
may be consequent upon some  other disease,
particularly  dysentery, enteritis,  hepatitis,  in-
flammation of the uterus and its appendages,
&c.   Dr. Baron and M.  Louis concluded that
chronic peritonitis, occurring primarily, is al-
ways associated with tubercles.  As  early as
1821,  I combated this  opinion,  and  adduced
two  cases  which were exceptions to the law
which  these pathologists  believed  to exist.
More recently, Dr. Hodgkin has stated that the
form of peritonitis which is  accompanied with
copious effusion, occurs without any tubercles;
and the same may be said of other cases,  in
which  the  concrete product of inflammation
had been more considerable.  However, it must
be admitted that  chronic peritonitis appearing
independently of injury, of rheumatism, of vis-
ceral disease, or  of  cutaneous eruptions,  is
generally tubercular, and is observed chiefly  in
scrofulous constitutions ; and that when it  is
consecutive of these maladies, or appears from
the suppression of external affections,  it  is
rarely associated with tubercular formations.
  48. A. The symptoms vary at the commence-
ment of chronic peritonitis, with the exact na-
ture, seat, and associations of the disease.—a.
When  it is tubercular, it is  always insidious,
slow, and often latent, until it is considerably
advanced ;  and soon after it is recognised,  it
often rapidly terminates fatally.  At first there
is  often very little pain, and in some cases
none at all.  In others, griping or colicky pains
are occasionally felt, and frequently after long
intervals. A sense of broiling or burning heat
is complained of in the epigastric and umbilical
regions. The bowels  are irregular, more fre-
quently relaxed than confined, the excretions
being offensive, deficient.in bile, and otherwise
morbid.  Nausea is often complained of, but
vomiting is not frequent unless at an advanced
stage of the disease.  The matters thrown up
are fluid, with mucus and  a little green bile,
and are more or less acid.  The urine is scan-
ty, high-coloured, and deposits a reddish sedi-
ment.   The tongue is usually red, glazed, and
chapped, its surface being often slightly fis-
sured and  uneven.  The surface of the body
is foul,  lurid, and dry, but perspires freely du-
ring the night.  The pulse is quick, small, and
weak.   The body is always  more or less ema-
ciated ; the countenance and eyes are  sunk;
and  the extremities  cold,  attenuated,  and
slightly livid or dark.  A livid or dark circle
surrounds  the eyes, and the face and  whole
body appear as if faded or blighted.
  49. The  abdomen is  always large  or  tumid
relatively to the rest of the body, particularly
at an advanced period of the malady.   If the
peritoneal cavity  contains any fluid secretion,
slight or obscure fluctuation will be detected,
and there will be dulness on  percussion,  par-
ticularly in more  depending situations.   When
pressing or kneading the abdomen,  a doughy
state is remarked ; and the inclosed viscera
and the abdominal parietes feel as if they con-
stituted one mass.  Tenderness is often not
considerable,  but it varies and is  more re-
markable in  one  part than in others, and the
seat of it varies in different cases, and even  in
the same patient  at different periods.  The ab-
domen  often presents irregularities, whieh are
sometimes mistaken  for enlarged mesenteric
glands.   These iregularities are generally ow-
ing to   the development of larger tubercular
masses accreting the intestines, and occasion-
ally by scybala; in the cells of the colon.  These
masses of tubercular accretion are often more
manifest on examination, when a fluid effusion
has been removed by absorption.
  50. Tubercular peritonitis is often insidious 
PERITONEUM—Chronic Inflammation of—Description.              81
 and slow in  its early stages, and may thus be
 almost latent until  shortly before death.  In
 these cases,  however, there have  been gener-
 ally an  irregular state  of the  bowels, some-
 times nausea, morbid evacuations, and more or
 less emaciation.  But  these  have  proceeded
 without creating alarm,  as they were attended
 by little, or only occasional pain.   At last the
 emaciation, the blighted appearance of the sys-
 tem, and the relaxed state of the bowels, at-
 tract attention ; or  acute  symptoms are sud-
 denly complained of, especially acute abdomi-
 nal pain, increased disorder of the bowels,  vom-
 iting, and rapid sinking of the vital powers.
 As soon as these symptoms supervene, the dis-
 ease proceeds with variable rapidity to a  fatal
 issue.
   51. In  a few cases the abdomen seems more
 flat than usual, but is  then  always duller on
 percussion than natural.  The  surface of the
 belly is generally warm, dry, and of a livid or
 dark hue ; and in many instances it is travers-
 ed by large blue, or distended  veins, indicating
 impeded abdominal circulation.  In addition to
 the inequalities just alluded  to, the inguinal
 glands  are generally enlarged, and painful on
 pressure.  The diarrhcea,  which was at  first
 slight, occasional, and interrupted  at times, or
 even alternated with slight  costiveness, be-
 comes more continued, and less under the  con-
 trol of treatment, for it then, as will appear in
 the sequel, is the result of ulceration.   The
 stools are always unnatural, and contain undi-
 gested  matters.   Life is soon afterward  ter-
 minated by gradual exhaustion of its powers.
   52. b. When  chronic peritonitis is consecu-
 tive of the acute state, or when it appears from
 the metastasis  of disease, or after visceral in-
 flammations,  or after suppressed eruptions, or
 when it is non-tubercular, although primary, it
 usually  presents  somewhat different phenom-
 ena.  In these circumstances,  the abdomen is
 the seat of a deep-seated but  not  very acute
 pain, which often intermits, and is either in-
 creased, or not much complained of unless
 upon pressure, or when the  abdominal muscles
 are contracted, or when the trunk experiences
 a shock, as when taking a false step.  Nausea
 and even vomiting are occasionally experien-
 ced, and digestion is always difficult,  food op-
 pressing the stomach, and  producing pains in
 the abdomen as  it passes  through the intes-
 tines. In  some cases, these pains are felt  in a
 particular part, in others their seats vary. Con-
 stipation is often present at an early stage ; it
 is subsequently alternated with diarrhcea ;  but,
 at  an advanced stage, the bowels are much re-
laxed, and the stools morbid,  sometimes con-
taining undigested substances.   Emaciation is
considerable,  and  always greater  as the  dis-
ease advances.   The countenance is sunk, anx-
ious, pale, and  sallow.   The skin is dry  and
unhealthy in appearance, the respiration is la-
boured,  short, or quick, and the pulse is  fre-
quent, particularly towards  evening and night.
When the chronic disease follows the acute,
the severe symptoms of the latter gradually
subside  and  lapse into  those  attending  the
former,  varying,  however,  with the  exciting
causes,  and the  circumstances developing the
 primary attack.
  53. The state of the abdomen varies with
 the presence  or absence of fluid effusion in the
    III                  6
 peritoneal cavity.  When fluid is present, the
 abdomen is enlarged, often so as to contrast
 remarkably with the emaciated limbs, and it is
 tense, distended, dull on percussion, unless  at
 the more elevated  parts.  Fluctuation  is sel-
 dom very manifest,  more frequently  it  is ob-
 scure.  Occasionally cedema of the lower ex-
 tremities, and of the more depending parts of
 the abdominal parietes, is remarked.   When
 there is no fluid in the cavity, the abdomen oft-
 en  appears diminished  rather than increased
 in size.  In some it is  quite flat, in others it
 presents a slight or an irregular swelling about
 the umbilicus, owing to the agglutination of the
 small intestines.   It is generally  somewhat
 dull  on percussion,  but not more  so in the
 more depending situations.  On careful  palpa-
 tion of the abdomen,  the experienced examiner
 will readily feel that the suppleness of health
 is wanting, and is replaced by an  internal re-
 sistance or tension, indicating the adhesion
 of internal  parts, while the  integuments are
 loose, and move readily over the more tense
 parts underneath.
   54. c.  Chronic peritonitis may be partial or
 general.  The  former occurs chiefly after in-
 flammation of some abdominal viscus that has
 extended to the peritoneal  surface.  In this
 case, the lymph thrown  out upon  that portion
 of this surface excites inflammation  in a part
 opposite to, or coming in  contact with, that first
 affected, and thus adhesions, or thickening of
 the opposite parts, or both, may be  produced,
 and the disease proceed no farther, the patient
 dying at  some subsequent period of some com-
 plication of this state of partial peritonitis, or
 of some disease developed at a more or less
 remote period.
   55. Partial  chronic peritonitis is sometimes
 observed after enteritis, after inflammation of
 the colon and  dysentery, after chronic ulcera-
 tion  and perforation  of the stomach or intes-
 tines, after hepatitis,  and after inflammations
 of the urinary and sexual organs.  When these
 maladies induce peritonitis in persons not re-
 markably debilitated, or otherwise of good con-
 stitutions and  habits of body,  the disease may
 not only proceed no  farther,  but it may be so
 limited, or so latent,  as not to give rise to dis-
 tinctive  phenomena  indicating  its existence,
 although slight uneasiness and pains,  increased
 on sudden motions, jerks, or muscular actions
 affecting the abdominal viscera, or on pressure
 in certain directions, are often present.
  56. When, however, peritonitis  supervenes
 upon any of the above maladies affecting scrof-
 ulous, cachetic, or broken-down constitutions;
 or in persons whose  excreting organs are tor-
 pid or diseased, and  whose circulating fluids
 are contaminated or  insufficiently depurated,
 it  usually spreads more or less, and becomes
 even general, and in  these cases  is  attended
 by more or less of  fluid effusion, unless in
 children, young persons, and the scrofulous di-
athesis, where it is more frequently accompa-
 nied  with tubercular formations.
  57. d.  The  terminations  or  consequences of
chronic peritonitis are those  organic lesiom
 which will be particularly described in the se-
quel, and which, although  most extensive,  can-
not be individually distinguished by symptoms,
as they are variously associated or grouped in
most cases, and when either far advanced in 
82                  PERITONEUM—Inflammation  of—in Children.
their  separate states, or associated, give rise
to  nearly the  same  phenomena, which are
those characterizing the advanced stage of the
malady.
  58. IV. Peritonitis in Children.—Perito-
nitis may occur even in ihefcelus, and hence
may be intra-uterine, and even congenital; but
it much  more frequently appears after birth,
particularly between the second and eleventh
years of age, and is one of the most important
diseases of childhood.   It may be either acute,
sub-acute, or chronic ; and it  may  be simple and
primary, tubercular and consecutive or complica-
ted.  It may also be partial and general: in other
words, in either its acute or chronic states, it
may be partial  or general, and each of these
may be primary and simple, or consecutive and
complicated ; and, farther, any of these states
may exist either with  or without  tubercular
formations, although the chronic form  is com-
paratively rarely seen unassociated with tuber-
cles.   Moreover, instances  have occurred of
simple or non-tuberculated  peritonitis having
been developed in the course of tubercular dis-
ease in other organs, as when  simple acute
peritonitis proceeds from perforation of the in-
testines or stomach,  occurring  in the course
of tubercular consumption, or of intestinal dis-
eases,  associated with tubercles in various or-
gans.
  59. A. Acute  and sub-acute peritonitis is more
frequently a consecutive than a primary  disease
in  children.  It  rarely occurs  primarily and
simply in the previously healthy,  but most fre-
quently in the  course of, or during convales-
cence  from,  fevers, particularly eruptive  fe-
vers ; and especially of those cases which have
presented predominant disorder of the  abdom-
inal organs or diarrhcea.  It may even occur
in the  advanced progress of the chronic form,
and prove fatal  in a short time.
  60. a.  Pain is generally the earliest symp-
tom, and is  often at first local or limited, but
it soon extends  over the abdomen, is increased
by pressure  and motion, and continues to the
termination of the malady.   Vomitings, which
are  frequent  in  the peritonitis of adults, are
much less so in that of children, and often do
not occur until an advanced  period.   The bow-
els are seldom  much confined, particularly as
the  disease advances.  They are more gener-
ally relaxed, and the stools  become more fre-
quent and morbid as a fatal  issue is approach-
ed.   Respiration is  accelerated,  but short and
shallow.   The tongue is generally moist, and
covered by  a whitish  or yellowish  coating.
The appetite is lost, and there is  always great
thirst.  The countenance is expressive of pain,
anxiety, and distress.  It is pale, collapsed, or
sunk.  Nervous  symptoms are rarely observed,
unless in very young children, and in these
convulsions are the chief form  they  assume.
The position of the  patient is always on the
back, with the knees drawn  up.
  61  The abdomen becomes tumefied very soon
after pain is first felt, is always tense, and then
sonorous throughout upon percussion.  When
the peritonitis is partial, the swelling and ten-
sion are often confined to the situation affect-
ed, and this partial state of the disease is most
frequently observed in the right flank,  or in or
near to the right iliac region.  As the  disease
advances, the abdomen, particularly in the sit-
uation of any manifest tumours, becomes more
dull than natural  on percussion, but the  ten-
derness often  prevents this mode of examina-
tion from being practised.   When the disease
is general, flatulent distention increases and is
more manifest.  Fluid effusion is seldom clear-
ly evinced by fluctuation.   The  surface  of the
abdomen is  usually warmer than natural.
  62. c.  There is always more or less sympto-
matic fever, which is seldom ushered in by  dis-
tinct  rigours.   The pulse  is very quick,  and
commonly the quicker, smaller, and weaker,
the more intense and the more general  the
disease.  The  urine is scanty and high-colour-
ed, and voided frequently ;  the skin is hot, dry,
harsh, and of a dull unhealthy appearance.
  63. d.  The duration of acute  peritonitis  va-
ries from twenty-four hours to thirty-eight or
forty days.  When the disease  proceeds from
perforation of any part of the digestive canal,
its duration is usually the shortest, as in adults.
When it continues longer than thirteen or four-
teen days, it is either partial, or presents a less
severe or sub-acute character.   When perito-
nitis terminates in resolution, the general or con-
stitutional symptoms are ameliorated ; the pain
subsides or  altogether ceases, and  the  abdo-
men gradually resumes its natural  condition.
The bowels become more regular, and the pulse
slower and fuller.  If much fluid effusion have
attended the inflammation, the abdomen is lon-
ger in resuming its former state.  If the dis-
ease continue to advance to a fatal issue,  the
swelling and tension of the abdomen increase,
the countenance becomes more sunk, the bow-
els more relaxed, the pain more severe and
more general,  and the pulse more rapid, small-
er,  and at last inappreciable.
  64. e.  Acute peritonitis is rarely associated
with tubercles  in children, but the chronic form
is very often thus complicated.   It sometimes,
however, supervenes in the course of tubercu-
lar  formations  in other or even distant organs,
especially of  ulceration  of the  intestines,  in
connexion with tubercular disease of the mes-
enteric  glands, and  of  tubercular  consump-
tion, and it occasionally appears in the progress
of the chronic disease, either simple or tuber-
cular.  In this latter case, acute symptoms  are
suddenly  developed,  the abdominal pains  be-
come more  severe, the fever, the distention,
and the heat of the abdomen are augmented,
the pulse is more rapid and smaller, and  the
countenance is more anxious and sunk.  The
disorder of the bowels increases,  and, with
the progress of the organic lesions, soon ter-
minates life.
  65. B.  Chronic peritonitis in children is gen-
erally associated with tubercular formations,
and is often then  more  or less  general.   It
may, however, occur without this association,
especially when it is partial, and consecutive
of inflammation of one or more  of the abdom-
inal viscera.   It may also follow the  acute
form  of the disease, either from the natural
decline  in^he  severity of the attack, or from
the treatment  resorted to.
  66. a.  Simple or  non-tuberculated chronic peri
tomtis can rarely be distinguished from the tu-
bercular during life, unless the history and cir
cumstances  of the case  be duly considered.
When it seems to follow inflammation of some
viscus, or the  acute disease, in children of a 
PERITONEUM—Inflammat
previously healthy frame, and free from  con-
stitutional  vice, then it  may be presumed to
exist independently of tubercles.   As respects
the symptoms, there appears hardly any differ-
ence between this  variety and the tubercular,
about to be noticed.  In  the former, however,
distinct tumour,  or inequalities  in the  abdo-
men, are more rarely or never observed ; and
there is often less  dulness on percussion   In
other respects the  phenomena and  progress
of both varieties  are the same.
  67. b. Chronic tubercular peritonitis in children
is generally attended by pain  from the com-
mencement, often before the abdomen presents
any swelling, although often also contempora-
neously with swelling and tension.  The pain
is in some  cases  local, in others general or er-
ratic, but it is not, when local or fixed, always
an  indication  of  the chief seat of tubercular
productions.   The  tongue  is moist, white,  or
coated  with a yellowish matter at its base;
less frequently red and glossy.   The appetite is
frequently but little, or even not at all, impair-
ed ; it is more generally irregular and capri-
cious.  It  is sometimes not materially dimin-
ished throughout.  Thirst is generally felt, and
it increases with the progress and severity of
the symptoms and  associated affections. Vom-
itings rarely occur  in this  state of peritonitis,
although they are not infrequent in the acute.
Diarrhoea is  commonly  observed, and it  in-
creases  as  the  disease advances,  especially
when ulceration  of the  intestines is present,
and this is rarely wanting in the last stage.
   68. The abdomen presents the most charac-
teristic appearances.  At an  early  period  its
form presents little or no  change beyond be-
ing somewhat more full  and sonorous on per-
cussion.  As  the disease advances, but at  no
definite period, the belly becomes distended,
and is either sonorous throughout, or is dull in
some parts and sonorous in others.  When the
dulness is found  always  in the same situation,
and is  attended  by some hardness or doughi-
ness, suspicion of the existence of the disease
is  generally well-founded.  In some cases an
obscure fluctuation is  felt in the more dull
parts of the abdomen, owing to a partial fluid
effusion attending the tubercular lesion of the
peritoneum.  With increased distention  and
tympanitic sound there is  often more  or less
tension, which is  sometimes  greater  in  one
side or part than  in another, and when it is
great the part is elastic rather than hard.   As
the disease advances,  particularly  in older
children, the  abdomen  presents many of the
changes already  noticed. When the tension is
very  great  the surface  becomes smooth and
shining, and afterward harsh or scurfy, owing
to desquamation  of the cuticle.  The veins in
the surface of the belly are then often large
and distended.
   69. c. The progress and duration of this form
of peritonitis vary  remarkably in different ca-
ses.  The disease is often far advanced before
it excites  alarm, and is mistaken for simple
disordered function  of  the bowels, and the
pains for those  of colic.  The flatulent  state
of  the digestive organs generally attending, as
well as preceding, the complaint, is frequently
considered  as  the source of all  the disorder
until serious  organic lesions  are developed,
and then emaciation, febrile exacerbations, diar-
ion of—in Complications.                83

rhcea, partial or general night perspirations, and
the symptoms just mentioned, disclose the na-
ture of the malady.  The duration of the dis-
ease can rarely be precisely determined, as the
exact period of its commencement cannot oft-
en  be ascertained.   The patient has been fre-
quently out of health for a considerable period
before the symptoms were  fully evolved, and
it is most probable that the tubercular forma-
tions connected  with  the  peritoneum  com-
menced about the period of the earliest indica-
tionof impaired health.  The continuance, there-
fore, of the malady may, according to my ex-
perience,  vary from  two or three  to eight or
nine months.  Instances of a  shorter or even
longer duration may occur, but they  can be
very rare.
  70. d.  The termination of this form of peri-
tonitis is always fatal.   But this  issue is not
owing to  the extent of the  tubercular disease
solely, but partly also to associated disease in
other organs, to tubercular formations in other
viscera, particularly  in the lungs,  in other se-
rous membranes, in  the mesenteric glands, to
ulceration of the  intestines, &c.
  71. V. Complications of Peritonitis.—The
several forms of peritonitis may be variously
complicated.  Peritonitis in the puerperal state,
as will be shown in the article on Puerperal
Diseases, is most frequently complicated with
disease in other  organs  and parts;  but those
states of peritonitis already considered are oft-
en also  complicated, although  not so frequent-
ly and so extensively as those occurring after
parturition.  The symptomatic fever attending
peritonitis can hardly be viewed as a  compli-
cation, as it depends upon the previous health
of the patient, the  state of nervous or vital
power, and the condition of the circulating flu-
ids  ; depression of power and contamination or
imperfect depuration of these fluids giving rise
to an adynamic  state  of fever, and favouring
the extension of  the malady and fluid effusion.
The  complications of  peritonitis  are  of two
kinds :  1st, those in which the peritonitis is a
consequence of the  disease with  which it  is
associated ; and, 2d, those which consist of ex-
tensions  of the peritonitic malady.  The for-
mer are the most numerous, frequent, and im-
portant.
  72. A. When peritonitis supervenes on other
visceral disease, and is thereby associated with
it, the inflammation  may be limited  to a  por-
tion of the peritoneum, or extended more or
less generally, the limitation or extension de-
pending upon the states of vital power, and of
the circulating fluids, as already specified (§ 4).
  73. a. The complication of hepatitis with per-
itonitis is generally with the partial form of the
latter, the former being the primary malady.
In this association, as will appear  by referring
to Liver—Inflammation of, the diaphragmatic,
or the parietal peritoneum, or other contiguous
portions,  may be affected, and recovery from
it is frequent, adhesions between the opposite
surfaces only remaining, and  these ultimately
become more cellular and less extensive. The
association of splenitis with partial peritonitis,
in a slight and chronic form, giving rise to ad-
hesions,, &c, is  not infrequent, especially in
marshy situations.
  74. b. The complication of gastritis with per-
itonitis is much less common  than that of he- 
B4                   PERITONEUM—Inflammation of—Lesions in.
patitis, but,  like it, is much more frequent in
warm than in temperate climates.   It is, how-
ever, a much more severe and dangerous mal-
ady. The symptoms are violent, the vomiting
is  almost constant, the  vital depression ex-
treme,  and the progress to a fatal issue gener-
ally rapid.   In the few cases of this complica-
tion that I have observed in this country, the
peritonitis has been partial.
  75. c. The association of peritonitis with en-
teritis, or with  inflammations of the cacum or
colon,  is not infrequent,  particularly in warm
climates, and in persons who have migrated
from Europe it  is more  commonly observed
than in natives.   In all such cases the disease
generally commences in  the mucous surface
of some portion  of the  intestinal  canal, and
extends through the other tunics to the perito-
neal coat, agglutinating the  opposite  surfaces
of the  bowels with each  other,  or  with those
of other organs or parts.  In cases of inflam-
mation of either  the small intestines, the cae-
cum, or colon, the resulting  peritonitis is most
frequently partial, the disease sometimes ter-
minating rapidly in gangrene, especially when
the appendix caci  is affected, or when strangu-
lation exists. When, however, there  is perfo-
ration of a portion of bowel, or when this com-
plication occurs in the course of exanthema-
tous or continued  fevers, or of dysentery, the
disease of the peritoneum is more or less gen-
eral, and is rapidly fatal, as described above
($ 27, et seq.).
   76. d. The association of  peritonitis with
diseases of  the  sexual  and urinary organs,  or
with inflammation of any of these organs after
surgical operations, often occurs,  particularly
in persons, of a bad state of health or constitu-
tion.  The peritoneal inflammation may be par-
tial or general, sthenic or asthenic; but, when
general, it is usually also asthenic ; and it may
be associated either  with hysteritis,  cystitis,
nephritis, or with inflammation of  the ova-
ria or fallopian tubes, or  with any two or more
of them.  These  complications  are almost al-
ways present in puerperal peritonitis, and are
also sometimes observed in other circumstan-
ces.  Partial peritonitis  not infrequently  fol-
lows inflammatory and organic diseases of the
uterus and  ovaria, and when thus associated,
or when complicated with inflammation of ei-
ther the sexual or urinary  organs, sometimes
terminates  favourably, adhesions  of contigu-
ous surfaces, however, generally remaining in
these, while serous effusions take place in the
more unfavourable cases.
   77.  B.  Complications seldom arise from the
extension of peritonitis to the organs which the
peritoneum invests; for, when the peritonitis is
general and acute, death commonly takes place
before inflammation in a distinct form, or other
organic change,  is developed in any of these
organs; and when the peritonitis is partial or
chronic, the affection of contiguous or enclosed
viscera is more functional than  structural.  In
children,  however, and even in  adults, both
partial and  chronic peritonitis may be associa-
ted with mesenteric disease, or with  tubercles
in the mesenteric glands and in the lungs.   In
these cases, also, there may be  a farther com-
plication with ulceration of the intestines, the
ulceration sometimes perforating the coats of
contiguous  convolutions of intestines, and form-
ing fistulous communications  between  them.
It is doubtful, however, whether the peritoneal
inflammation or the  tubercular  formation be
primary ;  it  is even  not improbable that the
former is  the  consequence of  the  latter in
some instances, although the existence  of tu-
bercles in the false membranes,  or within the
peritoneum, shows that the inflammation has
preceded the tubercular productions.  In many
cases of chronic tubercular peritonitis, the ul-
cerations  and  other  lesions of the intestines
are manifestly consequences of the peritonitis,
while in others the ulceration seems to be pri-
mary, or the sequence of organic lesion cannot
be readily established.
  78. a. When peritonitis commences  about
the  liver  and  extends  to  the diaphragmatic
peritoneum, the pleura of the same side not in-
frequently, also, becomes inflamed, partial peri-
tonitis thus becoming complicated with plcuri-
tis, and ultimately even with pleura-pneumonia.
I have  met with several  instances of these
complications  in the  course of my practice,
and in most of them complete  recovery has
taken place.  The association  of general peri-
tonitis with pleuritis of one, or even of both
sides, is frequent in puerperal  peritonitis, par-
ticularly as occurring in lying-in hospitals, es-
pecially if the  disease be not arrested  at an
early stage.  (See Puerperal  Diseases.)
  79. b.  Tubercular  peritonitis in children is
sometimes  complicated with  tubercles  in the
membranes of the brain, with softening  of the
central parts of the brain, and with serous ef-
fusion into the ventricles, or acute hydrocepha-
lus.  In  these cases, of  which  I have seen
several, the lesions of the  peritoneum and of
the brain and its membranes, were consequen-
ces of inflammation  in connexion with  tuber-
cular productions, in scrofulous constitutions.
  80.  VI.   Appearances on  Dissection.—i.
After Acute Peritonitis.—The changes pro-
duced by acute inflammation of the peritoneum
vary with the severity or activity of the dis-
ease, with the habit of body and constitution
of  the patient, and with the predisposing and
exciting causes ;  they differ  most essentially
according  as the disease presents sthenic oi
asthenic characters (y 8, 26), as  it occurs  pri-
marily or consecutively, and as  it  has been pre-
ceded by, or is associated with, depression of
vital power, or contamination of the circula-
ting  fluids.  I shall  therefore describe,  1st,
those changes  which are observed in the more
sthenic forms of the malady, or those affecting
persons whose vital powers are not exhausted,
and whose circulating fluids are  uncontamina-
ted ;  and, 2d, those alterations observed in as-
thenic states of the disease, reserving, however,
a more detailed account of these latter, until
they come  under  consideration in the  article
on Puerperal Diseases.
  84. A. After acute Sthenic Peritonitis.—a.  The
earliest change  in acute peritonitis is a loss of
the polish of the free surface of the membrane,
which assumes a dull, opaque, and occasionally
a dry-like appearance.   Red vessels are seen,
either grouped in spots, forming a number of
puncta, or in streaks.   The surface, appearing
dull, or even dry, is, upon a closer examination,
found to be covered by a most delicate,  unctu-
ous, and slightly viscid exudation. The dense
cellular tissue connecting  the peritoneum to 
PERITONEUM—Inflammation  of—Lesions in.
85
 the parts underneath, or at least the attached
 part of the membrane, is the situation in which
 the increased vascularity seems to commence.
 Even at this stage, the former is somewhat in-
 filtrated with an albuminous serum, giving the
 subserous tissue a thickened aspect, in which
 the membrane itself appears to participate.
 The  peritoneum may be  detached from the
 parts it covers with greater facility than in the
 healthy  state, owing to diminished cohesion,
 and infiltration of the inflamed subserous tissue.
 As yet, the minute capillaries, forming puncta,
 or streaks, or assuming a reticulated appear-
 ance, interspersed with red points or spots, con-
 sist of the colourless vessels of the membrane
 enlarged, so as to admit the red globules ; but,
 as the disease advances, the  vessels appear
 more and more superficially.  The small  spots
 become  more extended, approach each other,
 and at last coalesce, so as to form patches of
 various  dimensions.  The membrane itself is
 not,  as yet, materially thickened, beyond the
 slight degree just noticed, produced chiefly by
 the change in the subjacent cellular tissue and
 its adhering  surface.   The redness  now be-
 comes more intense, deep, and extended.  This
 may  be  considered as the first  stage of the
 changes caused by acute inflammation, and  is
 attended by intense pain, tenderness on press-
 ure of adjoining parts, a quick, hard pulse, and
 symptomatic fever.   It seldom exceeds three
 days, and sometimes does  not endure twenty-
 four  hours, until farther lesions supervene.
   82. b.  The most remarkable of these lesions
 is the exudation of lymph on the inner or unat-
 tached surface of the membrane.  This is ef-
 fused in  a fluid state, and at first is an increas-
 ed exudation  of the viscid matter already no-
 ticed as giving a dull and an opaque appear-
 ance  to  the membrane.  This exudation be-
 comes more copious, especially as the surface
 is  more  crowded  by capillaries injected with
 red blood.  It is generally of a straw colour,
 homogeneous, gelatinous,  semi-transparent,
 and coagulable, gluing together, as  it were, in
 a slight degree, those free surfaces  of the in-
 flamed membrane   which come in  contact.
 Sometimes the reddened colour of the surface
 is heightened by the exudation being red and
 sanguineous,  and adhering closely to it, giving
 it a villous appearance.  Sometimes the  exu-
 dation is of  whitish or whitish-gray colour.
 With the exudation of lymph, the redness be-
 comes more  extended;  in some it is nearly
 limited to the parts covered by,  and to those
 slightly adherent to the opposite surface through
 the medium of, this exudation.  In other cases
 the redness extends, in  a  somewhat less de-
 gree,  in  bands or stripes,  along  the surfaces
 between  the parts covered by this exudation ;
 these intermediate  surfaces being either near-
 ly dry or apparently so, and as  yet not advan-
 ced to the stage of effusion.  As the exudation
 proceeds in the more acute cases, it becomes
 more  abundant, and varies in  quantity  and
 density, according to the activity  and duration
 of the disease, and constitutional energy of the
 patient.  It constitutes the coagulable lymph of
 Hunter and other British pathologists, and the
albuminous exudation of Continental authors,
from  the large proportion of albumen which
enters into its composition.
  83.  When this substance is minutely exam-
 ined about the fifth or sixth day of the disease,
 or about the third from the commencement of
 its formation, it is generally of a pulpy consist-
 ence,  partially translucent, of a straw-yellow
 or grayish  colour, and, when  torn asunder,
 presents a cellular or cellulo-filamentous struc-
 ture in its  denser parts, from which more or
 less serous  fluid escapes.   Separated from the
 membrane  on which it has  been formed, its
 adherent  surface is rough, irregular, minutely
 honey-combed,  and  marked  by  more or less
 numerous minute dots of blood, arising from
 the  disruption of the recently-formed capilla-
 ries passing from the inflamed serous surface
 into the new product.  Here we have the most
 complete  example of the formative proeess be-
 ing one of the characters  of  inflammation oc-
 curring in persons of a previously healthy state
 of system.
   84.  c. This exudation, which is fluid when
 first poured out, and  has rapidly assumed the
 state now described, experiences farther chan-
 ges  during  the continuance  of life. These,
 however,  vary with the different states of the
 disease and circumstances of the case.   One
 of the most constant, is the  agglutination  of
 the  opposing  surfaces of the inflamed  mem-
 brane.  To  occasion  this, it  is not necessary
 that both the opposing surfaces shall have been
 previously inflamed; for the lymph effused from
 the  primarily inflamed surface, coming in con-
 tact with  a circumscribed portion of the oppo-
 site  surface, irritates and inflames it only, and
 thus increases the quantity of the effused lymph,
 which  becomes a connecting  medium* between
 the inflamed surfaces ; capillaries, carrying red
 blood,  passing from  both surfaces into the ef-
 fused lymph, so as to change  and organize the
 substance still farther.  In cases of this kind,
 the  portions of the peritoneum intermediate
 between the parts, whose accretion  has  been
 thu,s effected, have frequently presented  little
 or no  appearance of inflammation; or  have
 been moistened only by a small quantity of a se-
 ro-albuminous fluid, or have contained a larger
 quantity of  a similar effusion.
   85. d. The connexion or adhesion thus formed
 between the opposite points or surfaces of the
 peritoneum  varies much in its characters with
 the period which has elapsed since the effusion
 of the  lymph which produced it, and with the
 surfaces which it exists  between.  At  first
 the exudation is fluid, but it  soon coagulates
 into  a  gelatinous,  pulpy substance of various
 density, exhibiting a weak cellulo-filamentous
 structure,  enclosing in its  meshes the serous
 parts of it, and easily separated from the sur-
 faces it either covers or connects.  After a time
 its cellulo-filamentous structure becomes more
 firm, and is penetrated by minute capillary ves-
 sels, shooting into it from the inflamed mem-
 brane,  to  which it is now more strongly at-
 tached  by means of the vessels passing into
 it. The process of organization of the plasma
 or effused  lymph has  now commenced, and it
 proceeds more or less rapidly.  The vessels
 penetrating  the  newly-formed substance are
 now  more numerous, so as  to admit  of injec-
tion in fatal cases; its cellulo-filamentous struc-
ture  becomes firmer, more opaque, and some-
what whiter;  it is firmly attached to the se-
rous surfaces, which it connects more or less
closely, and  the serous portions of the exuded 
lMmation of—Lesions in.
 86                   PERITONEUM—Infla

 Ivmph contained between  the  meshes or cel-
 lules of the  cellulo-filamentous structure, are
 absorbed.  This substance is now nearly alto-
 gether  albuminous, and, as the inflammation
 which produced it declines, the vessels  pene-
 trating it contract, so  as ultimately to convey
 only the colourless portion of the blood.  This
 contraction of the vessels,  after the decline of
 the  inflammation  which formed them, is also
 accompanied by a great reduction of the bulk
 of the  newly-formed  substance, if not  to its
 entire removal, especially when the inflamma-
 tion and the albuminous exudation are limited,
 recovery from the attack taking place.
   86. e.  In less  acute, or, rather, sub-acute or
 partial forms of peritonitis, or when the  more
 acute symptoms have been  subdued, and where
 inflammation has existed from fifteen to thirty-
 five  days, or even  longer, before producing
 death, the albuminous  exudation  forms  false
 membranes of a grayish, whitish, or even red-
 dish colour,  establishing  adhesions  between
 contiguous  parts, and varying in thickness
 from half a  line to  three  lines, generally in
 proportion to the duration  of the  disease.
 When detached from the serous surfaces which
 produced them, and to which they adhere firm-
 ly, these  surfaces are  found much  inflamed,
 and sometimes dotted  with minute specks of
 blood, owing  to the rupture of the connecting
 capillaries.  The false membrane itself is here
 found firm and elastic,  and  not  pulpy and fria-
 ble,  as  in the most  acute  cases, or  in those
 which have more rapidly terminated in death.
 In these cases little  or no  effused fluid is ob-
 served,  that which may have  been poured out
 with the albuminous formation  during the ear-
 lier period of the inflammation having  been
 absorbed.
  87. According to the violence of the inflam-
 mation, to the duration of  it, and  to  the con-
 stitution of the patient, sthenic acute  peritoni-
 tis may give  rise to false  membranes, membra-
nous adhesions, cellular adhesions, or cellular
 bands,  and these  may  be  the chief or  only
 changes  produced, beyond  the  increased vas-
 cularity of the membrane underneath.  But in
many cases  other changes supervene.   The
 chief of these concern  the  morbid productions
 themselves, the  nature and character of the
fluids effused, in connexion with these produc-
tions, and the state of the membrane itself and
 of the subjacent cellular tissue.
  88. /. Where the false formations are consid-
erable, and have  assumed an organized and cel-
 lular structure, the vessels proceeding to  them
 are very minutely divided when  they  have
reached  the peritoneal  surface, and are about
to pass into the morbid production ;  but, having
passed into it, they again unite and  form larger
vessels, which ramify  in  different directions
through this production.  This distribution has
led some pathologists  to suppose that these
vessels are first formed in  the morbid produc-
tions, as in the envelope of the vitellus of the
 incubated egg; but this is  not  the case,  as is
 shown by the manner in which the capillaries
 shoot from  the  inflamed membrane  into the
 lymph thrown out upon its  surface  (i) 83,  84).
  89. The morbid formations  become firmer
 and less vascular, after they have been organ-
 ized,  as  the  period from  their production is
 prolonged (v 85).   They also become thinner
 as they grow older, and their surface assumes
 the appearance of a serous membrane, while
 their internal structure  is more strictly cellu-
 lar. When bands of adhesion stretch from one
 surface to the other, or when laminated pro-
 ductions  extend over a  large- superficies, or
 connect opposite parts, they are cellular in the
 centres and serous on their unattached surfa-
 ces, and,  at all the points of adhesion with the
 peritoneum, this membrane has lost its serous
 characters, the sub-serous cellular tissue being
 continuous with that which forms the centre
 of these bands, false membranes, or adhesions.
   90.  The progressive diminution of the vol-
 ume of those productions with the subsidence
 of the inflammatory  action which  produced
 them,  and with the lapse of time, as well as
 the history of cases, in which there  has been
 sufficient, reason to  believe that those produc-
 tions haa been actually formed, have led sev-
 eral pathologists to infer that they may be re-
 moved altogether.  M. Villerme was the first
 to  contend that the  adhesion formed between
 the surfaces of different organs sometimes sep-
 arate after a  time at their centres, and disap-
 pear, and the  observations of Dupuytren, Ce-
 clard, and Gendrin confirm this inference.  I
 have had reason  in the course of practice to
 concur with this opinion, the justness of which
 is of practical importance, and should not be
 forgotten in  our management of diseases in
 which  the serous surfaces are implicated; and
 I further believe, that the diminution and ulti-
 mate disappearance of these productions are
 remarkably favoured by whatever promotes the
 vital powers, and favours the healthy perform-
 ance of the several functions.
   91. g. In acute and sub-acute peritonitis, a
fluid effusion is either a concomitant or a con-
 sequence of the albuminous formation, or both.
 In  cases  of partial peritonitis  it is  most  fre-
 quently the consequence, particularly of ad-
 hesions.  In slight  and more  chronic cases,
 however,  the  effusion of a serous or sero-al-
 buminous fluid is often the principal phenome-
 non.   In the more acute cases, the liquid effu-
 sion is whitish-gray, or of a whey or milky ap-
 pearance.  In some it  is  unctuous, thick,  or
 abounding in albuminous flocculi, of a whitish,
 yellowish, or  lemon colour.   In others it is
 turbid, greenish, or  brownish-red, containing
 lighter-coloured flakes, but this  effusion occurs
 more frequently in acute asthenic peritonitis,
 the colour proceeding from a slight admixture
 of the  colouring matter of the blood.  In the
 most acute  cases of the  sthenic disease, the
 effusion of much fluid seldom occurs until the
 powers of life are much exhausted, or until the
 extreme capillaries and pores  have lost their
 tone, congestion of the venous capillaries either
 supervening or having already taken place.
  92.  In  many  cases, particularly in partial
 peritonitis, the adhesions, in their advanced or
 old states, are causes of irritation to the surfa-
 ces they connect, either exciting  an increased
 exhalation from the adjoining unattached por-
 tions, or being themselves the  seat of exhala-
 tion, the spaces between the adhesions becom-
 ing filled with fluid, either of a serous, a sero-
 albuminous, or sero-purulent character, accord-
 ing to  the degree of morbid action in the part
 and the state of the system.  This accumula-
 tion of fluid in the spaces between the adhe- 
PERITONEUM—I nfla
sions, or in cavities the parietes of which are
lined with an albuminous exudation in the form
of a false membrane, is often owing either to
a slight return or exacerbation of the inflam-
matory action after it  had  subsided  to some
extent, or to its continuance in a less severe
or chronic form, after the more acute stage had
been mitigated.   But,  in either case, conges-
tion of  the venous  capillaries, and impaired
tone of  the affected vessels and tissues, are
more or less concerned in  the production of
the fluid effusion.  When  the accumulation is
large, it constitutes a  species of acute dropsy,
and is dependant upon the  same pathological
states of the containing  membrane and  sur-
rounding  parts as have been explained when
treating  of the origin and nature of dropsical
effusions.
  93. The effusions of coagulable lymph, and
the consequent adhesions, are remarkable chief-
ly between the various convolutions of intes-
tines, between the prominent points of these
and the  omentum, in the pelvic and  iliac re-
gions, and between the serous surface of the
bowels or of the  other abdominal viscera and
the peritoneum lining the parietes of the abdo-
men. In some, the greater number of the folds
of the intestines are agglutinated together, and
these partially cemented to the omentum, or to
adjoining viscera or surfaces, by means of an
opaque  lymph, of a lemon-yellow colour and
pulpy consistence.   In others, the  agglutina-
tion is more partial, and the omentum is shrunk
or contracted, and drawn up to the arch of the
colon.   In some of the most acute and violent
cases, the surface  assumes  a purplish-red or
violet colour,  and in these  the intestines are
often united to each other,  or to the opposite
surfaces, without the  intervention  of a  false
membrane, beyond  a very thin film of a whit-
ish or grayish albumen.
  94. In cases of partial peritonitis, when the
disease  has been of longer  duration, or when
the patient  has recovered, adhesions more or
less extensive, or bands of various dimensions,
are often formed  between  various parts of the
opposite surfaces,  or  between the omentum
and one or more of the convolutions of the in-
testines, between the margin of the omentum
and fundus of the uterus,  or between other
parts, according to the particular seat and cir-
cumstances of the  partial peritonitis of which
these adhesions were the consequences. These
albuminous exudations and  adhesions present
other forms, especially  in sub-acute and chron-
ic cases,  and are often attended by  more or
less fluid effusion of a similar description to
that now noticed.
  95. The peritoneum  itself is often variously
changed, besides being injected in the manner
already noticed, and generally the change im-
plicates  more or less the sub-serous tissue ; in-
deed, this latter seems often more particularly
altered,  being  cedematous, or infiltrated by co-
agulable lymph in some cases, and softened in
others.  In these,  the peritoneum is frequently
also more or  less softened, or more  readily
torn, and  somewhat thickened.   In the  most
acute cases, this membrane  becomes in places
of a deep  brownish red or  purple  colour, or
even almost black, but  it very rarely advances
to gangrene, unless in partial peritonitis caused
by strangulated hernia, or by inflammation of
mations of—Lesions in.                  87

 the appendix of the caecum, and then  this le-
 sion is limited to the part thus circumstanced,
 and the  peritoneum only participates with the
 other tissues in the change.  M. Scoutetten
 remarks, that he has met with black gangre-
 nous eschars of a small size, and never exceed-
 ing one or two inches in extent.  These, how-
 ever, occur chiefly in the asthenic form of per-
 itonitis,  and even rarely in it, as death gener-
 ally takes place  before  gangrene can super-
 vene ; and in those  cases where it is observed
 on dissection, it is most probably a post-mortem
 change, or at least very shortly antecedent  to,
 or concomitant with, dissolution.
   96. The changes  just described, particularly
 as respects the membrane itself and its false
 productions and adhesions, are often partial or
 limited,  and  when  this obtains, they are ob-
 served more frequently in the peritoneum li-
 ning the pelvic viscera, the caecum, and appen-
 dix, and next most frequently in parts of that
 reflected  over the large and small intestines,
 the liver, diaphragm, and either surface of the
 omentum, and less frequently in the transverse
 meso-colon and mesentery, that covering the
 stomach being most exempt from them.
   97.  B. The lesions consequent upon asthenic
 peritonitis differ materially from those  caused
 by the sthenic form of the disease.  While in
 the latter they are  more frequently  partial or
 limited, in the former they are more general,  or,
 at least, extended;  while, also, in the sthenic
 disease,  albuminous lymph, false membranes,
 and adhesions are frequently the chief or only
 changes, in the asthenic these are very rarely
 observed, or in a very imperfect and unorgan-
 ized and unorganizable form.  In some cases,
 a  thin muco-albuminous or soft  and dark-col-
 oured film is found extending over the surface
 of the inflamed membrane, and a large quantity
 of a turbid serum,  of every shade of colour,
 from a whitish or grayish hue to  a  brownish
 dark sanguineous or sanious appearance, is  ef-
 fused in the peritoneal cavity. This fluid varies
 in quantity from a few ounces to several pounds,
 but it is very rarely above this amount in the
 acute form of the disease.  It seldom contains
 the large flocculi or masses of coagulated lymph
 or albumen sometimes  met with in  the more
 sthenic form of  the malady,  unless in those
 cases which approach more or less to that char-
 acter.
   98. The peritoneum often presents a soften-
 ed or sodden and somewhat thickened appear-
 ance, in which  the subjacent  cellular  tissue
 participates.  It is generally more readily torn,
 and, in some cases, I have found this greater
 lacerability very remarkable, particularly when
 there was  much dark  discoloration of  the
 surface, which is more or less altered  in col-
 our, being commonly of a dark brownish, gray-
 ish brown, or purplish tint, the shades varying
 in different situations.   Various other appear-
 ances are olten observed in this  membrane, in
 the viscera over  which  it is reflected,  and in
 the fluids effused into its cavity; but, as these
 most  frequently occur in the puerperal states
 of peritonitis, they are described in the article
 Puerperal Diseases.
   99. ii. Lesions caused by Chronic Perito-
 nitis.—When the peritoneum has been chron-
 ically inflamed, the lesions which present them-
 selves are very various according to the con- 
88                   PERITONEUM—Inflammations of—Lesions in.
stitution of the patient, and the duration of the
disease.  But they differ also most remarkably
according as thev proceed from an  inflamma-
tion which  has become chronic, consecutively
upon an acute form of the disease, and as they
result from a slow,  insidious, almost latent,
and primary state of inflammatory irritation or
action, according as they are consecutive or pri-
mary.  They differ, moreover, as the peritoni-
tis is simple or associated, as it is non-tubercu-
lar or tubercular.
  100. A. The changes which follow  chronic pe-
ritonitis consequent upon the acute vary with the
duration  and circumstances of the  case. — a.
In some, after the duration of fifty or sixty
days, the peritoneal cavity is filled with a con-
siderable quantity of a  whitish  serum, occa-
sionally resembling partially curdled  milk.  Nu-
merous bands of adhesion and portions of false
membrane  presenting the same appearances,
and formed as above (§ 81, et seq.) described,
unite the greater part of the intestines to  each
other, or line the intestinal  peritoneum and
omentum.  These false membranes  often form
partial sacs, containing a fluid, the  characters
of which are various.  When  the false mem-
brane is detached, the portion of the peritoneum
underneath has not so red or so vascular  an
appearance as in the acute disease ; sometimes,
indeed, it is hardly coloured.  In many of these
cases, the quantity of fluid effusion is incon-
siderable, and the false  membranes are less
extensive and thinner, opposite surfaces being
united by adhesions or bands, and not by con-
tinuous albuminous layers.
  101. b. In some subjects, a considerable quan-
tity of a yellowish limpid serum, without clots
or flocculi, is found  in  the peritoneal cavity
about this  period of the disease, but without
any trace of false membrane or adhesion, the
peritoneum  being, however,  reddened, thick-
ened, and injected.   The omentum, in these,
is very much thickened, red and fleshy, and
sometimes  contains small vesicles or cysts.
  102. c. In other cases, and particularly at a
later period of the disease, the abdomen is dis-
tended by the accumulation  of serum.  The
intestines are pushed  towards  the vertebral
column, and sometimes adhere slightly, or more
or less extensively, to each other.  The  peri-
toneum is  generally thickened and papillous,
having a grayish, lardaceous appearance, occa-
sionally with bloody striae and red spots, seem-
ingly formed by slight extravasations of blood.
In some of these cases, furrows  or broad su-
perficial erosions  are formed in the thickened
peritoneum.  The fluid  collected is occasion-
ally clear and yellowish ; in some it is turbid,
grayish, brownish, or even sanguineous, par-
ticularly  where the bloody striae  or spots are
observed in the thickened membrane. In rare
instances hemorrhage  has occurred, owing to
the destruction of small  vessels by the super-
ficial erosions just mentioned.  These erosions
in rare instances become more and more deep,
and are converted into ulcers, which destroy
the membrane and  advance to the subjacent
tissues, forming the primary peritonitic ulcers
Of ScOUTETTEN.
  103. d.  Gangrene very rarely is observed in
chronic peritonitis, and only when a  recurrence
of the acute disease takes place, or when acute
inflammation attacks the subjacent  structures,
and then  only  limited portions of the mem-
brane are implicated.  In these, eschars  of a
gravish slate or dark colour are formed their
surfaces being covered by a dirty, grayish mat-
ter.  The eschars in these instances generally
extend to the subjacent tissues.
  104. B. The lesions consequent upon primary
non-tubercular peritonitis are, in some instances,
not very different from the foregoing, in others
they differ materially. — a. Very slight redness
of the peritoneum  is often observed, and as
frequently this is entirely wanting.  When it
occurs, it is usually of a brownish shade.  If
more remarkable, or of a brighter tint, it is
then owing to an acute state of inflammation,
which had supervened upon the chronic, and
terminated life; but, in these cases, other marks
of acute action are often found united  to the
characteristic alterations of the chronic.
  105. b.  Thickening with increase of density
is one  of the chief changes  observed  in the
primary form of chronic peritonitis.  The thick-
ening is owing not only to increase of the mem-
brane itself, that being seldom very great, but
also to infiltration and tumefaction of the sub-
jacent cellular tissue, identifying it completely
with the serous coat in such a manner  that it
is impossible to distinguish the exact limits of
this membrane,  particularly  in very chronic
cases.  The difficulty is also much increased
by the organized false membranes often form-
ed  upon the peritoneum,  and which become
ultimately identified with it, in such a manner
as themselves to become inflamed and to give
rise to similar productions.
  106. c.  The increase of density of the chron-
ically inflamed  peritoneum is usually consider-
able, so that it is generally torn with greater
difficulty than in the healthy state, or especially
after acute inflammation.  It  is detached  also
with much more  difficulty from the subjacent
parts,  owing to the increased density of the
connecting  cellular tissue, and is much  less
friable than in the acutely inflamed state.
  107.  d. The surface of the  membrane is ru-
gose, dull, and  presents a number of small ele-
vations, w-hich are  perceptible to the touch as
well as to the sight, are whitish, somewhat flat-
tened, and irregularly intermixed with brown-
ish specks ;  these specks resemble those which
are observed in  acute inflammations, and oc-
casion  no elevation  of  the  surface.   These
small  elevations, although generally observed
on the surfaces of the thickened membrane, are
not confined to these surfaces, being frequent-
ly also found on false membranes ; they are
usually called granulations.  Some have con-
founded them with  the tubercles which some-
times are developed, either under the inflamed
peritoneum, or in its substance, or in the false
membranes.  They may, however, be  distin-
guished  from  these latter by the  following
marks: the small,  whitish, flattened  granula-
tions arise upon an  exhaling surface, and seem
to elevate an epidermis whiter and more opaque
than the serous texture  itself, indicating  that
they exist in the  substance of this membrane.
Around them there is always observed a slight
vascular injection, very evident under the mi-
croscope, and sometimes apparent to the unas-
sisted eye.  Upon  dividing the membrane, a
minute infiltration of whitish serum is observ-
ed at the points where the granulations have 
PERITONEUM—Inflammations of—Lesions in.
89
 been divided, with a slight increase  of thick-
 ness of the parts of the membrane where they
 are  developed.  They are not enclosed in any
 cyst, but are mere infiltrations into the struc-
 ture of the part in which they are formed,  as
 first shown  and  contended for by me  in  a
 memoir  on  chronic  peritonitis, published  in
 1821 (see  Lond. Med. Repos., vol. xvi), and
 since confirmed by M. Gendrin and others.
   108. e. The  false membranes found in this
 state of peritonitis  are  completely organized
 and  dense.  Occasionally they  are indurated,
 of a fibrous  or lardaceous structure ; in other
 cases  they are entirely  wanting, and  it is  in
 these latter  that the thickening of the perito-
 neum has  taken place, chiefly in the direction
 or at the expense  of the  subjacent cellular tis-
 sue, the free surface of the  membrane appear-
 ing  as a rugose  epidermis  of a dull, grayish-
 white  colour, elevated by  numerous  granula-
 tions, and  spread over a thickened and indu-
 rated coat of the connecting cellular tissue. In
 other,  but rarer cases, the peritoneal cavity is
 nearly obliterated by dense false  membrane, in-
 durated or cellular in parts, or united to the op-
 posite surfaces by large bands ; or then by one
 mass of indurated cellular  tissue, having its
 areolae filled  with  a  gelatinous substance.  In
 some instances the false productions consist
 of several layers, of different degrees of thick-
 ness and density.  They  are not always, as M.
 Gendrin has shown, closely adherent to the
 subjacent peritoneum, being sometimes  sep-
 arated from it either by an effused fluid, or then
 by more recently-effused lymph, owing proba-
 bly to an acute action having taken place short-
 ly before death.
   109. /. In  a few cases the peritoneum pre-
 sents a brownish  or very dark colour, is  less
 dense and coherent than  usual, and is infiltra-
 ted,  particularly in parts, by a  dark-coloured
 blood.   At first sight the membrane seems to
 be gangrenous, but, on examination, it  is not
 disorganized, its surface  being rugose, granu-
 lated, and sometimes elevated by small ecchy-
 moses, or clots of dark blood, effused under its
 surface or in its  substance.  This change  is
 observed only in persons of a cachectic, scor-
 butic, or broken-down constitution.   M. Gen-
 drin views this alteration as a complication  of
 haemorrhagic  congestion with chronic inflam-
 mation.  Occasionally it  is  accompanied with
 an exhalation of bloody serum into the cavity,
 and  very rarely with a puriform exudation on
 the surface.  In this latter case it may be pre-
 sumed that a subacute state of inflammatory
 action had  taken place shortly before death.
   [Andralis of opinion that this melanotic de-
 posite, when  in layers, is nothing more than
 false membrane infiltrated with melanotic mat-
 ter.  Others  contend that the discoloration of
 false membrane does not proceed from mela-
 nosis, but from a blackening of the blood in the
 false membrane by intestinal gases and acids.
 It is also maintained that  genuine melanosis
 in layers on the peritoneum is an independent
 secretion, forming either a  mere pigment on
 the serous  surface, or a more substantial stra-
 tum  of a jelly-like consistence,  enclosed in a
 delicate web-like membrane  of new formation,
 and  capable of being dissected off without in-
jury  to the peritoneum itself.  It  may be doubt-
 ed whether the melanotic deposites which are
 found adherent to the peritoneum, in round pe-
 dunculated tumours, isolated or agglomerated,
 are the result of chronic peritonitis, as they are
 more commonly situated on the omentum, and
 covered  by a fine membranous film of their
 own.]
   110. g. If acute  inflammation have  super-
 vened upon  the chronic,  and  continued  for
 some days, it may produce not only albumin-
 ous  formations, but also vascular injection of
 the part of the peritoneum thus affected.  This
 injection may be either punctated, striated, or
 even general; and in this last case the surface
 of the membrane is sometimes lined with a pu-
 riform or perfectly purulent matter.
  111. C. Tubercular chronic peritonitis, although
 generally assuming a  chronic character, does
 not always commence as such ; and, even when
 it is  primarily chronic, as it is most frequently,
 it may pass into the acute, at least in a partial
 or limited manner.—a. At an  early stage of the
 disease, coagulated lymph, in the form of a soft,
 false membrane of a grayish yellow colour, and
 amorphous, is thrown out upon the inflamed
 surface.  The  organization of this  substance
 soon commences, but  in a morbid state ; small
 whitish grains soon  appear  in this hitherto
 amorphous production, which presents  a  few
 rudimental vessels.  These grains are  diaph-
 anous, more dense than the coagulated lymph
 containing  or  surrounding them, and  from
 which they are readily separable.  When viewed
 by the microscope,  they are  seen surrounded
 by a  vascular net.  The false  membrane forms
 adhesions to the peritoneal  surface that are
 more intimate where these small grains or con-
 cretions,  the  commencing tubercles,  are most
 numerous.  These adhesions soon become very
 intimate, the false  membrane  more vascular
 and more organized ;  and the inflammation, if
 of an acute character,  passes into the chronic
 state ; and the serous surface,  and  the false
 membrane covering it, are still more  intimate-
 ly united, so as to form apparently but one very
 thick coat, in the substance of which the tu-
 bercles  are  developed and  adherent.  This
 membrane is often very vascular, the capillary-
 vessels passing into it  being often very large ;
 the tubercles acquiring considerable  size,  and
 being much larger than the granulations above
 described (y 10tf).  The tubercles do not exist,
 as is the  case with the latter, in the substance
 of the peritoneum, but are  formed within  the
 false productions, and  at the same time with
 them ; while the  granulations are found only
 after these productions are  fully formed, when
 seen on  the  surface of them,  and  in  conse-
 quence of their inflammation.
  112. b. Although tubercles cannot be said to
exist in  the peritoneum itself,  yet  they  are
often found in  the sub-peritoneal cellular tis-
sue, and are to be distinguished in this situa-
tion,  as well as in false productions  or mem-
branes, by  their being always  encysted ;  the
tunic or cyst  arising from the condensation of
the cellular tissue in which the tubercular mat-
ter is effused.  When  these tubercles form in
the  mesenteric or omental subserous  tissue,
they  often reach a larger size than when they
occur in the sub-serous tissue  of the intestines,
and are much more numerous.  Dr.  Hodgkin
remarks,  that in the latter situation they ap-
pear  as if the part were sprinkled with parti- 
90
PERITONEUM—Inflammations  of—Lesions in.
 cles of rice.  They are often surrounded by a
 vascular areola, the  tint of which varies with
 the colour of the blood injecting the capillaries
 forming the areola, and are readily distinguished
 from the miliary granulations found in the per-
 itoneum  itself,  in  the manner  above noticed
 (y 107).
    113.  c. Chronic tubercular peritonitis is often
 associated with ulceration and perforation of the
 intestines, sometimes so extensive, as I have
 occasionally observed, particularly in children,
 as to form direct fistulous communications be-
 tween  distinct  but  contiguous  convolutions.
 These  communications may arise from prima-
 ry ulceration of the mucous coat advancing to
 the peritoneal, and producing consecutive, par-
 tial, or more general peritonitis, of a subacute
 or chronic  form, independently  of tubercular
 formations;  but they are more frequently at-
 tended  by these  formations, and  then it  is
 doubtful,  at least in  some cases, whether the
 ulceration has commenced and proceeded  in
 this way, or  has originated in the situation  of
 the tubercles, which, being softened, are fol-
 lowed by ulceration and perforation of the bow-
 el from without inward.  Dr. Hodgkin remarks,
 that puriform collections, varying from  the size
 of a pea to that  of an orange, sometimes form
 in  those situations in which the  exudation  of
 concrete lymph  is greatest, as in  the  angular
 and lateral parts of the abdomen, and that these
 collections are often attended by ulcerative ab-
 sorption of those points of the  peritoneum in
 contact with them,  the ulceration extending  to
 the subjacent coats, until a communication be-
 tween these  collections  and the canal of the
 bowels  is effected.  The ulcerations thus con-
 sequent, 1st, upon  softened tubercles, formed
 either in the plastic lymph, or beneath the per-
 itoneum ; and, 2d, upon the purulent collections
 just mentioned,  may, severally, give  rise to
 communications  not  only  between different
 parts of the bowels, but even between the in-
 testine  and the  external surface, thereby pro-
 ducing artificial anus.
  114. D. After  this,  as well as  after the pre-
 ceding form of chronic peritonitis,  the perito-
 neal cavity frequently contains  more  or less
fluid, which is usually opaque, of a whitish yel-
low colour, sometimes milky, and occasionally
of an unpleasant or even fetid odour, particu-
larly when this  membrane has been long in-
flamed.—a. In a  few cases the fluid partly con-
sists of a  mucopuriform matter, whitish, of the
appearance of a semi-concrete albumen, mixed
with pus ; in  others it is  nearly puriform, but
much more frequently it is limpid, or it resem-
bles clear whey.  In very rare instances it is
gelatinous, with  a thicker gelatinous or slimy
coating  over all the  inflamed surface.  The
quantity of fluid effused is variable;  sometimes
it is so great as to distend the abdomen ; when
in  smaller quantity, the  cavity is partly  filled
with false membranous productions of a cellu-
lar  texture,  occasionally infiltrated with pus.
In  a few of these cases the inflamed cavity has
its capacity somewhat diminished by a  sinking
inward  of its parietes, an alteration observed
after the disease had  appeared to tend toward
recovery.
  115. b. In those cases attended by liquid ef-
fusion into the peritoneal cavity, the omentum
is contracted or  corrugated  under the  greater
 curvature of the stomach, and often  reduced
 to a small size.   If, however, an old adhesion
 have  taken place between some part of it and
 an  adjoining surface, the omentum is usually
 found extended in the form of a chord  between
 the stomach and the part at which the  adhe-
 sion exists.
   116. E. Dr. Hodgkin remarks, that in chron-
 ic peritonitis the mesentery is  found  more or
 less shortened,  by  which the   intestines are
 drawn up to the spine ;  and if a hernia had ex-
 isted, it will  sometimes be found  completely
 reduced.  The intestines are reduced more fre-
 quently in their length than in their calibre.
 " In extreme cases," he adds,  *' they probably
 lose nearly or quite half their dimensions, and
 the valvulae  conniventes are consequently
 placed close to each other.   This contraction
 of the omentum, mesentery, and intestinal  canal
 seems to  depend on the contractions which
 newly-formed parts  undergo after they  have
 become organized  or  permanent,  as in the
 large  cicatrices  of extensive  burns."  This
 shrinking  evidently  depends  upon  the  false
 membranes covering the peritoneum, and part-
 ly upon the deposite on the attached surface.
 The original structures, also, are probably them-
 selves reduced by absorption ; partly under the
 influence of the contraction of the adventitious
 deposite, and partly  under the pressure of the
 fluid effusion.  These contractions were first
 noticed  and  explained  by Dr. Hodgkin, in his
 work on " the Pathology of Serous Membranes"
 (p. 152).
   117. F. Cartilaginous or semi-cartilaginous in-
 duration and thickening are sometimes met with
 in parts of the peritoneum in consequence of
 chronic  inflammation.  This  change is much
 more rarely seen in this membrane than in the
 pleura ;  but it has been  remarked  by Sandi-
 fort,  Portal, Cruveilhier,  and  others.  I
 have met with this change twice in that por-
 tion of  the peritoneum investing the  spleen,
 and once in that  covering one of the ovaries,
 the situations, I believe, where  this change is
 most frequently observed.
   118. G. Ossification of, and ossific deposites in,
 the peritoneum, have been noticed by authors,
 particularly in the omentum, sometimes in  con-
 nexion with osseous, calcareous, or  cartilagi-
 nous tumours.   Most of these instances are
 not strictly referable to the peritoneum,  this
 membrane being only consecutively implicated.
 Others  are probably only cases of calcareous
 deposits under the peritoneum, resulting from
 ultimate changes in tubercular matter in  that
 situation.
  119.  H. Gaseous fluids are sometimes found
 in the peritoneum, generally in connexion with
 the effusion of serum, and with one or more of
the other lesions already described.   The ques-
tion  as to their source has been often agitated;
but I agree with Baillie, Hodgkin, and others,
that  although  the peritoneum  may, in a state
 of disease, secrete  a  gaseous fluid, yet  that
most generally this fluid is the result o'f cadav-
eric change when found in this situation.  But
there still remains another question : may not
the gaseous fluid  be evolved during the life of
the patient from the  changes in, or partial de-
composition of, the  products of inflammation
lodged in the peritonea] cavity 1  This result is
 by no  means  improbable, when  the quantity, 
                      PERITONEUM—Infla

the nature, and the physical condition of the
effused  fluids are considered,  and when  the
inefficiency of the vital influence  in this dis-
ease to  prevent those changes  to which these
fluids are prone is taken into the account.  My
experience of this disease, particularly in its
asthenic forms,  and in  the puerperal  state,
leads me to infer that the effused fluids actual-
ly undergo in the peritoneal cavity, during the
life of the patient, and at an advanced stage of
the malady, such changes  or such partial de-
composition as produce gaseous fluids, which
aggravate the symptoms, and which, by their
partial absorption, contaminate the blood.  Many
years ago I contended that this was the principal
source of the gaseous fluids sometimes  found
in the peritoneum and pleura in connexion with
the products of inflammation ;  and the opinion
is now entertained by several pathologists.
   120. VII. Diagnosis.—The diagnosis of peri-
tonitis is often extremely difficult, particularly
the partial and  chronic states  of it.  Partial
peritonitis, whether acute or chronic, is so fre-
quently consequent upon,  and associated with,
inflammation of the organ or organs which the
inflamed peritoneum invests, that  it is often
difficult to form  a correct idea as  to the part
affected, either solely or principally.  Still, the
history  of the case, in connexion with its caus-
es and  the  early symptoms, and the grouping
of the existing symptoms especially character-
istic of peritonitis, particularly the abdominal
pain, tenderness, swelling, and tension ; the po-
sition and aspect of the patient; and the states
of the pulse, stomach, and bowels, when duly
weighed, will generally guide the physician to
a  correct conclusion.   Even  in those  cases
which are consecutive of inflammation of the
enclosed viscus, and which are  strictly partial,
the characteristic phenomena of peritonitis are
usually  present, although more  or  less limited
to the situation affected.  These are the acute,
burning, or sharp pain, swelling,  tenderness,
and  tension; the position best calculated to
take off pressure from the seat of disease ; the
sharp and anxious  countenance ;  the quick,
sharp, hard, constricted,  or small  pulse ;  the
short, small, frequent, and thoracic  respiration ;
the dread  of coughing, sneezing,  or of a  full
respiration ;  the retchings, vomitings, or flatu-
lent eructations ; and the symptomatic fever,
in various grades of severity, according to the
intensity  and  extent of  the   inflammation,
whether partial or general; the chief differ-
ence being in the limitation or extension of the
local symptoms.
   121. When inflammation of one or more of
the abdominal viscera is followed  or attended
by these symptoms, the inference that the per-
itoneum investing them  is implicated, or has
become chiefly affected, will generally be cor-
rect ;  and if these symptoms appear primarily,
without any marked  functional  lesion  having
preceded them  of the organs invested by the
peritoneum, to which the symptoms are limit-
ed, it may safely be inferred that the peritone-
um of that region is primarily  and principally
attacked, and the treatment should be directed
conformably  with this conclusion.  The dis-
eases for which  peritonitis is most liable to be
mistaken are, enteritis, gastritis, colic, rheuma-
tism of the abdominal muscles, neuralgic and
hysterical pains in the abdomen, &c.   Of all
imations of—Diagnosis.                   91

 these the diagnosis between enteritis and peri-
 tonitis is the most difficult.
   122.  A.  Enteritis is with great difficulty dis-
 tinguished from peritonitis; and in many cases
 the diagnosis can hardly be made, especially in
 that state of enteritis where the peritoneal cov-
 ering of the small intestines is chiefly affected.
 (See art. Intestines, v 31, 69,  74).  Cullen,
 Wilson Philip, and others have insisted upon
 the difficulty of the  diagnosis in these cases ;
 and when the peritonitis is limited to the serous
 covering of the intestines, or has commenced
 in this situation, it is certainly and necessarily
 very great; for the disease is, in truth, a partial
 peritonitis, becoming more and more extensive.
 Many of the diagnostic symptoms so strongly
 insisted  upon by authors, who have copied their
 descriptions of disease from  those  who have
 written  before them, instead of writing  from
 their own observation,  either are fallacious or
 occur only in certain circumstances.   Thus the
 greater  sensibility or tenderness of the abdo-
 men, and the  more  acute pain,  said  to distin-
 guish peritonitis from enteritis,  cannot be de-
 pended upon,  for these will depend, in either
 case, upon the susceptibility and sensibility of
 the patient and the intensity of the disease.
 Neither can the states of the bowels be always
 viewed  as offering  any  indication  of  impor-
 tance.   The confidence, indeed, with which di-
 agnostic symptoms have been advanced by some
 recent writers  tends more to mislead than to
 instruct the inexperienced.  After long expe-
 rience and tolerably close observation, I  may
 remark, that all diagnostic symptoms, particu-
 larly between these diseases, should be  cau-
 tiously estimated ; and  although it may not be
 of much importance, as  respects the treatment,
 whether or not the one malady be distinguish-
 ed  from the  other,  still something may be
 gained, in  this regard, as well as respects the
 prognosis, by a greater precision of information.
   123.  In the more  general states of peritoni-
 tis the diagnosis is often not so  difficult as in
 those just  adverted  to,  or when  the intestinal
 peritoneum is inflamed.   Here there are often
 observed,  although  not  always,  greater  and
 more general, and  more  superficial pain  of a
 burning  or acute  kind  ; greater  sensibility to
 pressure ;  more remarkable  swelling and ten-
 sion of the abdomen; less tolerance of motion
 of  the body and of the  abdominal muscles ; a
 greater dread  of coughing, sneezing, and  of a
 full respiration, and  less motion of the  dia-
 phragm, than in enteritis. Vomitings or retch-
 ings are generally not so early nor so frequent
 in  peritonitis  as in  enteritis, although often
 equally  so in an advanced stage of the former;
 but in many instances they are not very urgent
 until  the disease is verging towards a fatal ter-
 mination.  The bowels  are usually constipated
 in both  maladies, unless in the more asthenic
 states of peritonitis, when they are sometimes
 even  relaxed, especially in the low, infectious
 form  of puerperal peritonitis.
   124.  B.  The other diseases which are said
 sometimes to simulate  peritonitis can  hardly
 be confounded with it, if due attention be paid
 to the symptoms.—a. Gastritis will not be mis-
 taken for it if the abdomen be  carefully ex-
 amined  ; for the seat of pain, the desire of cold
 fluids, the  thirst, and early vomitings, always
 following the ingestion of fluids,  will generally 
mmations  of—Diagnosis.
92                   PERITONEUM—Infla

indicate the affection of the stomach.   If the
peritoneal coat of this viscus is inflamed, the
disease may be considered either as a form of
gastritis, or as partial peritonitis, according to
the views of the physician ; but this portion of
the peritoneum is the most rarely affected, at
least alone, and in this climate.  Some aid may
occasionally be afforded in this case, as well as
in others,  by auscultation; for,  although  the
motions of the diaphragm are generally  slight,
yet sometimes an imperfect or obscure rub-
bing sound is heard, with the respiratory  move-
ments, in the sthenic forms of peritonitis ;  and
when much affusion takes place, and percussion
is tolerated, a dull sound is emitted where the
affusion is considerable.  These modes  of ex-
amination may assist in distinguishing peritoni-
tis from  the  diseases just noticed, as well as
from colic and some other maladies.
  [We believe that Dr. Beatty, of Dublin, first
called the attention of the profession to  this
physical  sign  in peritonitis in the year 1834.
(Dublin Jour. Med. 6r Chirurgical Science, Sept.,
1834.)  " In Jan., 1832," says Dr. B., " a wom-
an, aged  30,  was admitted into  my ward for
the diseases  of females, in the City of Dublin
Hospital, labouring under dropsy of  the  left
ovarium.  The tumour filled the abdomen from
the pubis to  the ensiform cartilage,  and was
remarkably hard and unyielding.  A few days
after admission, she was attacked with severe
pain in the belly and febrile  symptoms,  which
continued for a week, and required the  abstrac-
tion  of blood, and other  antiphlogistic  treat-
ment, before she was relieved;  during  which
time a remarkable  sensation  was communi-
cated to  the  hand when applied  over  the  um-
bilicus and its neighbourhood.   The sensation
was that of a grating or rubbing together of
two uneven and rather dry surfaces, and  was
rendered most evident by ordering the patient
to take a full inspiration, thereby causing the
abdominal parietes to move more freely over
the surface of the tumour.  By the application
of the stethescope, a loud  and distinct '  frotte-
ment' was audible, extending over a space of
about five inches in diameter, with the umbili-
cus for a centre.   In a few days the pain  and
inflammatory symptoms  subsided, under  the
treatment employed, and, with them, the  sensa-
tion just  described, and the audible phenomena
altogether disappeared."—Loc. cit.
  Sementini states, that in all cases  of peri-
tonitis, in whatever part of the abdominal cavity
the inflammation is seated, there is pain in the
pubes and upon the great trochanters ; which,
if not spontaneously felt, is always developed
by pressure, and of which the severity is di-
rectly proportionate to that of the peritonitis.
This fact, if, indeed,  it be such, may be  ex-
plained by the relation of the nerves  of the
parts, in which the pain is felt, to the peritone-
um, and by its connexion with the fasciae  and
muscles about them.   In addition to its value
in the diagnosis of even the most obscure and
latent cases of peritonitis, in all  of which, we
are told, this sign is present in a degree propor-
tioned to the severity of the  disease,  Dr. S.
has found it of value as an indication of treat-
ment, and has obtained great benefit from the
application  of leeches and  blisters  over  the
trochanters, instead of on the abdominal walls.
—Annaii Univ. di Med., Sept., 1840]
  125. b. Certain states of colic sometimes re-
semble peritonitis, especially when the former
is attended by much abdominal distention and
pain ; for I have seen in some instances the
tenderness on pressure so  great, owing to the
stretching of  the peritoneal covering of the
bowels by the  flatus distending them, as to re-
semble peritonitis.   In these the absence of
fever, the state of the pulse, the cool or natural
temperature of the  abdomen, and other con-
comitant symptoms, will guide the  physician.
Still, the occasional supervention of peritonitis
or enteritis  in these cases should be kept in
recollection.   In the  more common states of
colic, when pressure is tolerated, or even gives
ease,  there can be no mistake as to the nature
of the disorder.  (See art. Colic)
  126. c. A hysterical form of colic and a hys-
terical state of  neuralgia may somewhat resem-
ble  peritonitis, chiefly owing to  the apparent
tenderness of the abdomen, which, however, is
tolerant of firm pressure unexpectedly made on
it.  In these  cases  the presence of other hys-
terical symptoms, the borborygmi, and the flatu-
lent state of the digestive canal;  the situation
of the pain, and its. connexion with uterine ir-
ritation,  and  occasionally with  tenderness in
some portion  of the dorsal or lumbar spine;
the absence of fever and of several other in-
flammatory symptoms ; the states of the urine
and of the catamenia, &c., will generally indi-
cate the nature of the disorder.   I have, how-
ever,  met with cases of hysterical colic, in con-
nexion with dysmenorrhcea, where the extreme
tenderness, the acute pain and tension in the
lower regions of the abdomen, the retchings
and vomiting,  and the disturbance of the circu-
lation induced a dread of inflammation of the
portion  of the peritoneum  reflected over the
uterine  organs ; and, most  probably, the con-
gestion  of these organs had so  affected the
peritoneal covering, either by stretching or in-
jecting it, as to develope its sensibility, the re-
moval of the  congestion by the  supervention
of the discharge  removing, also, the suffering
with the cause.
  127. In all  cases, when  the abdominal ten-
derness of hysteria most closely simulates peri-
tonitis, a remarkable incongruity of symptoms
is observed.   The states  of the countenance,
of the pulse, of the tongue, of the evacuations,
and of respiration are inconsistent  with peri-
toneal inflammation.  The breathing is hurried
and laborious, and  not suppressed, short, and
shallow, as in  peritonitis ; the pain and tender-
ness shift, or suddenly appear and as suddenly
depart; the catamenia are usually more or less
disordered ;  and leucorrhcea is often present.
In the hysterical affection the state of the tem-
per and of the moral feelings, and  the frequent
occurrence of other hysterical symptoms, often
of themselves sufficiently characterize the dis-
order.
  128. d. Rheumatism rarely affects  the ab-
dominal muscles, but when it does it may be
mistaken for peritonitis, owing to the intense
pain felt on pressure and  motion.  Dr. Parr
states that the pain in  rheumatism of these
muscles is felt chiefly at their origins and inser-
tions, shooting to  the false ribs  and spine of
the ilium.  This, however, does not agree with
my observation; for I have considered the
sheaths and aponeurosis of the abdominal mus- 
PERITONEUM—Inflammations of—Prognosis—Causes.
93
cles to be the chief seat of the rheumatic affec-
tion in those cases which I have seen.  A care-
ful examination of the abdomen, the state of
the countenance, and the absence of retchings,
and of the chief symptoms characteristic of per-
itonitis, will readily indicate  the nature of the
disease.  It should, however, be kept in recol-
lection that acute rheumatism of these muscles
may be  followed  by peritoneal inflammation.
Such instances  are rare, but I have met with
two  or three.   The pains and  girding sensa-
tion, or feeling of tension around the abdomen,
often attending irritation  and inflammatory ac-
tion  in the spinal  chord or its membranes, can
hardly be mistaken for peritonitis, if the least
attention be paid to the history  and symptoms
of the case.
  129. VIII. Prognosis.—A. At an early pe-
riod  of acute sthenic peritonitis, much confidence
may be  entertained in a  favourable result, al-
though considerable danger  should be appre-
hended until  the  good effects  of  active  and
prompt treatment become apparent.   If, how-
ever, those effects are not manifested soon af-
ter the measures  have been resorted to that  I
am  about to  advise at an early stage of the
malady; if the  disease have  advanced far be-
fore suitable treatment was adopted; if indica-
tions of any of the unfavourable terminations
mentioned above (v 32, et seq.) have appeared ;
and  if the case presents the asthenic  form, or
a complicated state, an unfavourable prognosis
should be given ;  but hopes of recovery should
not  be entirely relinquished.   The prognosis
of peritonitis occurring in the puerperal state de-
pends upon various circumstances peculiar to
this state, and must be considered in connexion
with Puerperal Diseases.
   130.  The most favourable indications are fur-
nished by the symptoms already enumerated
of resolution of the inflammatory action (<J 31)
by a subsidence of all the  painful and urgent
symptoms.  On the other hand, if the symptoms
increase in severity, especially  after judicious
means have been administered ; if the heat of
the  abdomen augment, or is more harsh ; if the
 vomiting become  more urgent;  the pulse more
 frequent, smaller, irregular, or intermittent; the
countenance  more anxious  and collapsed, or
 the  extremities cold or clammy ; if the breath-
ing  be very short, interrupted, painful, and at-
tended by distress and restlessness ; if singul-
tus  supervene with or without meteorismus, or
apumping-up of the contents of the stomach, or
eructations of fluid matters,  and if constipation
be obstinate,  no hopes of the recovery of the
patient should be  entertained.
   131. The causes of the disease, and the vari-
ous  circumstances and complications attending
and  characterizing particular cases, should be
duly estimated before we form or give an opin-
ion as to the result.  Thus, peritonitis caused
by perforation of the stomach or intestines, or
that appearing in  the  advanced course of con-
tinued and exanthematous fevers, or following
abscess  in, or the  rupture of, any viscus, rarely
or never admits of complete recovery.  Peri-
tonitis, also, following surgical  operations in-
volving  the peritoneum, and that caused by or
consequent upon, or connected with, erysipelas,
is attended  by very great danger, particularly
in the crowded wards of an hospital, or in an
impure  atmosphere.  Various  other  circum-
stances of only casual  occurrence will  also
weigh with the intelligent physician when he
forms his prognosis in any case.
  132.  B. The chronic forms of peritonitis  very
rarely admit of recovery in any case which is
distinctly characterized.   The slighter or  even
partial states, following the  acute, may, how-
ever, be  removed  more or less  completely by
careful treatment and regimen, especially when
affecting persons not far advanced in life, and
of an  otherwise good constitution ; but the
more general form of primary chronic peritoni-
tis, and still more particularly the tubercular
complication of it,  should be considered as en-
tirely hopeless, although life may be prolonged
for some months.
  133.  IX. Causes.—The causes of peritonitis
are many of those which most  frequently oc-
casion  inflammation of other internal viscera
and  external  parts  (see Inflammation, v 91-
121); but there are  some  causes which de-
termine  more especially  the  development of
this  disease, and which may be more particu-
larly adverted  to.—a.  Many of these act directly
upon the seat of inflammation; as wounds,
operations,* bruises, lacerations, ruptures, dis-
placements, strangulations of parts, &c, impli-
cating  the peritoneum more or less ; great or
unusual stretching or distention  of this mem-
brane ; the passage into its cavity of matters
foreign to it,  as blood, chyle, bile, faeces, pus,
tubercular matter  or  other morbid secretions,
&c.; invaginations of portions of the bowels,
or stricture or undue pressure of parts of them,
or of the omentum by tumours, bands of old
adhesion; inordinate  and continued pressure
by or on surrounding or adjoining parts, and
prolonged and unusual exertion  of the abdom-
inal  muscles, &c.
   134. b. Other causes act from contiguity, as
pre-existent disease of some viscus covered by
the peritoneum, especially dysentery, diarrhcea,
and  ulceration of the stomach or bowels  ; en-
largements or tumours of subjacent parts ; in-
flammation of any of the  viscera or structures
enveloped by this membrane, particularly of the
intestines, urinary bladder, uterus, ovaria, liver,
and  spleen ; and malignant or other structural
lesions of adjoining parts.   This class of causes
generally occasion partial or limited peritonitis.
   [Peritonitis from  perforation  of the  serous
membrane is  not an  unfrequent affection, and
may generally be distinguished by the sudden-
ness of the attack, and the rapidity with which
the disease runs on to a fatal termination, in
spite of all medical treatment.  The causes of
this  accident are,  1st, external injuries, eithei
of the  solid or hollow viscera of the abdomen,
or of the parietal peritoneum merely; 2dly, rup-
ture  of the bladder from distention, and of the
uterus during parturition ; 3dly, rupture of some
portion of the digestive tube, from softening of
its coats ; 4thly, ulcerative perforation  of the
serous  membrane, arising either from disease
in any  part of the  subdiaphragmatic portion of
  [* Most cases of the Cesarean section terminate fatally,
from consequent peritoneal inflammation.  Operations for
tying- the iliac  arteries often cause death in the  same
way, as in a recent case, where the internal iliac was tied
by Mr. Liston,  of London, for a wound of a superficial
artery  of the thigh,  received in a  duel.  Owing to the
great danger of this result, operations for removing ovarian
tumours are, in our judgment, altogether unjustifiable, and
should be abandoned.] 
94
PERITONEUM—Inflammations of—Treatment.
•
the digestive tube ; from suppuration of the solid
viscera opening into the peritoneum ;  from ul-
ceration of the bladder,  or ovaries ;  or from
perforation of the diaphragm by purulent col-
lections on its thoracic surface.  There can be
no doubt that ulcerative  perforation of the in-
testinal tunics often takes  place,  especially in
typhoid fever, without an  escape of the con-
tents of the canal into the abdominal cavity,
owing to adhesions being formed between the
two surfaces of the peritoneum at a point cor-
responding to the situation of the ulcer.  Again,
owing to inflammatory adhesion, and subse-
quent  ulceration  of different  portions of the
intestinal tube, we sometimes find communica-
tions thus formed, the foecal contents thus pass-
ing across the serous membrane without enter-
ing its cavity.   We often  meet with perforating
ulcers of the digestive tube communicating with
the solid viscera, as where the  base of an ulcer
of the colon is formed by the tissue  of the kid-
ney, and ulcers of the  stomach resting on the
spleen, or of the duodenum on the liver ; in all
these cases effusion into the abdominal canal is
prevented—a cicatrix is formed, and the health
of the individual preserved.  In these  cases
circumscribed peritonitis only ensues, and they
are generally the consequence of chronic dis-
ease, so that time is afforded for the exudation
and organization of lymph.
  This  disease most frequently, however, oc-
curs from a perforating ulcer of the  lower por-
tion of the  ilium,  consequent on acute disease.
The  following remarks of Louis are  worthy of
record : " The patients who have been the vic-
tims of this disease were young and vigorous,
with the exception of the first, who was weak
and of a lymphatic temperament; they  had a
good constitution, were rarely ill, not addicted
to excess, and presenting a  sanguine, a bilious,
or a lymphatic sanguine temperament.  Almost
all had  been but a short  time in  Paris.  The
causes of their disease were unknown.  If we
except a single case, it  commenced as a slight,
continued fever, and presented no severe symp-
tom before  the period of the perforation ;  in but
one patient was there a severe diarrhcea, which
was, however, of but  short continuance;  in
another it had been moderate ; still  less  in the
subjects of the second and sixth cases, and not
occurring in the remainder.   Those with whom
the diarrhcea was for a short time severe had
slight pains in the epigastrium, and more severe
pains in other portions of the  abdomen, while
in the remainder they were very slight, or not
at all present before the period of perforation.
Three of them believed themselves convales-
cent, and were considered  so  for some days,
when the symptoms of  this lesion occurred.  A
fourth seemed to have  been cured rapidly of a
slight enteritis ; so that not only in  these four
subjects nothing occurred which could lead to
the anticipation of the disease under which they
sank, but it would have been absurd, from the
mildness of their symptoms, to have apprehend-
ed any serious consequences ;  and at this mo-
ment we have before  us the history of many
patients who have died from an acute perfora-
tion  of the intestine, and who, with this ex-
ception,  presented  no  symptom which  could
distinguish them from  analogous cases, where
there was a rapid return to  health.  If the pe-
riod of the  formation of these ulcerations can-
 not be accurately determined, we shall scarce-
 ly be far from  the  truth in supposing  that it
 coincides with the first symptoms of the dis-
 ease,  from  which  it  would result that the
 progress  of these ulcerations has  been very
 rapid, and that  they have arrived at their last
 period in from twelve to twenty five days, rare-
 ly later.
   " At  a certain period of the disease,  on ac-
 count of which  the  patients had entered the
 hospital, they experienced suddenly an  exqui-
 site and tearing pain of the abdomen, rapidly
 followed by alteration of the features, nausea,
 and vomitings, &c.   These symptoms continu-
 ed with greater or less  violence from twenty to
 fifty-four  hours,  presenting  remissions  which
 were more or less well marked, and indicating
 a most intense  peritonitis, produced by a vio-
 lent cause acting in a  hidden manner, just as
 occurs when an  irritating substance is applied
 to the surface of the peritoneum.   It is  by the
 reunion of these signs that the lesion that now
 occupies us has been recognized by MM. Leb-
 minier, Chomel, and  Martin  Solon,  under
 whose  care the patients were.   From these
 circumstances it appears that we may regard
 the following as characteristic signs of perfo-
 ration of the intestine  : if in an acute disease,
 and in an unexpected manner, a violent pain of the
 abdomen suddenly supervenes,  if this pain is ex-
 asperated by pressure accompanied by rapid alter-
 ation  of the features, and more or less promptly
 followed by nausea and  vomiting, we may  believe
 and announce that there is a perforation of the in-
 testine."  (Recherchcs Anatomico-Pathologiques,
 Paris, 1826 )]
   135. c.  Certain causes occasion peritonitis
 through the organic and vital actions, and the
 circulating fluids, there  being, however,  a pre-
 disposition in the peritoneum, or some part of
 it, to  become affected, or pre-existing circum-
 stances determining the inflammatory action to
 this membrane.   Many of the causes just enu-
 merated may be merely determining influences
 in developing the morbid action in this situation,
 other causes affecting  primarily the vital and
 circulating functions, and producing the inflam-
 matory diathesis or constitution.  Of these lat-
 ter, the most frequent  and influential are, ex-
 posure  to cold,  humidity, or both conjoined,
 and to  currents  of cold air ; sleeping on the
 ground  or in the open  air, or in damp beds or
 bed-clothes ; sitting in  wet clothes ; the con-
 taminating or infecting influences of foul air,
 or of animal miasms upon injuries, wounds, &c,
 communicating either directly or indirectly with
 the peritoneum ;  the suppression of accustom-
 ed discharges or evacuations,  and of determina-
 tions  of blood from more external parts; the
 retropulsion  of cutaneous eruptions, of rheu-
 matism, erysipelas, &c.; repeated attacks of
 ague, occasioning vascular determinations to
 the liver and spleen, and unusual stretching of
 the investing peritoneum, favouring the super-
 vention of inflammation of it; changes  in the
•state  of the  blood, as  respects both quantity
 and quality;  and the puerperal states, and the
 various circumstances  attending them.   (See
 Puerperal Diseases.)
  136. X. Treatment.—Having described the
 several  states of local and general morbid ac-
 tion characterizing this malady, their varying
 consequences, and their complications, each of 
PERITONEUM—Inflammations of—Treatment.
95
which requires a different or modified plan of
treatment, it becomes necessary that the means
appropriate to each of them should  be  fully
stated.   In every case, however, the treatment
ought to be conducted according to its individ-
ual features and circumstances ; but in all, the
measures should not only be efficient, but they
should also be  promptly  employed, and  with
due reference to the stage and  progress of the
disease, and the other peculiarities of the case.
   137. i. Treatment of Acute Peritonitis.—
A. Acute sthenic peritonitis, whether partial or
general, requires a prompt recourse to measures
calculated, 1st, to arrest the inflammatory ac-
tion locally, and the general febrile commotion ;
2d, to prevent the most injurious consequences
of inflammatory action from supervening, and
to remove  them, as much as may  be  possible,
if already they have more or less taken place.
These objects  comprise  all  the   indications
which have been paraded by some writers, and
which can rarely be individually  followed  or
even mentally recognised in the course of prac-
tice ;  the intention being  to take the shortest
and most  efficient  method  of accomplishing
these ends.  It should always  be  recollected,
when treating this form of the disease, that,
although most frequently commencing in a par-
tial or limited form, it may rapidly become more
and more extended,  sometimes unexpectedly;
and that the surest means of preventing this
extension are active and prompt measures rel-
atively to the constitutional  powers of the pa-
tient.
  138. a.  First.  To arrest  the morbid action,
whether more or less extensive, or of longer
or shorter duration, the  most antiphlogistic
measures are required, and should be energeti-
cally employed, particularly in the more violent
cases, and during an early stage of the disease,
or before indications of much effusion into the
peritoneal cavity, or of a  very  general exten-
sion of the disease, present themselves.   In
these latter circumstances the  powers of life
are often too far depressed by the extent and
severity of the morbid action—the constitution-
al energy has  sustained too severe a shock,  at
least  in many instances—to admit of very ac-
tive antiphlogistic means, or too copious deple-
tions, especially at such an advanced stage of
the disease as these changes characterize.  Du-
ring the earlier  periods of this form of the
malady, and  particularly in  young and robust
or plethoric persons, venesection should be re-
sorted to, in the  manner so frequently recom-
mended in this work (see article Blood, (/ 64,
et seq), and blood taken until a marked  impres-
sion is made upon the pulse, but short of faint-
ing, for the reasons elsewhere  assigned.   Im-
mediately after the depletion, full or even very
large  doses of calomel and opium—from five to
fifteen, or even twenty, grains  of the former;
and from one and a half to three, or even four,
of the latter—ought to be given.  These will
generally have the effect of allaying irritability
of the stomach, of equalizing the  circulation,
of procuring perspiration or a relaxation of the
skin, and of keeping down the vascular action
to the point to  which it was brought by the
blood-letting.
  139. If these effects are not produced in the
course of a few hours, and more especially if
the pulse  still  continue hard or  constricted,
 and the abdomen tense and  tender, or if the
 pulse should begin to rise, and the pain to in-
 crease or to return, blood-letting should be again
 practised, generally in smaller quantity, and be
 followed, as before, by a repetition of the calo-
 mel and opium, in the same, or in somewhat re-
 duced doses, according to the effects produced
 by the former.  In this disease, and more espe-
 cially  at an early period of  it,  the physician
 should not be deterred from blood-letting by the
 smallness of the pulse ; for the  pulse will be-
 come fuller and softer, and often  less frequent,
 as the depletion proceeds. It may be necessary,
 in some cases, to repeat the blood-letting a third
 time in the  manner already recommended, and
 to follow it by the calomel and  opium as be-
 fore ; but in most  instances of this form of the
 malady this will not be requisite, and in many,
 where a doubt may exist as  to  its propriety,
 leeches may be placed on the abdomen, in num-
 bers according to the severity and other cir-
 cumstances of the case; and be followed by
 fomentations, &c, and by calomel and opium, in
 doses suggested by the quantity and effects of
 those already taken,  and by  the  period which
 has elapsed between the exhibition  of them.
   140. Having carried vascular depletion as far
 as may prudently be attempted, and  having em-
 ployed calomel and opium as now advised, the
 disease will be either entirely or  partially sub-
 dued.  If, however, pain, distention, and ten-
 derness  of the abdomen still remain—if the
 stomach be  irritable, and the  bowels constipa-
 ted, the gums or tongue indicating no incipient
 mercurial action—the calomel and  opium may
 be again exhibited in quantities  suggested by
 circumstances,  and  several  folds  of flannel
 should be wrung as dry as possible out of very
 hot water and  freely  sprinkled with spirits of
 turpentine, and placed over the abdomen, and
 covered by oiled silk or by napkins, so as to con-
 fine the terebinthinate fumes as much as possi-
 ble to the part.  This fomentation ought to be
 applied as long  as it can be endured, and even
 be repeated in many cases.  The  admirable ef-
 fects of it have been proved  to  me on many
 occasions at this stage of the  malady, both be-
 fore  and since  I wrote in favour of it in  1821.
 (See  a Memoir  on Terebinthinate  Remedies in
 Disease,  in Lond.  Med.  and  Physical Journ.,
 vol. xlvi., p. 107, 185.)
  141.  The usual effects of this application, af-
 ter the  measures  advised to  precede  it have
 been duly employed,  are a diminution  of the
 abdominal pain, distention and tenderness, and
of the irritability of the stomach  ; a reduction
of the frequency of the pulse, which becomes
fuller and softer;  and a general  diffusion of
heat, usually with perspiration over the surface
and extremities.
  142.  b.  It is  possible still that the above en-
ergetic means may fail, both in arresting the
progress  of the malady  and  in affecting the
gums and tongue in the way which is desired.
It should, however, be recollected that many
 cases will proceed  favourably,  and to complete
 resolution, without any mercurial effect upon
these parts; but when such  effect begins to
appear, it should be viewed as  a favourable in-
dication,  and the calomel should either be relin-
quished or much reduced in  quantity, as this
effect may rapidly  increase.  If, however, nei-
ther of these beneficial influences appears to 
96
PERITONEUM—Inflammations of—Treatment.
follow, depletions being no longer admissible,
and the terebinthinate embrocation having also
failed, a blister, or the vesicating fluids recently
introduced, may be applied over the  abdomen,
and vesication be promoted by a warm bread-
and-water  poultice.  Afterward,  the  cuticle
should be removed, if the symptoms  persist,
and mercurial ointment  be applied,  either on
the surface of a poultice or in the usual way.
The object in thus persisting in the use of mer-
curials, as now proposed, is not  only to aid in
arresting the inflammatory action, but also to
prevent the more serious of those consequen-
ces, namely, albuminous exudations and serous
effusions, which frequently result. They should
be exhibited from the commencement of treat-
ment, in full, or in  frequently repeated doses,
conjoined with opium, so as to aid the blood-
letting in  making an early and  energetic im-
pression on the disease, and not be delayed un-
til an  advanced period.
  143. I have been called to cases where blood-
letting has been  pushed  too far,  with the mis-
taken idea that the  frequency of the pulse is to.
be reduced by it.  But, although this effect is
often observed when blood-letting has an imme-
diate influence on the disease, and in healthy or
robust persons, yet in other circumstances, par-
ticularly in weak, or nervous, or irritable con-
stitutions, the pulse will more frequently  be-
come  quicker, and even sharper, from the repe-
tition  of it.
  144. B.  There are three symptoms which often
increase the difficulty of treating peritonitis and
augment the severity of the disease, and which
are often aggravated by  the mode of treating
them.  These are the irritability of  the stom-
ach, the constipation,  and  the  flatulent  dis-
tention of the bowels.  To each of these I ad-
vert.—a. The sickness and retchings at an early
stage  of the malady are  best encountered by
calomel and  opium  as above advised, and by
turpentine fomentations, after bleeding has been
duly resorted to, aided in some cases by crea-
sote conjoined with the calomel and  opium,  or
by hydrocyanic acid.   The attempts to allay this
symptom by effervescing draughts are general-
ly futile, for the stomach readily reacts upon the
distention caused by these draughts and throws
off the ingesta.  Neither ought  much fluid  or
cold fluids to  be  given ;  the mouth and throat
should be  merely rinsed  with tepid  fluids,  or
small  quantities of them only be sipped.  The
retchings or pumping up of the contents of the
stomach, characterizing a fatal issue in extreme
cases, and often associated with singultus, will
not be removed, and seldom even alleviated by
any means whatever.
  145. b.  Constipation is frequently  removed,
even when most obstinate, by the treatment 1
have advised, without having recourse  to pur-
gatives.  I have often seen much mischief re-
sult from the  officious interference of the prac-
titioner in these cases ; the irritability of the
stomach and  the severity of the disease being
heightened by repeated endeavours to operate
on the bowels by drastic purgatives  given by
the mouth.  It is best, at an early stage of the
disease, to wait  the effects of the treatment
advised above for a reasonable period, and then
to have recourse to enemata containing spirits
of turpentine, with  castor or olive oil, or with
both,  in a thick decoction of barley.  These
 may be repeated from time to  time, until the
 bowels are sufficiently evacuated, without any
 dread of the complaint being aggravated either
 by their  frequency or the amount of the ingre-
 dients.   At a somewhat  advanced period of the
 disease, particularly when the irritability of the
 stomach has been removed by the calomel and
 opium,  and  much flatulent distention of the
 bowels still  continues,  from  two  or three
 drachms, or half an ounce, to six drachms each
 of spirits of turpentine  and castor oil may be
 taken on the surface of milk or peppermint wa-
 ter, and  repeated according to  circumstances.
 I have often seen this medicine productive of
 great advantage ; and, at a still  more advanced
 stage of the malady, it has remained  on the
 stomach, although vomitings, unattended by ef-
 fort  or by retchings, were  present,  and every
 thing besides was instantly rejected.
   146. c. Flatulent distention of the abdomen
 may continue, and perpetuate pain and  tender-
 ness  after inflammatory action has been re-
 moved or much reduced.   In these cases the
 flatulence is the result chiefly of the lost tone
 or contractility of the coats of the bowels ; and
 the distention by  gaseous fluids of the tender
 and inflamed peritoneum, or of the peritoneum
 independently of  inflammation, develops the
 sensibility of this tissue, and indicates a great-
 er amount, or a longer persistence, of inflam-
 mation than actually obtains.   A recurrence
 to blood-letting in any  form in such circum-
 stances,  which, as I have had reason to know,
 is not an infrequent practice, and was formerly
 much  more  so,  is  generally most  injurious.
 The good effects of terebinthinate enemata and
 embrocations in these circumstances are almost
 always remarkable, and are still more so when
 the spirits of turpentine are taken internally, ei-
 ther as just advised or in other forms, in which I
 have so often prescribed this medicine and rec-
 ommended it in the course of this work.
   147. d. It was advised by the late Dr. Sut-
 ton  of Greenwich, and by some German phy-
 sicians, by whom I have seen many years ago
 the practice adopted, to  apply cold or evapora-
 ting lotions, or ice, to the abdomen in peritonitis.
 If the  practice is admissible at all, it is in this
 form of the disease, and at an early stage of it,
 that it should be employed.  My recollections
 of it are  not, however, such as would induce
 me to recommend it, while my  experience of
 the practice I have prescribed above has been
 so long and extensive as to fully warrant my
 commendations.  Dr. Symonds,  however, re-
 marks that, in some cases, cold evaporating lo-
 tions have seemed preferable to  other applica-
 tions,  the  evaporation  being accelerated by
 blowing the surface by a common bellows ; and
 that he has placed the patient in a warm bath,
 sufficiently long and shallow for him to lie ex-
 tended,  and for the  tumid  abdomen to  rise
 above the level, so  that a jet  of cold water
could be poured upon the latter.  " The relief,"
he adds,  " has been most striking, even when
the disease was too far advanced for a cure."
(Op.  Cu., p. 145.)
  148.  e. When the disease yields, as it usual-
ly  does, to the above means, when early em-
ployed, and the indications of resolution appear,
little more is requisite  than attention to the
state of the secretions and  excretions,  which
should be promoted by gentle alteratives and 
PERITONEUM—Inflammations of—Treatment.
97
   aperients, aided by an  occasional recourse to
   oleaginous or emollient enemata.   As the pulse
   usually continues  frequent for some time after
   the other symptoms subside, owing to  loss of
   blood  and debility, this circumstance  should
   neither create alarm nor lead to an officious or
   unnecessary interference.   A  premature re-
   course  to tonics or stimulants, or to an exci-
   ting diet or heating regimen, would be injuri-
   ous, and lowering  measures, on the other hand,
   would only protract  convalescence.  In this
   state mild diaphoretics  and diuretics,  as the
   camphor  mixture, with the liquor  ammoniae
   acetatis and spiritus aetheris nitrici, will gener-
   ally prove both safe and beneficial;  while the
   functions of the skin should  be promoted by
   warm baths, by warm clothing, by flannel worn
   next the skin, and by  avoiding  the exciting
  causes.  The lower extremities should always
  be kept warm ;  and  the bowels and urinary
  functions ought to receive  the strictest atten-
  tion long after the  patient has recovered.
    149. C. The second object, namely,  to prevent
  the injurious consequences of peritonitis,  and to
  remove such as may  have been already produced, is
  best  accomplished by a  prompt and  judicious
  recourse to the measures already recommend-
  ed.   But the physician may have  been  called
  too  late to prevent these consequences ; the
  disease  may have  advanced to  that stage at
  which one or other of the  more unfavourable
  results described above  (Y 33,  et seq.) has ei-
  ther supervened or is  in progress.   If effusion
  have taken place, or is even proceeding, blood-
  letting in any form may be of little use, or even
  injurious.  Still, it  may be practised with due
  caution while the  pulse  retains  some  power
  and is not very frequent, and when the patient
  is young, and his vital powers not remarkably
  depressed.  In similar circumstances, also, cal-
  omel and opium may be prescribed and repeated
  from time to time ;  although, at this late period
  of the malady, the mercurial effect on the sys-
  tem  may not be  readily,  or  even at all, pro-
  duced.   A few grains of  camphor, added to the
  calomel and opium, will often be  of service in
  these cases.  The terebinthinate fomentation over
 the abdomen, and terebinthinate enemata, a ter-
 ebinthinate draught, also, being occasionally
 given,  are most important measures in  these
 circumstances, whatever may be the amount or
 the exact nature of  the lesions produced by the
 inflammation.   Vesicatories,  followed  by poul-
 tices,  with or without  mercurial ointment, as
 circumstances indicate, may be applied to the
 abdomen, as  above  advised (y 142); but they
 require discrimination,  especially as to the pe-
 riod of their  application.  In most instances
 they  should be large and efficient.   In  some
 cases a prolonged discharge from them may be
 procured in the usual way  ; and, when the gums
 have not been affected by  the mercurials previ-
 ously given, the application of mercurial  oint-
 ment to their  surfaces, the  cuticle being re-
 moved, will often produce a local and constitu-
 tional effect.  In other cases a repetition of
 blisters may be requisite, while mercurial alter-
 atives and aperients, as Plummer's pill  with
 soap, the bi-borate  of  soda  with the watery
 extract of aloes, &c, and oleaginous or emollient
 enemata, are being employed.   In some instan-
ces, especially when much liquid effusion has
taken place in  the peritoneal cavity, 1 have di-
    III              7
   rected the following embrocation, sprinkled on
   two or three folds of flannel, to be applied over
   the abdomen, and kept there for a considerable
   time, or even worn for some days, when the
   amount  of irritation produced by it admits of
   its continued  application.   In  other  circum-
   stances a repeated recourse to it should be in-
   sisted on:
    No.  307.  R  Linimenti Camphors coinp. :  Linimenti
   Terebinth.; Olei Olivse, 55, fjss; Olei Cajuputi, 3jss. M.
   Fiat Embrocatio vel Liuimentum.
   When the physician is called late in  the  dis-
   ease to a case of acute peritonitis, it is  prone
   to pass  into the  chronic state ; and this may
   be the most favourable result which can be an-
   ticipated from the extent of lesion already pro-
   duced.  In these instances the treatment about
   to be  mentioned as appropriate to the  chronic
   disease  is in many respects  the same  as that
   now advised, and should be resorted to, taking
  care, however, not to reduce the powers of life
  so low as to render them unable to resist  the
  extension of the morbid changes.
    150. D. The treatment of acute asthenic peri-
  tonitis (y 26)  is  rarely entered upon with any
  hopes of advantage, unless at the commence-
  ment,  or  at an early stage of the malady ; and
  then the most energetic means are required to
  arrest its progress, and even they will frequent-
  ly fail  if they be not employed with discrimina-
  tion, the extension and course of the disease
  being extremely rapid, and effusion quickly su-
  pervening.  This form  of peritonitis  occurs
  most frequently  in  the  puerperal  state,  both
  sporadically and epidemically, and  especially
  in lying-in hospitals, where  it often spreads
  throughout the wards (see Puerperal  Disea-
  ses).   Instances, however, of this form of peri-
  tonitis are observed in  other circumstances,
  especially in  connexion  with erysipelas, and
  with other maladies already alluded to  (y 26).
  In these the chief object is to arrest the  exten-
  sion of the morbid action by those remedies
  which  will make  the most powerful impres-
  sion, and in the shortest period,  upon the or-
  ganic nervous  and vascular  systems: an im-
  pression  which shall enable these systems, at
  the same time, to resist the extension  of the
  local mischief, and  to  remove  the changes
  which have already taken place.   After having
  made trial of various remedies and methods of
 cure in this form of the disease, the means
 which  I have had reason  to  confide in  are, a
 combination of camphor, calomel, and opium  in
 large doses, repeated every  four, five,  or six
 hours, according to the  features  of the  case;
 in some instances sulphate of quinine, camphor,
 and opium in  frequent doses; epithems  or fo-
 mentations of warm spirits of turpentine over the
 abdomen, renewed or repeated according to
 circumstances ; terebinthinate  enemata, and oc-
 casional doses of  spirits of turpentine by the
 mouth,  with or without castor-oil, or other med-
 icines.  I have employed this treatment  since
 1823, modifying it with the peculiarities  of in-
 dividual cases;  but it is more fully described
 in the article on the several forms of fever and
 of peritonitis in  thefuerperal state.  (See Puer-
 peral Diseases.)
   151. E. Peritonitis from perforation of the stom-
ach or intestines may assume various forms, ac-
cording  to the circumstances under which  the
perforation occurs.—a. As I have shown above 
98                  PERITONEUM—Inflammations of—Treatment.
 (v 27), if it result from chronic  ulceration of
 any portion of the digestive canal, it may be
 limited to that portion of the membrane more
 immediately surrounding the perforation ;  and,
 coagulable lymph having been effused, that part
 becomes agglutinated to the opposite surface,
 and effusion of the contents of the canal into
 the peritoneal cavity is thereby prevented.   In
 this case the symptoms only of partial peritoni-
 tis  are manifested, and  the disease  may as-
 sume an acute, sub-acute, or chronic character.
 An instance occurred in  my practice of a fe-
 male who lived between two and three years
 after peritoneal symptoms, caused by ulceration
 and perforation of the stomach, appeared ; she
 was treated chiefly by opiates, and upon  dis-
 section the peritoneum, for a considerable space
 around the large perforation, was thickened, ad-
 herent to the opposite surface, and almost car-
 tilaginous.   (See art. Stomach.)
  152. b. In many cases, however, especially
 when the perforation takes place in the course
 of continued or exanthematous fevers, and of
 phthisis, the constitutional powers and the state
 of the circulating fluids are such  as generally
 admit not of the production of coagulable lymph,
 and the formation of adhesions between the op-
 posite  peritoneal  surfaces.  In these  circum-
 stances, a  portion of the contents of the di-
 gestive canal escapes into the peritoneal cavi-
 ty, occasioning a rapid form of general asthenic.
 peritonitis.   Sometimes, however, the disease
continues  for a time more or less limited, acute
 pain and tenderness being confined chiefly to
the region in which they were first  experienced.
 In this case some  hopes  may be anticipated
from treatment.  Dr. Graves  and Dr. Stokes
first suggested the most rational  principle and
 means of cure in this state, namely, to enable
the constitution to produce  coagulable lymph,
by which the opposite surfaces of  the peritone-
um may become adherent, and  to keep  the
bowels quiescent until this end  be  attained.
The most  efficient means  to accomplish these
intentions are, frequent and full doses of opium,
and the remedial, dietetic, and regimenal meas-
ures usually employed to promote the strength
of the  patient, accommodated variously, so as
to suit the peculiarities of particular cases.
  153.  E.  Peritonitis consequent upon paracente-
 sis abdominis, or other operations, especially if
there be any connexion between it and erysip-
elas (y 28), generally  assumes  the asthenic
 form, and  should be treated upon  the principle
of enabling the constitution to form coagulable
lymph, and of assisting the powers of life  to
resist  the  extension of the malady.   With
 these views, opium, in full and frequent doses,
 Bhould be given,  and the usual remedial  and
 dietetic means of supporting the  vital powers
 ought to be employed.  In short, the treatment
 advised above (y 150)  should be  adopted, and
 modified so as to meet the exigencies of each
 case.
  154. ii. Treatment of Chronic  Peritonitis.
 —A. In a  few cases only of the general and tu-
 bercular forms of the disease can it be hoped
 that very great advantage will  be  procured
 from treatment.  Much, however, may be done
 in alleviating  the more unpleasant symptoms,
 especially the attendant diarrhcea, and even in
 prolonging the life of the patient.  In some
 cases, particularly where the powers of the pa-
 tient are not much reduced, local depletions, by
 means  of  leeches, repeated as circumstances
 will suggest, will be of considerable service ;
 but  venesection can rarely be attempted.   I
 have found most benefit to be  derived from the
 turpentine liniment  or embrocation recommended
 above  (Y 140), with the addition of a little of
 the iodide of potassium and vinum opii.  It should
 be perseveringly used, and be  aided, particular-
 ly when there is much liquid effusion, by the
 iodide of potassium given internally  with opium,
 or with the compound tincture of camphor and
 sarsaparilla.   Opiates are  indispensable in most
 instances, and more especially when the bowels
 are much relaxed.   They may be given as just
 recommended, or  alone,  or  with  absorbents,
 mucilages, and emollients.  I have employed
 the  iodide  of potassium  in this disease since
 1S24, but it is most beneficial when taken in
 very small  doses, and when long persevered in.
 Even in moderate  doses it is prone to develop
 an acute state  of peritonitis ;  and in this case
 the application of  leeches, of turpentine fo-
 mentations with opium, &c, to the  abdomen is
 indispensable, in order to subdue the acute or
 sub-acute action thus produced, the iodide being
 relinquished.
  155.  B Partial chronic peritonitis,  existing ei-
 ther simply, or associated  with chronic visceral
 disease, is  often either permanently removed
 or reduced to a state which is inconsistent with
 the performance of the functions, evtn of that
 organ, the peritoneal surface of which has been
 more or less implicated.   The disease may de-
 generate into  adhesions of a  loose or cellular
 kind, which may not interrupt materially the
 offices  of the  connected  organs.   Still,  these
 adhesions may excite farther  change, may oc-
 casion  inflammation, or may themselves be the
 seat of it.  It is not infrequently observed that
 inflammation  of a viscus  covered by the peri-
 toneum extends to this membrane, or the in-
 flammation may commence in and be limited
 to a portion of the peritoneum in an acute or
 sub-acute form, and, being either neglected or
 only partially removed, continues for an indef-
 inite time  afterward in  a chronic  state.  In
 this case, attention to  the functions of the or-
gan  affected  or consecutively implicated, the
occasional  application of  a few leeches when
pain or tenderness are felt, followed by warm
fomentations or the terebinthinate embrocation; by
opiates  with alteratives, cooling diaphoretics, and
diuretics, and such other means as the seat, se-
 verity, and  associations of the  disease will sug-
gest, are the  means upon which the chief de-
 pendence should be placed.  In some instances
 of this partial state of chronic peritonitis, the
 iodide of potassium, or the  iodide of  mercury, in
 small doses, may be tried subsequently to a due
 recourse to the means just  mentioned, with
 the view of reducing adhesions ; but the effect
 should be carefully observed.   Partial chronic
 peritonitis  is most frequently  observed in the
 peritoneal coverings of the spleen, liver, and
 female sexual organs, as a consequence of in-
 flammation of the subjacent viscera, and is
 there more readily removed by treatment  than
 in other situations;  or, at least, is more easily
 reduced to a  state  of comparative  innocuous-
 ness.
   156. iii. The Complications of Peritonitis
 require attention in both  the  acute  and chronic 
PERITONEUM—Inflammations of—Treatment.
99
 states of this disease.  It is chiefly, however,
 in the partial forms of peritonitis, or early in
 the more general malady, that these complica-
 tions  become  objects  of the  greatest impor-
 tance.  In every case it is necessary to ascer-
 tain, as far as may be, the organ or part prima-
 rily affected, and  the  extent  of the superin-
 duced disease ; for in many the primary mala-
 dy will perpetuate the consecutive affection of
 the peritoneum—a. When hepatitis extends to
 the peritoneum  covering the  convex  or  the
 concave surface of the liver, the portions  of
 the riiembrane reflected over the diaphragm in
 the one case, and over the stomach, colon, and
 duodenum, &c,  in the other, are often impli-
 cated (v 71-74).   The  disease  may even  ex-
 tend farther, not merely as regards the perito-
 neum, but as respects other  parts.  Thus I
 have  seen diaphragmatitis, pleuritis, and ulti-
 mately pleura-pneumonia, follow  hepatitis, on
 the one hand, and partial or even  general peri-
 tonitis supervene on the  other.  In  these cir-
 cumstances, and especially before the disease
 has thus extended, every  effort should be made
 to bring the  system under the influence of mer-
 cury as soon as possible, while  at  the same
 time the constitutional powers should  be aid-
 ed in resisting  the farther  extension  of the
 malady.   In addition,  therefore,  to judicious
 vascular depletions, calomel, camphor, and opi-
 um should be exhibited as  above advised (y 139,
 et seq), and be aided by terebinthinate fomenta-
 tions and enemata.
   157. b.  The  association of peritonitis with  in-
 flammation of the  cacum, or of the appendix caci
 (y74), is one of the most frequent and  impor-
 tant  which comes before the physician.   In
 many instances, as I have shown in  the article
 Caecum, the  impaction of a hard body into the
 appendix perpetuates the inflammation of it, as
 well  as of the peritoneum, and prevents  a  fa-
 vourable result, however judicious  the  treat-
 ment  may be.   When the partial  peritonitis
 caused by  the disease of  the Caecum (see that
 art., v 18-20) is  acute, the treatment already
 recommended (y  138, et seq.) for simple sthenic
 peritonitis, or that advised above for the com-
 plication with hepatitis, should be adopted.   I
 may  refer the reader, also, to  the  treatment
 recommended by me for inflammation extend-
 ing  to the peritoneum, in the  article CjEcum
 (v 32).  In the more chronic slate of this asso-
 ciation, the means already prescribed for par-
 tial chronic peritonitis (y 155) may be adopted,
 due attention being paid to the secreting and
 excreting functions of the liver and bowels.
   158. c. The associations of enteritis, and  of
 acute or chronic dysentery with partial peritonitis,
 are very common (y 74); and even  in general
 peritonitis, both the small and large intestines
 are often more or less affected.   These com-
 plications  are generally the  most difficult  to
 manage ; for, if the bowels be obstinately con-
 stipated, attempts to move them by drastic pur-
 gatives frequently aggravate the disease.   The
 treatment in this case should be directed almost
 entirely to the inflammation, and consist  of
 those  means which I have  advised for the
sthenic form of it (y 140, et seq.), aided by suit-
able enemata.  When  the  inflammation has
been allayed, and the bowels still remain con-
fined, such  mild laxatives as may solicit, rather
than force, the action of the bowels, only ought
 to be  employed.  On  the  other  hand,  if the
 bowels are much relaxed, or if diarrhoea or a
 dysenteric  state be present, the arrest of the
 increased discharge from  the mucous surface
 of the  bowels may increase the morbid action
 in the peritoneum, while the persistence  of the
 diarrhcea may arise from ulceration, which has
 either  already caused, or  will  aggravate, the
 peritonitis.   The early history of cases of this
 kind is the  chief guide of the physician, aided
 by the extent and severity of the peritoneal
 symptoms.   If the diarrhcea be merely an at-
 tendant on  the peritonitis,  as it sometimes is
 in the  asthenic form of the disease, attempts
 ought not to be made to arrest, or even to mod-
 erate it,  unless  it  be excessive,  and  exhaust
 the patient; whereas, if the peritonitis, in any
 form, supervene on diarrhoea or  upon dysen-
 tery, the  persistence of the latter, whether ul-
 ceration or  perforation exist or not, will aggra-
 vate the peritonitis;  and, therefore, while the
 chief attention ought  to be directed to it, stren-
 uous efforts should also be  made  to moderate
 or remove the disorder of the bowels.  In the
 first case, the  bowel affection depends upon the
 peritonitis,  and the treatment, as I have ad-
 vised, should  be directed with promptitude and
 activity to this latter—to the primary and chief
 disease.  In the second case, the disorder of
 the bowels has not merely caused, but still con-
 tinues to perpetuate and to aggravate the peri-
 tonitis,  and  ought, therefore, to  be moderated
 or controlled  even where it might not be pru-1
 dent at once to arrest it, supposing this  to be
 in our power.   In this complication, whatever
 may be the  sequence of morbid action, an ex-
 tensive  experience has  proved to me that the
 terebinthinate remedies, used both  internally
 and externally, are most to  be depended upon
 when judiciously prescribed.  That the  right
 use may not be made of them, in respect both
 of the circumstances and period of the disease
 in which  they should  be used, and the modes
 of exhibiting  and combining them, and hence
 that they  will  sometimes disappoint many who
 may have recourse to them, I can fully believe.
 But in  these  contingencies they participate
 with all our other  most efficacious remedies.
 Opium,  with ipecacuanha in  large doses, when
 the bowels  are much disordered; appropriate
 enemata,  and   other  means already  noticed,
 adapted or combined so  as to meet the exigen-
 cies of particular cases, are  also important ad-
juvants  in the treatment  of these complications.
   159. d.  The association of peritonitis with in-
 flammation, or  with organic lesions of the urinary
 and sexual organs (y 75),  is not infrequent, espe-
 cially among females, and in the puerperal state.
 In ordinary circumstances the associated peri-
 tonitis is generally consequent upon the visceral
 disease, and  is  commonly partial, unless in puer-
 peral or cachectic states, or in the course of
fevers, where it often  rapidly becomes more or
less general.   It sometimes, also, passes into a
chronic form, especially  when it is consecutive
of organic lesions,  or is  independent of the
puerperal condition.  In these several associa-
tions the treatment should partly depend  upon
the extent of the peritoneal affection, and upon
the degree  of vital power characterizing the
disease. When the asthenic and diffusive form
is present, the  treatment advised above is most
appropriate (y 150); but  when the more sthenic 
100
PERITONEUM—0
'rganic  Lesions of.
and partial or limited  state of morbid  action
exists, then the means already recommended (y
140) are those which are most beneficial for this
state of complication.   In either case the peri-
tonitic disease claims the more immediate and
the chief attention, as upon the limitation  or
extension of it depends the recovery or the loss
of the patient.   It being arrested, or more  or
less  subdued, the treatment  should be more
strictly directed  to  the primary lesion of the
sexual organs; and the functions of these or-
gans ought  to be promoted, especially as  re-
spects the  menstrual  discharge.   Even after
the disease is apparently subdued by the vascu-
lar depletions, &c, prescribed  above, still pain
or tenderness often recurs, especially about the
expected catamenial period, and is sometimes
attended by scanty or difficult discharge.   In
such cases leeches should  be applied below
each groin, and be followed by fomentations, as
already advised (y 140), by small doses of the
biborate of soda in camphor and orange-flower
water, and by such other means as the peculi-
arities of individual cases will  suggest.
   160. iv. Treatment  of Peritonitis in Chil-
dren.—A. The principles of treatment which I
have advocated for adults are also applicable to
children.  In the latter class of subjects, how-
ever, acute peritonitis generally assumes a sthenic
or phlogistic  character, unless when it follows
eruptive  fevers or mesenteric  disease, when a
subacute and diffusive  state is often assumed,
not infrequently lapsing into the chronic form,
particularly in the scrofulous diathesis.   In  the
more sthenic of these  states of disease, local
depletions, calomel, terebinthinate fomentations
and injections, emollient warm baths, with the
other means already advised,  according to the
circumstances of the  case, are the  measures
upon which our dependence ought to be chiefly
placed.  When peritonitis follows the maladies
just mentioned—when it presents, either local-
ly or as  regards the constitutional symptoms,
the asthenic, diffusive, or subacute state—calo-
mel  with camphor, and with  opium in small
doses, when the age of the patient will admit
of this last, and  terebinthinate remedies in  the
several forms already  prescribed, and duly re-
peated or continued, are the principal means  of
cure.
   161. B. If the disease pass  into the chronic
state, or  assume this  form primarily—if it  be
tubercular, as it  most frequently is, or simple,
and attended by fluid effusion into the peritoneal
cavity—a cautious recourse to iodine, especially
to the proto-iodide of mercury, to the iodide of*
potassium, with liquor potassae  and sarsaparilla,
and a  frequent or continued use of the tere-
binthinate embrocation over the abdomen,  as
above  advised (y 140,141), either with or with-
out the iodides externally, should in no case be
neglected ; but  they should be perseveringly
employed, and  the  iodides ought  to be given
only in very small doses, especially at first, and
be aided by change of air, and exposure to light
and sunshine.  When  chronic peritonitis is at-
tended in children by diarrhcea, when it is far
advanced, and its tubercular nature manifest,
then ulceration, or, at least, a state of lesion
almost precluding hope, may be inferred.  Our
treatment should then be directed to the  alle-
viation of urgent symptoms ; to the moderation
 of the attendant diarrhcea and pain by means
of absorbents and opiates, by  hydrarg. cum
creta with compound ipecacuanha powder, an*
warm baths, or fomentations over the abdomen.
  162. v. Convalescence from any of the forms
of peritonitis requires the utmost care and cau-
tion, especially in  respect of diet and regimen.
During the continuance of the disease, particu-
larly in the acute form, bland or emollient fluids
only should be allowed.   The compound decoc-
tion  of barley may be taken in small quantities ;
and, when a relaxing effect upon the bowels is
desired, then about a  drachm of oleum olivae
may be given on its surface three or four times
in the day, or oftener.  In the acute state of
the disease, this, or simple barley, rice, gum-
water, rendered agreeable with loquorice pow-
der, is all that is required, both as drink and as
aliment.   In the chronic states,  however, or
during the  early stage of the  convalescence
from the acute, the same  watery decoctions,
with small  quantities  of ass's  or other milk
[rennet whey], or weak arrow-root, or other
farinaceous substances, may be  allowed; and,
subsequently, according to the progress of the
case or the amount of debility, mutton, or veal,
or chicken broths, or beef-tea, in small quantity,
with dry  toast, or with boiled  rice or stale
bread, may be cautiously permitted. The great-
est caution should be used  in returning to ani-
mal food ; and that which is the mildest, least
stimulating, and most digestible only should be
allowed, in small quantity, once in the day.  All
heating or stimulating beverages, and flatulent
or ascescent vegetables, ought to be avoided.
Chocolate  or  cocoa-nibs should be substituted
for tea and coffee; and, in the case of infants
or children, ass milk warm  from the animal,
either pure or diluted, is one of the best articles
of food, as well of drink, that can be adminis-
tered.
  163. During the course  of, as well as con-
valescence  from,  this  disease,  a perspirable
state of the surface ought to be preserved by
flannel worn  constantly next to  the skin, by
warm baths rendered emollient by an alkali, by
decoction of marsh-mallows, or infusion  of lin-
seed, &c.   If the bowels, after  recovery, con-
tinue irregular  or constipated, the emollient
decoctions or infusions may be employed as
enemata, to which oleum ricini or oleum oliv.ae
may be added ;  and small doses of these, par-
ticularly of the latter, may be taken frequently,
on the surface of any suitable diluent or demul-
cent, until a regular action shall be established.
XI.  Organic Lesions of the Peritoneum, in-
  dependent of Inflammation.
     Classif.—IV. Class,  I. Order (Author).
  164. i. Description.—The lesions of the per-
itoneum which have already been noticed have
chiefly been those which are consequent upon
inflammation in some one or other of its sev-
eral forms or types.   Tubercular formations
are, however, an  exception ;  and these have
been noticed only incidentally, and in as far as
they are associated with  chronic peritonitis,
particularly in scrofulous constitutions. A brief
notice only will be taken of those changes which
are not essentially caused by inflammation, as
they are generally, especially in  the circum-
stances in which  they usually present  them-
selves, but  little influenced by  medical treat-
ment.  Certain  of these changes affect  rather
the attached surface,  or the sub-peritoneal tis- 
PERITONEUM—O
rganic Lesions ob".
101
sue, than  the peritoneum  itself;  while  others
consist in  the presence of fluids altogether for-
eign to the peritoneal cavity.
  165. A.  Various changes of colour are occasion-
ally presented by the peritoneum, which  are in-
dependent of inflammation.—a. Yellowish or
even greenish tints are sometimes observed in
those parts of the membrane in  the more im-
mediate vicinity  of the gall-bladder, and are
owing to  the exudation of bile.   The  extent
and the intensity of the colour generally depend
upon the colour and quantity of bile contained
in the gall-bladder  and ducts,  and upon the
duration of the  period  from  the death  of the
patient.  Various shades  of colour are often
observed in the peritoneal surfaces of the liver
and spleen, and are  generally owing, when they
are very deep or dark,  bluish or brownish, to
venous congestion of these organs, or to accu-
mulations  of black  viscid bile in the hepatic
ducts. These deep shades of colour are most
remarkable in warm climates, after hepatic, pe-
riodic, and other fevers.— b. The peritoneum
may also  present a  reddish hue without  having
been  inflamed.   This always is owing  to the
escape of blood, from accident  or rupture of
vessels, into the peritoneal cavity ; and hence
its  nature is apparent.  It  is always a post-
mortem change.
  166. B.  The sub-peritoneal cellular tissue is not
infrequently the seat of various changes,  which,
although sometimes connected with, is oftener
independent of, inflammatory action.—a. Oedema
of this tissue is occasionally observed in con-
sequence  of chronic disease of the heart, liver,
lungs, or kidneys ; and is  most conspicuous in
those situations where the  cellular tissue is
most  abundant and  loose ; as in the vicinity of
the pancreas, kidneys, and sexual organs.
  167. b.  Minute transparent vesicles, varying
from the size of a millet-seed to that of a pea,
or even of a marble.  They occur most fre-
quently about the Fallopian tubes, ovaries, and
broad ligaments.    Serous cysts  are not infre-
quently found between the folds of the broad
ligaments, and sometimes attain  the size of a
large orange, simulating  ovarian disease, and
constituting one of the forms of encysted drop-
sy.   (See  art. Dropsy, y 206, 212.)
  168. c.  Tubercles and scrofulous tumours are
the most frequent and important organic  lesions
primarily  occurring in the sub-peritoneal cellu-
lar  tissue  independently  of  inflammation, al-
though, with all other morbid formations in the
same situation, generally  inducing chronic in-
flammatory action in their progress.  Scrofulous
tubercles  in this  situation, and when well de-
fined, seem to be encysted, owing to the con-
densation  of the cellular tissue directly  invest-
ing them.   Dr. Hodgkin states, that these scrof-
ulous  tubercles or tumours are most frequently
seen, and  are the largest,  between the folds of
the  mesentery;  but  they obviously implicate
the  glands in that situation.  They also attain
a considerable size in the omentum.   Under
the  peritoneal coat  of the intestines they are
generally  small, but numerous.   Dr. Hodgkin
considers  the small  miliary granulations, which
I have described above (y 107), as consequences
of inflammatory action, and which are  found,
both below and in the peritoneum, to be  incipi-
ent  tubercles.   I have already endeavoured to
distinguish between those granulations  which
seem to result from chronic inflammation and
scrofulous tubercles.
  169. C.—a.  Malignant deposites, or formations
of a scirrhous  or fungoid character, occur occa-
sionally on the attached surface of the perito-
neum, and sometimes they extend from the sub-
jacent structures, and invade this membrane.
Dr. Hodgkin remarks, that in  the former case
the tumours which result are often remarkable
for their size,  number, and diffusion ; but that,
even in these, some portions of the peritoneum
more frequently  escape than others.   Thus,
these morbid  growths are not so often  met
with on the parietes as in the omentum, or in
the intestines ; and, when formed in the parie-
tes, they are generally of a smaller size.  Nei-
ther the mesenteric glands nor the other organs
invested by the peritoneum are apt to become
affected by the extension of the disease.  These
growths  are  sometimes, although not neces-
sarily, attended by serous effusion into the per-
itoneal cavity, causing distention, which is oc-
casionally very considerable.  When  the dis-
ease is propagated from the primarily affected
organ, it is generally to the vicinity only;  thus,
in  scirrhus of the pylorus, a  sprinkling of
minute scirrhous  tubercles is often seen under
the peritoneum in the neighbourhood ; and in
malignant disease of  the uterus, the convolu-
tions  of the intestines which  happen  to come
in contact  with it often exhibit growths  of a
corresponding character beneath their perito-
neal coat.
  170. b. The free  or internal surface of the
peritoneum is very rarely the seat of malig-
nant  growths.   Dr. Hodgkin, however,  met
with two instances in which it was the seat of
these growths ; but in these, malignant forma-
tions  also  were  found in organs  invested by
this membrane, and were manifestly developed
primarily in these organs.   In one case, in ad-
dition to fungoid  disease of the kidney, there
were small malignant  tubercles situated in and
beneath the peritoneum, and others seated on
the free  surface  of it; and in the other case
these tubercles were scattered beneath the per-
itoneal coat of the intestines, and on  its free
surface, the chief and primary fungoid tumour
being in one of the ovaries.
  171. c.  Melanosis, also,  is  sometimes  met
with,  invading, rather than primarily affecting,
the peritoneum;  and it is chiefly observed on
the attached surface of the membrane, to which
it has extended from the subjacent structures
and cellular tissue; where, however, it presents
the usual characters assigned it when treating
of it elsewhere.   (See art. Melanosis.)
  172. Although scrofulous tubercles and scir-
rhous and fungoid productions affect the peri-
toneum independently of inflammation, and ap-
pear in those  circumstances, and from causes
which are fully developed in the articles devoted
to those several subjects,  still they not infre-
quently are found accompanied with more or
less abundant  effusion  of serum, and with bri-
dles, or films of adhesion,  indicating, the latter
especially, that a chronic form of inflammatory
action had  been excited by their presence and
in their vicinity.
  173  D.  True  hydatids  or acephalocysts are
sometimes  produced beneath the peritoneum,
and occasionally they attain a very large size
so as to resemble encysted dropsy, from which 
)rganic Lesions  or.
 102                       PERITONEUM—*

 they are with difficulty distinguished during the
 life of the  patient, especially when they form
 between the folds of the broad ligaments of the
 uterus.  They are met with chiefly under the
 •peritoneal covering of the liver, beneath that of
 the spleen, in the broad ligaments, and in the
 mesentery ; but the first is their most frequent
 seat.  They may burst into the peritoneal cav-
 ity without producing any signs of inflammato-
 ry action ;  but a chronic and limited state of
 inflammation may be occasioned  by them.  In
 either of these situations they may pass through
 those changes which have been described when
 treating of them.  (See article Hydatids, v 15-
 25.)
   174.  E.  Ecchymoses and small bloody points
 are occasionally found in the peritoneum, ow-
 ing to  minute extravasation of blood,  caused
 by diminution of the tone of the capillaries and
 of the vital cohesion of the sub-peritoneal tis-
 sue, and probably, also, of the peritoneum itself.
 They are most frequently observed under and
 in the peritoneal coat of the small intestines,
 but are also sometimes met with  in other situ-
 ations.  They occur chiefly in purpura haemor-
 rhagica, in  adynamic fevers, and in scurvy, in
 which last I have observed the ecchymoses as-
 sume the form of vibices, or patches, as large as
 half-crown  pieces.  Dr. Hodgkin remarks, that
 he has seen the peritoneum  sprinkled  with
 small bloody points,  not only in purpura, but
 also in jaundice.
   175.  F.  Various substances foreign to this situ-
 •ation are sometimes found icilhin  the  peritoneal
 cavity.—a.  The most common is  an accumula-
 tion of serous fluid.  This fluid may result from
 increased  exhalation of serum,  arising  from
 congestion, or impeded return of  blood from
 the abdominal viscera,  consequent upon dis-
 ease of the liver, heart, lungs,  kidneys, &c.
 In these circumstances, the effused fluid con-
 tains comparatively but  little  albumen ; and
 when this  is the case,  and the  more  watery
 and limpid the effusion, the less prone the peri-
 toneum is  to be  irritated  or inflamed by  it.
 Still, a state of chronic inflammatory action is
 sometimes  induced by  the state  and quantity
 of the effused fluid, affecting chiefly the omen-
 tum and mesentery, and occasioning more  or
 less shrinking of these parts.  The  disposition,
 also, to chronic, or even to acute asthenic peri-
 tonitis, occasioned by serous effusion into the
 peritoneal cavity, is further evinced by the fre-
 quency of its supervention upon paracentesis ab-
 dominis.  It has been stated above (y 101, 102)
 that the effusion of fluid into this  cavity conse-
 quent upon inflammatory action  is often very
 great;  but  in this case, whatever may be the
 form of inflammatory action producing it, the
 fluid contains more or less albumen,  occasion-
 ally, also, blood globules or colouring matter,
 and even  pure or dissolved  blood,  although
 much more rarely ; and the peritoneum is alter-
 ed in structure, or  it  presents other  morbid
 products.
   176.  b. Blood, fluid or coagulated,  recent or
■ partially altered, pure  or  mixed with  serum,
 &c, is in rare cases found in this cavity; but
 generally in consequence of rupture of some
 one or other of the invested organs, or of an
 aneurism.  Broussais contended that it is some-
 times effused in considerable quantity, owing
tto a haemorrhagic peritonitis, or  to a state of
action partaking of both an inflammatory and a
haemorrhagic character.  This may be probably
the case, but on rare occasions.   Haemorrhage
may also occur into this cavity to a consider-
able extent, owing to the ulceration attending
some states of chronic peritonitis, of which I
have met with a  remarkable instance.   When
blood is effused into the cavity owing to wounds,
injuries, &c, it always rapidly produces inflam-
matory action, which is followed by the effusion
of coagulable lymph, if the powers of the con-
stitution are not remarkably depressed; and
this  lymph  may limit or surround the blood ef-
fused, and  thus in some respects isolate or en-
cyst it, and  thereby even confine and ultimately
repair  the  mischief.  The effused lymph, by
subsequently becoming organized in the manner
desoribed (y 82-84), may even give rise to va-
rious changes  in the blood surrounded by it,
similar  to  those  remarked in coagula found
some time  after extravasation into the paren-
chyma of organs.
  177. A partially  decomposed blood, mixed
with more  or less serum, or a sanious fluid, is
in rare instances found in the peritoneal cavity
unconnected with inflammation, and chiefly in
the same circumstances and in the same cases
as have presented ecchymoses  of the perito-
neum.  This state of the effused fluid I have
seen only.in scurvy, purpura, adynamic fevers,
malignant puerperal fever, and malignant small-
pox ; and  in these circumstances the sanious
or bloody state of the effusion, as well as the
ecchymoses, is owing as much to alteration of
the blood as to the impaired  vital cohesion o|
the peritoneal surface and capillaries.
  178. c. Chyle, bile, urine, and even the amni-
otic fluid,  have been  found in the peritoneal
cavity, but  only in consequence of wounds and
injuries of  the peritoneum  and  parts involving
the vessels concerned in transmitting, or the
organs containing, these fluids.   Rupture  of
the  fundus of  the urinary bladder, or of the
uterus,  is  necessarily  followed by the escape
of the contents of these organs into the peri-
toneal cavity.  Purulent matter is sometimes
found in this cavity independently of inflamma-
tion of the membrane, owing to the bursting
of an abscess, especially of that of  the liver.
Tubercular  matter is in rare instances found in
this  situation, owing to perforation of the peri-
toneum, particularly after scrofulous or tuber-
culous disease of the  mesenteric glands, and
in chronic tubercular peritonitis.  The aliment-
ary, facal, or gaseous contents of the stomach or
the intestines occasionally escape into the peri-
toneal cavity, and even intestinal worms axe also,
in rare cases, found there, owing to perforation
of these viscera, either no adhesions, or partial
adhesions only, having existed between the op-
posite  peritoneal surfaces  adjoining the per-
foration.  In all cases of the passage of these
foreign  substances  into the  peritoneal cavitj
peritonitis is quickly induced, and extends with
a rapidity co-ordinate with the acridity, quanti-
ty, and diffusion of the foreign substance and
the susceptibility of the patient.
  179. d. It has been shown above (y 119) that
gases are  sometimes found  in the peritoneal
cavity,  causing more  or less true peritoneal
tympanitis or meteorismus, owing to the partial
decomposition of a  portion of the products of
inflammation, especially when  these products 
                          PERITONEUM—C

are long retained.  This  source  of the gases
sometimes found in this cavity is  now general-
ly admitted by pathologists.  But it has been
supposed—been contended  for by some  and
denied by others—that air may be secreted on
the free surface of the peritoneum, independent-
ly of inflammatory action.  Portal, Combalu-
sier, Frank, and others have adduced instances
of the accumulation in this cavity of air, inde-
pendently of either disease of the  membrane or
perforation  of the digestive canal.  There is
no doubt of the secretion of air from the digest-
ive mucous membrane, independently of any
obvious structural disease of it;  and while the
possibility of a similar phenomenon occurring
in respect of the peritoneal coat of the digest-
ive tube may be admitted, the rarity of its ap-
pearance  cannot be questioned.   Scoutetten
believes that he has found air in the peritoneal
cavity without any lesion of the membrane;
but was it secreted there  before death, or pro-
duced afterward ]  M. Ribes considers that an
elastic fluid exists in  the serous cavities, aris-
ing from the vaporization of a portion of the
secreted serosity with which they are provided.
   180. e.  Perfectly detached bodies or concre-
tions, generally of a rounded form, are  some-
times found in the peritoneal cavity.  They are
of a semi-cartilaginous, cartilaginous, or even
bony character.   They vary in size from that
of a pea to that of a cherry.  Dr. Hodgkin  re-
marks respecting their  formation, that " they
commence as an isolated clot of coagulated
lymph, the  smooth convex surface of  which
has contracted no  adhesion, either to the se-
rous or to any other portion of false membrane.
In process of time the surface acquires a suf-
ficiently membranous  and firm  consistence;
and the detached body, instead of forming a
clot of cheesy matter, contracts,  losing its se-
rous or watery part.   If this take place rapidly,
and materially reduce the size of the detached
body, the  surface exhibits an uneven  and cor-
rugated appearance.  When of small size, they
more often retain their  smooth surface, an  in-
creasingly firm structure, which becomes load-
ed with  earthy matter, as I apprehend, by a
process of endosmosis.   These detached bod-
ies may be seen in the most recent state, whol-
ly consisting of coagulable lymph, having a
cellular character, infiltrated with serum, and
presenting the figure and  size of  an egg-plum,
somewhat flattened;  but I have never seen
them, in the firm and advanced stage which I
have described, larger than a pea or a  marble."
(Op. Cit., p. 53.)
   181. Now without questioning that some of
the bodies,  in their recent or soft state, or in
that  of lymph, are produced in the manner  for
which Dr. Hodgkin has argued, or consist of
portions of lymph thrown out with, or isolated
by, a liquid effusion produced at the same time,
still the subsequent changes, whether cartila-
ginous, or earthy, or bony, cannot be explained
conformably with this opinion, even  although
the process of endosmosis  be called in aid of it.
I believe  that the lymph, formed in a greater
or less clot, or  mass, and with  more or less
serous effusion, continues connected  with the
peritoneum by a narrow neck or pedicle, through
the medium of which successive  changes take
place in  it;  and that, with the  condensation
and contraction of this mass, the pedicle also
rganic Lesions of.                      103

 shrinks, becomes thinner, and  is at last de-
 stroyed or broken off, the body ultimately being
 altogether detached.   That it should undergo
 the  successive  changes of cartilaginous, os-,
 seous, or earthy degeneration, after its com-
 plete separation from the living structures, as
 Dr. Hodgkin supposes, is countenanced neither
 by analogy, nor by observation, nor by what is
 known of the process of endosmosis.
   182. ii. The Symptoms of those organic le-
 sions of the peritoneum which have now been
 described are extremely equivocal and obscure.
 Many of these lesions are detected only after
 death, and are associated  with alterations of
 other or connected organs or parts, which as-
 sume a more prominent place in that state of
 more or less general disturbance, or of cachexia,
 which is usually  present.  Where there is ef-
 fusion of fluid into the peritoneal cavity, this
 may be readily detected, but it may be compli-
 cated with one or other, or even  with more, of
 those changes  of the  membrane which have
 just been noticed, and which the effusion may
 mark, or which may not  be  evinced by any
 characteristic phenomenon.  When the altera-
 tion is of a malignant kind, it will generally be
 attended, at least at an advanced stage, by a
 cachectic, anaemial, and languid or debilitated
 state of the frame.  Even when a distinct tu-
 mour is present, its exact seat will frequently
 be undeterminable, and it will be equally impos-
 sible to ascertain the extent to which the peri-
 toneum is implicated by it.   The matter can at
 best be one of inference, to  which the physician
 will be led<by a number of varying circumstan-
 ces, many of them peculiar to individual cases.
   183. Of all these lesions, probably hydatids,
 seated beneath the peritoneal covering  of the
 liver, is that which is ascertained with the great-
 est certainty during the life of the patient.  Yet
 this is not always the case, for much depends
 upon  the particular part to which these para-
 sites  are attached, upon the size of the tumour
 they produce, and upon various  attendant cir-
 cumstances.  But the  symptoms are stated in
 the article Liver (y 232).  Some of the lesions,
 while they only  partially, or  even  to a small
 extent, invade the peritoneum, are seated chief-
 ly in  organs or parts enveloped by this mem-
 brane ; their precise seat being indicated  chief-
 ly by the way in which  particular functions are
 disturbed, and the amount of the disturbance.
 If the lesion consist of a deposite of morbid or
 heterologue matter, occasioning  more or less
 tumour, the seat  and relations of it, viewed  in
 connexion with the kind and  extent of disor-
 dered function, and with the evidence of con-
 stitutional disturbance manifested in both the
 nervous, vascular, and cutaneous systems, will
 generally furnish  some indication of the  nature
 of the malady, particularly when aided  by the
 state of sensibility evinced during a careful ex-
 amination of the different regions of the abdo-
 men and pelves, and by percussion.  Still, the
 amount, as well as the exact  nature,  of the
 peritoneal  lesion may not be made apparent;
 and  it  may not  even be easy  to  ascertain
 whether or not the alteration be one proceeding
 from chronic inflammation, or one or other of
 those which I  have now considered as  being
 independent both of inflammatory action and
 of its usual results.  It is chiefly by comprising
 within our mental vision all the circumstances 
Drganic Lesions  or.
 104                      PERITONEUM—(

and phenomena characterizing the causes, ori-
gin, progress, and full development of the case,
that an approach can be made to a just view of
the nature of the distemper.
   184. iii. The Causks of the organic lesions
which I have viewed as altogether independent
of inflammatory  action, although sometimes
associated with, or productive of, a  state of
asthenic or chronic inflammation, vary accord-
ing to the nature  of the existing lesion ; each
of these lesions  proceeding from predisposing
and exciting causes, which are more or less
peculiar to it.  Thus the tubercular,  the scir-
rhous, or the fungoid deposites, formed beneath or
invading the peritoneum, proceed from causes
which are enumerated  in  the articles  devoted
to these diseases.  The same remark applies to
kamorrhagic, hydatidic,  and other changes im-
plicating this membrane ; these appearing from
the same causes and in  the same circumstances
as give rise to them in other situations.   Of all
the alterations of structure,  however,  which
have now been briefly noticed, it may be stated,
in general terms, that  they commonly proceed
from,  and are characterized by, both  at their
commencement and during their course, a con-
dition of the vital powers and of the circulating
fluids  that have been fully described in the ar-
ticles  Debility and Disease.  Debility, appear-
ing either primarily or consecutively, as shown
when  treating of this subject, or, in other words,
depression or exhaustion of vital energy, by
occasioning those changes in the assimilating,
the circulating, and depurating organs and func-
tions,  which I have fully developed in the arti-
cles Blood and Disease, gives rise to the sev-
eral alterations of structure just described ; one
or other  of them appearing, according as the
predisposition resulting from original conform-
ation, temperament, age, and modes of  living,
and as the influences  exerted by air, climate,
mental emotion, previous or concomitant dis-
ease, &c, determine  its character or relations.
  185. iv. The Treatment of organic lesions
of the peritoneum, like  the consideration of the
causes producing them, should have strict ref-
erence to the nature  of the alterations inferred
to be present in each  case.  Still, the  same
principles are applicable to nearly all of them
—whether of prevention, of alleviation, or of
cure.   It has just been  stated that  all  these
lesions generally originate in depression or ex-
haustion of vital power, and in its more  imme-
diate  consequences in  the assimilating, circu-
lating, and depurating functions and  organs ;
and a reference to those articles where  these
distempers are fully discussed, and with due
reference to their causes, will fully confirm the
general statement now made.   It must, there-
fore, be manifest that a continuance of the pri-
mary  morbid condition will necessarily  aggra-
vate or increase the  consecutive changes, and
thereby favour the development of the specific
organic lesion, and its  inroads upon the consti-
tution.  On the other hand, it  must be equally
evident, that whatever has the influence to re-
move the primary morbid condition ; to rally or
promote the depressed  or exhausted powers of
life; to aid the assimilating,  circulating, and
depurating functions, will  most efficiently re-
sist the progress of the organic mischief, and
even  overcome  it  ultimately (although we
should seldom be so  sanguine in our expecta-
tions), when it has not advanced so far as to
impede the functions of life, or when it is not
of a nature which precludes hope of ultimate
success.   By enabling the constitutional ener-
gies to resist the advancing evil, we may sue-
ceed in prolonging the contest;  we may very
considerably prolong life, even when we cannot
hope to avert an ultimately fatal result.
  186.  Having determined the principle of treat-
ment, the means which range themselves under
it are readily suggested ; the selection of them
depending upon the inference drawn from previ-
ous and  existing phenomena as to the nature
of the particular case.   The number and vary-
ing characters of the alterations just described,
the different and even changing circumstances
in which they appear, and the numerous visce-
ral  maladies with which they are  generally
complicated—these maladies  often  being the
original evils from which the peritoneal lesion
springs, or by which the membrane is invaded—
preclude the possibility of noticing the several
methods of treatment, the numerous means of
cure or  of palliation,  and the  interminable
modes of combining these means that may be
employed in these pathological conditions.  I
can only indicate the general character of the
means which experience has shown to be most
beneficial, and notice a very few from  among
these means which deserve  to be employed.
  187. I have  just  now  contended  that the
only remedies which should be resorted to in
the organic lesions of the peritoneum are those
which  support or rally the depressed  powers of
life.  Unfortunately, many of  these lesions in-
vade  the peritoneum  consecutively of a  pro-
tracted existence  in some one of the viscera
enveloped by this membrane, and not until vi-
tal depression and constitutional contamination
have made considerable progress ; or they may
not come before the competent  adviser until
reasonable expectations of cure are  precluded,
either  by their nature at their commencement,
or by the amount of disorganization.  Still, in
either  case, the chief indication is  nearly the
same for all, namely, to enable the powers of lift
to resist as long as possible the farther progress of
disorganization ; and, when the case admits of the
attempt, to aid them in removing whatever altera-
tion of structure may  have already taken place.
It is very obvious that this object can be at-
tained  only by those means which support, or
rally without  exhausting,  vital  energy ;  and
which  at the same time aid the  due perform-
ance of the several digestive, assimilating, and
depurating functions.  Care should be taken
always to keep the stomach in good humour, by
the aid not merely of medicine, but also of  suit-
able diet and  beverages.  The  medicines most
appropriate to the peculiar features  and com-
plications of the case should  be  selected, and
their influence upon  the functions of digestion
and  excretion  carefully  observed.   Although
tonic or restorative medicines are requisite,yet
those which are the  best suited to the circum-
stances of the case, and the  temperament or
idiosyncrasy of the patient, ought to be studied.
Where there is increased irritability of the sys-
tem, with a  frequent  or  excitable  pulse, the
milder vegetable tonics or bitters only  will be
tolerated; and these may be prescribed  with
calmants, as the hydrocyanic acid, Hoffmann'b
anodyne, or with henbane, conium, morphia, oi 
PERITONEUM—:
Bibliography, etc.
106
other preparations of opium.  If more  or less
anaemia  be present, chalybeate  medicines, se-
lected and combined according as the peculiari-
ties of the case suggest, are the most appropri-
ate.   It will be often  beneficial  to combine al-
teratives  with tonics  or restoratives ;  and the
choice of those is generally difficult, as  those
which depress vital power or irritate the stom-
ach  are  generally prejudicial.   The prepara-
tions of sarsaparilla and of iodine are the most
efficacious, when judiciously administered ; but
the latter should  be prescribed in very  small
doses, especially at first, and the  iodide of po-
tassium  be preferred.   This medicine  may be
given with the liquor  potassae or with sarsapa-
rilla,  or in tonic  infusions or decoctions ;  or
with  the liquor potassae in Hodgson and Ab-
bott's* pale  ale, a beverage which I  have for
many years recommended in several disorders
characterized by more or less debility.  When
the iodide of potassium is found to  agree with
the patient, the iodides of mercury may  also be
given in small doses at  bedtime, with an ano-
dyne or opiate.   If anaemia exist, the iodide of
iron should be prescribed in the  sirup  of sarsa,
and the advantages of  light  and sunshine  en-
joyed as  far  as may  be prudent.  The  several
emunctories  ought to  be  duly  aided in  their
functions ;  the  regular   action  of  the  bowels
and of the kidneys promoted ; and the insensi-
ble perspiration increased by wearing  flannel
next the  skin, and by keeping the  extremities
always warm.
   188. If  the stomach  be  irritable,  creasote
may be given, with or  without  opium or ace-
tate of morphia ;  or  hydrocyanic  acid may be
prescribed  in demulcents  or  emollients; and
such  beverages  be selected as will  support  the
strength, and agree best with the digestive or-
gans.  In some cases,  the pale ale just  men-
tioned may  be  made the  vehicle  of various
medicines, according  to the exigencies of  the
case ;  but in every instance, and  particularly
when the stomach is  weak and  irritable,  tea
ought to be avoided.   Chocolate or cocoa-nibs
are  preferable; or a little milk, with seltzer,
soda, potass, or magnesia water.   The choice
of these  or of mineral waters  should  depend
upon the  nature of the  case, and especially of
the  visceral  disease characterizing  it.   The
diet and regimen must be regulated by the  same
circumstances.
  Biblioo.  and Refer.—Tulpius, Observ. Med., 1. iv.,
cap. 44.—Graham, in Philosoph. Trans., No. 460.—Meckel,
in Mem. de l'Academie a Berlin, 1753, p. 102.—Morgagni,
De Sedibus et Caustis Morborum, Epist., xvi., 30 ; xxii., 18;
xxxviii., 52; Ivii., 20.—Lieutaud, Hist. Anatom. Med., vol.
i., Obs. 2, 3.—Sandifort, Observat. Anat. Pathol., vol. iii.,
No. 3 ; et Mus. Anatom., vol. i., p. 246.—Bang, in Act Reg.
Soc. Med. Hafn., vol. i.. p. 93.—De Haen, Rat. Medendi,
&.c, pars vi., cap. 4.—Stoll,  Rat. Medendi, <fec,  vol. i., p.
290.—J. Hunter, On the Blood, <fec, p. 244.-7. G. Walter,
De Morbis Peritonei et de Apoplexia, 4to.   Berl., 1785.—
»S. Hulder, De Morbis Omenti, 4to.  Gott., 1786.—Parr, in
Medical Dictionary, vol. ii., p. 21.—Bichat, Anat. Generate,
t. i.—/. P. Frank, De  Curandis Horn. Morbis, 1. ii., Order
iv.—Portal, Cotirs d'Anatomie Medicale, &c, 8vo.  Paris,
1804, t. v., p. 126 ; et Memoires sur plusieurs Maladies, t.
iv., p. 249.—R. T. H. Laennec, Hist, d'lnflammat. du Pe-
ritoine, 8vo.  Paris, 1804 ; et in Journ. de Medecine, vol.
v.  Paris, 1803.—Jahn, in Stark's Archiv., b. ii., st. 2, p. 131.
—Neumann, in Hufeland,  Journ. der pract. Heilkunde, b.

  * I recommend this beverage in preference to the various
imitations of it  which have  more recently appeared, be-
cause I know that it is pure, well fermented, and  prepared
from the best materials.  The utmost precautions are also
taken against adulteration.   For many years  it was the
only article of the kind, and it is still the most wholesome.
xx., St., 2, p. 37.—C. R. Pemberton, On Diseases of the Ab-
dominal Viscera, ch. i., 8vo.  Lond., 1807.—Greiner, in An-
nalen der Heilkunst, 1811, p.  513.—F. J. V. Broussais,
Histoire des Phlegrnasies  Chroniques, t. ii.   Paris,  8vo,
1808.—T. Sutton, Tracts on Delirium Tremens and Perito-
nitis, See, 8vo.  Lond., 1813.—Double, in Journ. Gener. de
Med., t. xxiii., p. 378 (Cartilaginous induration).—Gase and
Monfalcon,  in  Diet,  des  Sciences Medicales, t.  xl.,  8vo.
Paris, 1817, art. Peritoine et Peritonite.—Moncrieff, Trans-
actions of Medical and Chirurgical Society of Edinburgh,
vol. i., p.  260.—M'Dowel, in Dublin Hospital Reports, vol.
ii., p.321  (Acute Peritonitis consequent upon Rheumatism).
—J.  Copland, Memoir on  Chronic Peritonitis, with cases,
&c. ;  in  Lond.  Med. Repository, vol.  xv., p. 372,  8vo.
Lond., 1821.—D. A.  G. Richter,  die Specielle Therapie,
&c, b. i., p. 650.—/. Baron, An Inquiry into the  Nature
of Tuberculated Accretions of Serous Membranes, and the
Origin of Tubercles and Tumours, &c, 8vo.  Lond., 1819;
and Illustrations  of the Inquiry  respecting Tuberculous
Diseases,  &c.  Lond., 8vo, 1822.—/.  Abercrombie, Pathol.
and Practical Researches on the Diseases of the Stomach
and Abdominal  Viscera, 8vo.   Edin., 1828.—Gibert, in
Nouv. Bibliotheque Medicale, t. ix.,  p.  392 (shows the ill
consequences of allowing the presence of the menses to in-
terfere with  the institution of blood-letting).—Andral, Clin-
ique  M6dicale, Maladies  de l'Abdomen, t. iv., p. 539.—
Roche et Sanson, Elemens de Pathologie Medico-Chirurgi-
cale, <fec, 8vo.   Paris,  t. i., p. 585.—Scoutetten,  in  Ar-
chives Gener. de Medecine, t. iii., p. 500 ; et t. iv., p. 392 ;
et t. v., p. 537.—Legallois et Bouillaud, in ibid., t. iv.—
Lombard,  in ibid., t. ix., p. 191.—Broussais,  Gasc. Aber-
crombie, Pemberton, and  Monfalcon, revd. in Johnson's
Medico-Chirurg. Review, -vol. i. p. 161.—R. Bright,  Re-
ports of Medical Cases, 2 vols., 4to.  Lond.,  1827-31, p.
453,  et passim.—Louis,' Recherches  Anatomico-Patholo-
giques, 8vo.  Paris,  1826 (Peritonitis  from Perforation of
the Digestive Canal).—Graves, Dubl. Hosp. Reports,  vol.
v.; and Dublin Journ. of Medical Science, vol. ii.—Cho-
mel, Diet, de Medecine,  t. xvi.—Scoutetten, in  Lond. Med.
Repository,  vol. xxii., p.  333.—A. N. Gendrin, Histoire
Anatomique des Inflammations, 2 tomes, 8vo.  Paris, 1826 ;
t. i., p. 61, et seq.—Duges,-Diet,  de Med. et Chirurg. Prat.,
art. Peritonite.—Clarus, De Omenti Laceratione,  et Mes-
enterii Chordapso, Leips.,  1830.—E.  Gintrac, Observ. sur
les Mai. Organiques du Peritoine, &c.; in Mem. et Obser-
vat. de Med. Clinique,  Bordeaux, 8vo, 1830.—J. Cruveil-
hier, Anatomie Pathologique, fol. Paris, 1833, livrais, xiii.—
M'Adam,  in Cyclop,  of Pract. Med.,  vol. iii.,  p. 291 ;  and
W. Stokes, in ibid., vol. iii., p.  308.—.4.  Velpeau, De l'eni-
ploi des Mercuriaux  dans le Traitemenit de la Peritonite,
8vo.  Paris ; and  in Archives Gener. de Medecine, t. xix.,
p. 535.—Gauche, in ibid., t. xxi.. p. 277.—T. Hodgkin, Lec-
tures on the Morbid Anatomy of Serous and Mucous Mem-
branes, in  2 vols.,  vol. i., of Serous  Membranes, Svo.
Lond.,  1836; sect, vi.,  p. 138.—Symonds, in Library of
Medicine, vol. iv., p. 141, 8vo. Lond.,  1840.  (See  the
Bibliography and References to article Puerperal
DlSEASEs/or the Literature of Puerperal Peritonitis.)
  Peritonitis  in Children.—/. B. T. Baumes, Traite
de 1'Amaigrissement des Enfans, accomp. de 1'elevation et
durete  du Ventre, &c, 8vo.,  2d  edit.  Paris, 1806.—G.
Gregory, in  Trans, of Med. and Chirurg. Society of Lon-
don, vol. xi., p. 262.—Billard,  Maladies des Enfans Nou-
veau-nes et  a la Mamelle, &c, 8vo.  Paris, 1828, p. 449.—
M'Adam,  Cyclop, of Pract. Med., vol. iii., p. 299.—Cum-
ing, Trans, of King and Queen's Coll. of Phys. in Ireland,
vol. v., p. 48.—/. Stewart, Practical Treatise  on the Dis-
eases of Children, 8vo.  New-York, 1841, p. 266.—Barthos
et Rilliet, Traite Clinique et Pratique des Maladies des  Ea-
fans, 8vo.  Paris, 1843, t. i., p.  555 ; et t. iii., p. 400.
  [Amer. Bibliog.—See American works on the Practice
of Medicine, referred to under other  Diseases; also,  "A
Treatise  on the  Practice  of  Medicine.  By  George B.
Wood, M.D., Prof, of Mat. Medico) and Pharmacy in  the
University of Pennsylvania; 2 vols., 8vo.  Phil., 1847."—
Many valuable cases and essays  on Peritonitis are scattered
through  American periodicals,  especially the American
Journal of Medicine, which the reader may profitably con-
sult.]

  PESTILENCE.—Under  the head pestilence
I comprise certain  maladies  which  have  ap-
peared as wide-spreading and  devastating epi-
demics,  but  which  have  surpassed  all  other
epidemics in their rapid extension, in their fa-
tality, and in the duration of their prevalence.
Nor have  they appeared only as  most fatal  ep-
idemics, for they have continued, in  countries
favourable to their perpetuation, to appear from
time to time in  a much less alarming and  ob-
trusive  manner; occurring for a time only in
few or widely-scattered instances, and at more 
 106                                 PESTI

 distant intervals, until certain favourable cir-
 cumstances,  arising out of predisposition, at-
 mospheric constitution, or some unknown, but
 more generally-diffused influence, have arisen
 and rendered what had been either unsuspect-
 ed  or  but little feared, suddenly most mani-
 fest, diffused, fatal, and appalling.   To these
 irruptions, to their rapid extension, and to their
 great fatality, the generic term pestilence may
 be justly applied ; and  the history of medicine,
 in recent times, furnishes  three maladies to
 which this term is especially applicable, name-
 ly, the recent distemper, which has generally,
 but injudiciously, been  called cholera, yellow fe-
 ver, and the plague or pest.  To these might be
 added, perhaps, small-pox, scarlet fever, mea-
 sles, and some other infectious fevers; but these
 diseases only occasionally, or even very rarely,
 and then only in peculiar circumstances and in
 certain races, assume forms which, as respects
 either malignancy, prevalence, or fatality, can
 entitle them to be placed in the samecategory
 with those now about to be considered.
  1. If the history of pestilences, ox of pestilential
 epidemics, be  studied in Grecian,  Roman,  and
 Arabian writers, and in  the writings of the four-
 teenth and fifteenth centuries,  it will be maniT
 fest that the causes to which these pestilences
 were  imputed  are nearly the same  as have
 been assigned in modern times.  Hippocrates
 ascribed epidemics generally to the food, drink,
 and air;  and  Galen, with Lucretius, Avicen-
 na, and others who copied him, considered at-
mospheric heat, and the miasms exhaled from
 the soil and from the putrid bodies of animals,
 as the  chief causes of  all pestilences.   Aven-
 zoar enumerates, as their sources, a warm and
humid  air, unwholesome food, and emanations
 from  stagnant water  and  from dead  bodies.
 Haly* Abbas assigns the same causes as Aven-
 zoar, but  attributes a share of the influence to
the nature of the seasons.  From Homer to the
present time, considerable influence in the pro-
duction of pestilences has been imputed to great
heat of the sun and to very hot seasons.  Di-
 odorus Siculus ascribed the plague of Athens
 and the disease which attacked the Carthagin-
ian army in Sicily to the excessive heat of the
 sun, to exhalations  from the soil, and emana-
tions from the bodies of the dead.  Ammianus
Marcellinus considered extremes of heat or of
cold, of drought  or  of moisture, exhalations
from the earth, and the effluvia from the dead
 and from putrid animals, as the chief causes
 of pestilential epidemics.  But, although these
were assigned as the chief causes of pestilen-
ces by nearly all the  ancient writers, still oth-
 ers, and particularly infection  and contagion,
 were also viewed, as I  have shown in the arti-
cles Epidemic  Influence  and Infection, as
 contributing tb their propagation.  Tiiucydides,
 as Mr. Adams, the learned translator of Paulus
 ^Egineta, remarks, evidently  considered  the
 plague of Athens infectious, for  he  mentions
 that physicians were more attacked by it than
 others, as having most  intercourse  with the
 sick; and he  describes  the terror which the
 citizens felt to approach the affected,  and inti-
 mates that it was often contracted by such in-
 tercourse. Many historians, poets, and physi-
 cians among the ancients, since  Tiiucydides,
 have considered pestilential epidemics to be in-
 fectious^—not always, however, by contact, but
more generally by emanations from the sick,
which contaminate  the  surrounding air,  as
shown in  the article  Infection (y 11, et seq.).
Marx, Omodei, Adams, and others have refer-
red to the opinions of the ancients on this sub-
ject, in order to disprove what had been falsely
alleged  by a few writers of  small  reputation,
that the doctrine of infection  or contagion was
altogether modern.   That the. ancients, how-
ever, entertained correct views of the matter
is evident  from a reference to the writings of
Aristotle, Livy, Pliny, Dionysius ofHalicar-
nassus, Diodorus Siculus, Appian, Plutarch,
Quintus Curtius, Dio Gassius, Eusebius, Mar-
cus Antoninus, Chrysostom, Seneca, and Is-
idorus  Hispalensis.   The last  of these  re-
marks, that " Pestilentia est contagium quod
quum unum  apprehenderit celeriter ad plures
transit."  "Pestilentia est morbus latevagans
et contagio suo quae contigerit  interimens."
  2. A belief in the infectious or  contagious
nature of pestilential fevers  and some other
diseases was entertained by Aret.eus, Celius
Aurelianus, Galen, Aetius, Paulus ^Egineta,
and by several of the Arabian medical writers.
Mr. Adams remarks, that the result of his ex-
amination into the opinions of the ancients on
this subject leads him to the conclusion that all,
or at least the most intelligent of the medical
authorities, held that pestilential epidemics are
communicated, not by  any specific virus, but
by the contamination of the surrounding air by
effluvia from the sick.   As to this, as well as
to other sources of pestilential  diseases, the
ancients did not differ materially  from the best
informed of the moderns.  Indeed, faithful ob-
servers in all ages must have arrived at nearly
similar conclusions ; for, although various sub-
ordinate circumstances may have  changed with
the progress of time, and some causes may have
assumed more intense,  and others less promi-
nent forms, still the chief and efficient sources
and  influences must have been reproduced in
the succession of ages after indefinite intervals
in those states and combinations which devel-
op and propagate either pestilence or less ma-
lignant epidemics.  If we consider the changes
continually taking place near  the  embouchures
of rivers with the progress of time, the deep
and exuberant soil that  is there accumulating,
and the frequency of inundations ; if we reflect
upon the circumstances  affectirig the physical
conditions of large cities, and upon the con-
taminations of the air, water, and soil, arising
from these and other crowded and ill-ventilated
places of  human resort, we  shall find causes
sufficient  to  explain a  portion of the morbid
phenomena, but not the whole, which  present
themselves to the physician,  especially during
warm and humid states of the atmosphere, and
under the influence of certain electrical condi-
tions, or of unusual stillness of  the air.   Yet
even these are not of themselves sufficient to
account for all the phenomena which occur du-
ring the prevalence of  destructive epidemics.
Conceding all that can  be contended for as to
the baneful influence on  the human  constitu-
tion of exhalations from rich, deep, and humid
soils  into a warm, stagnant, and moist atmo-
sphere ; of effluvia from  the exuviae of living
human beings and other  animals congregated
in masses in camps, cities, and towns; of ema-
nations from dead and  putrefying bodies, in- 
PESTILENCE, CHOLERIC.                           107
sufficiently covered by the  soil,  and diffusing
their elements through the soil, and transmit-
ting them to the atmosphere within  or around
these  localities ;  and  of the water  of  these
places impregnated with putrid animal matter ;
granting, in their full  force  of pestilential gen-
eration, the infecting influence of these causes,
still an  additional cause is required  to explain
many of the phenomena falling under  the cog-
nizance of the physician ; and that cause often
presents itself in a  manner that  cannot be
mistaken,  and, in many instances,  in such a
way as  admits not of dispute.  That other and
most  influential cause, often superadded to or
generated  by the  foregoing, is infection, or, as
I have  shown in the article on this subject,
the effluvium or miasm which emanates from
the sick,  contaminates the  surrounding  air,
and  the patient's day or night  clothing,  and
thereby, propagates  to the healthy a disease
similar  to that from which itself proceeded, and
often in circumstances and  in situations  where
the other  sources of the disease cannot have
existed.
  3.  If the circumstances, physical and  moral,
characterizing congregations of our  species,
whether in camps or  in cities, in ancient  times,
be considered as far as we possess the informa-
tion,  and be compared with those which exist
in respect of similar congregations  and  locali-
ties at  the present day, we shall find that, al-
though  a few  causes  of malignant disease are
no longer  in' operation^ others have sprung up,
and have  become excessively injurious,  not-
withstanding  that numerous  influences  aid in
counteracting or limiting the mischief.  Many
of the rites, even of religion and of supersti-
tion,  during early ages and  in pagan countries,
tended  remarkably to diminish the sources of
infection and of  pestilence.  The embalming
of the dead by the Egyptians and other ancient
nations, the laws  rigidly enacted  by Moses and
enforced by Jewish  rulers,  the burning  of the
dead by several nations, and the  modes  of sep-
ulture adopted by the Chinese from the earli-
est  ages,  were all more or less calculated to
 prevent the bodies  of the dead from proving
 sources of destruction to the living.   But with
 Christianity,  and with the  superstitions which
were successively ingrafted upon  the  purest
and  most sublime doctrines, sprang  up prac-
tices of the most injurious tendency to public
health, and these have now, particularly in large
towns,  advanced  so  far as to become matters
of traffic with some  of those who profess the
greatest  anxiety for  the souls,  if not for the
health,  of their species.  The desire of deposit-
 ing the dead within the consecrated sphere of
spiritual instruction,  or of  boasted inspiration,
 became general, and the places of such  depos-
 ite also became, especially in recent times,  a
source  of emolument. Thus religion was made,
 even by the  sanctimonious,  the  handmaid  of
Mammon ; and often, in no lengthened process
of time, the accumulated  bodies of  the dead
furnished  pestilential  emanations,  diffusing
sickness and  deaih among those who congre-
gated in their vicinity.   Thus, also, sleek hy-
pocrisy, in the garb  of sanctity, lured its vic-
tims within the sphere of infection, thereby in-
creasing the rate of mortality, and at  the same
time augmenting its  revenues by swelling the
general mass of animal corruption, and multi-
plying the sources of infection.  I have shown
elsewhere (see articles Endemic and Epidemic
Influences  and Infection) that the accumula-
tion of human exuviae, and the interment of the
dead among the living, and in  places  of fre-
quent public resort, occasion, in the course of
ages, a state of the soil which is most produc-
tive of noxious emanations, especially under
the influence of a hot sun, and a  warm, stag-
nant, and humid atmosphere, and which, more-
over, contaminates the water in the vicinity.
Thus  ancient cities  have generated the sour-
ces of their own decay, which circumstances
have  retarded or accelerated, according  as
these  sources have been counteracted or aug-
mented  by  legislative  measures  either of a
beneficial or of an  injurious tendency.
PESTILENCE, CHOLERIC—Synon. Pesti-
  lential Cholera, Pestilential Asphyxy, Asphyxia
  Pestilenta, Author.   Epidemic Cholera, Auct.
  Var.  Spasmodic Cholera, Cholera Spasmod-
  ica, Auct.  Var.  Epidemic Spasmodic Cholera,
  Hawkins.   Cholera  Asphyxia, Asiatic Chol-
  era, Indian Cholera,  Malignant  Cholera,  va-
  rious authors.   Convulsive Nervous Cholera,
  Gray. Hyperanthraxis, Clanny.  Cholera Mor-
  bus, Cholera  Epidemiquc,  Cholera  Asiatique,
  Fr.  Die Epidemische Cholera, Asiatische Chol-
  era, Germ.
    Classif.—II. Class, III. Order (Author in
      Preface).
  4. Defin.—i. Nosological.—Anxiety and op-
pression in the chest, epigastrium, and pracordia ;
disturbance of the bowels, with nausea, faintness,
giddiness, and depression of vital power ; frequent
ejections of  an offensive fluid, resembling rice-
water, from  the bowels and  stomach, followed by
spasms, tremours, distress;  a cold, clammy, pur-
plish, and shrivelled slate of the surface ;  coldness
and rawness of the expired air; a sense of painful
or burning heat at the  epigastrium, with urgent
thirst, and rapid disappearance of the pulse;  the
distemper being often preceded by indigestion and
diarrhoia, and frequently followed by febrile reac-
tion, affecting chiefly the brain and abdominal  or-
gans.
  5. ii.  Pathological. — A discharge from  the
bowels and stomach of the  watery portion of  the
blood; more  or less complete paralysis of the lungs,
and arrest of the changes effected by respiration on
the blood, and of the hepatic and renal secretions;
depression of the heart's action; the circulation
of a thick, dark, or venous blood through the  ar-
teries, with congestion in the large veins, and im-
perfect circulation through  the  capillaries, owing
to the thick, glutinous state of the blood.; the con-
gestion of the viscera in many cases being followed
by an obscure or asthenic reaction, affecting chiefly
the cncephalon and abdominal viscera.
  6. I. Introductory Remarks.—Circumstan-
ces had induced the author to pay more than
ordinary attention to the nature and progress
of the pestilential cholera, from its irruption in
Bengal to the present time.  He  had perused
with the utmost care, much of what has been
published respecting it; and an opportunity had
been afforded him of examining the reports and
documents  relating  to it  sent, from  1817  till
1827, by the medical boards and superintending
surgeons of the three Indian presidencies,  to
the Board of Directors of the East India Com-
pany.  He  had frequent  opportunities of  ob-
serving and treating cases of the malady in thi§ 
108
PESTILENCE, CHOLERIC—Introductory Remarks.
 country, and of examining the bodies of the
 dead.  During these inquiries, he was particu-
 larly struck by some important facts, respecting
 which he conceived that much misapprehension
 and error were entertained and widely dissem-
 inated,  and  which required  refutation.   The
 first of  these is connected with the origin and
 nature of the distemper.  Many suppose it  to
 be the  common spasmodic  cholera of warm
 climates, in an epidemic form merely, an opin-
 ion  entertained by able  writers, both in this
 country  and on the Continent, until they had
 opportunities of witnessing it.   This  opinion
 was, however, opposed to the author's experi-
 ence of the forms of cholera met with in warm
 and insalubrious countries, between which and
 the  recent pestilence  there is a very  marked
 distinction ;  and it was contrary to the belief
 of the oldest European residents in India, and
 of the  natives  themselves, who might  have
 been supposed to know something of the usual
 manifestations of cholera among them, unbias-
 ed by preconceived notions, or by medical sys-
 tem and authority.   Instead of looking upon it
 as an aggravated form of cholera, they regard-
 ed it, wherever it broke out, as an unheard-of
 pestilence and scourge; and at its appearance
 whole villages and towns were deserted in con-
 sternation to escape its  infection ; while the
 greater part of the English practitioners, having
 been taught  to consider cholera to consist of
 purging,  vomiting, and spasms of the lower ex-
 tremities, and finding these symptoms  present
 in the distemper they were called to  treat, be-
 lieved it  to be that disease merely, in an aggra-
 vated form, without taking into  consideration
 much more  important phenomena uniformly
 presented by it, and without sufficiently advert-
 ing to the fact that these symptoms are often
 slight, or nearly altogether wanting, in the most
 severe cases.
   7. So  strongly was the author struck by this
 misapprehension, that in the beginning of 1822,
 when editor of  the Medical Repository,  after
 noticing  various facts  connected with the dis-
 ease, he observed, " A careful  review of the
 symptoms of this disease convinces us that the
 deranged actions which take place in the sys-
 tem  during its continuance, are no more those
 to which the term cholera morbus ought to be
 applied than they are those belonging to fever.
 It appears that this malady is the  result of a
 peculiar cause, which impresses the vital ener-
 gies of the system in such a manner as to sub-
vert the power of reaction in many cases, and
to render it imperfect and unavailing in  others,
without the assistance of art.  The cause of
the disease seems to act as a poison on  the ex-
 tensive surface of the bronchiae and air-cells
when the system is most liable  to  its attack ;
and, in many instances,  it appears to destroy
its victim in a few hours."  (Lond. Med. Reposit.,
vol. xvii., p. 407.)
  8.  That the author's opinion was  neither
prematurely advanced nor inaccurate, has been
shown by the subsequent  researches  of the
most eminent observers.   He had treated many
cases of spasmodic cholera in a warm and most
insalubrious climate, and had experienced the
disease most severely  in his own person ; and
while he  recognised in these cases the accurate
description of Paisley, Curtis, Girdlestone,
and Dr. James Johnson, he never met with, in
 any of them, the pathognomonic symptoms of
 the late pestilence.  In this opinion he is borne
 out by the experience of every  well-informed
 and candid observer who has seen the disease
 in  this country, and who will readily concede
 that it is  altogether distinct  from the severe
 forms of common cholera.  (See art. Cholera.)
   9.  The  second error, which has been exten-
 sively propagated,  both  in  this country  and
 abroad, is, that the malady never exhibited any
 proofs of infection in the East.  Knowing, how-
 ever, from the best sources of information, that
 this statement is  erroneous, the  author  has
 gone fully into the  refutation of  it,  and  has
 shown  that  much mischief has resulted from
 this opinion, and  from the fact  that, although
 evidence of its infection was everywhere fur-
 nished in India, no means of limiting the exten-
 sion of the  pestilence, no sanitary measures,
 were adopted in our Indian empire.  That  the
 distemper  should extend  less  rapidly there, and
 exhibit its infectious property in a less  remark-
 able manner than in Europe, was to be expected
 from free ventilation, and other circumstances
 tending to diminish  the  chances of infection,
 particularly  among  Europeans  in  warm cli-
 mates.
   10. A third error very generally entertained,
 both on  the  appearance  of the distemper and
 in the present day, is, that it is caused by  some
 unknown constitution of the air.   But we have
 no instance on record of an epidemic of nearly
 thirty years' duration, without any interruption,
 unconnected with infection.   Although  the au-
 thor admits  that the pestilence is  greatly ag-
 gravated by certain  states of the air, to which
 the term epidemic is strictly applicable, not-
 withstanding our ignorance of the precise na-
 ture of these states,  yet there seems no doubt
 that it is propagated, and prevails to a certain
 extent, independently of an epidemic concur-
 rent influence.  We  know that some diseases
 are simply infectious without being epidemic;
 that others are both infectious and epidemic;
 and others are epidemic, and only contingently
 infectious.   But the  author believes that, like
 eruptive and typhoid fevers, this  distemper is
 infectious,  is not essentially epidemic, although
 it will, during  favourable states of the atmo-
 sphere, «Scc,  assume  epidemic characters, and
 be modified accordingly.  An attentive review
 of the various manifestations  of the malady in
 India, throughout Asia, in Europe, and in Amer-
 ica, seems  to justify  this view, and to confirm
 the conclusion as to its being a specific disease,
 arising from a specific cause, but promoted and
disseminated more widely by the aid of various
concurrent causes, among which  epidemic, or
 unhealthy constitutions of the air; dirty, crowd-
ed, and close apartments ; and crowding of the
sick, are the  most prominent.*
 [* Whatever character cholera may have assumed on the
other side of the Atlantic, and especially in India, we think
we shall be borne out in the assertion that, in this country,
 it was essentially epidemic, and  propagated by atmospheric
 influences, independently, in  general, of infection.  Thus
 its first approach was marked by a general prevalence of
derangements of the digestive organs, which few, indeed,
escaped, and  which continued  to prevail as long as the
disease itself continued.  When the epidemic  influence
 wns slight, cholerine, ns it was called, prevailed, marked by
 languor, furred tongue, impaired digestion, colicky  pains,
and perhaps diarrhcea ; hut when this epidemic  influence
had attained a certain degree of intensity, then well-marked
cases of cholera occurred, usually among the lower and
intemperate classes; other cases soon occurred, not  ex- 
PESTILENCE,  CHOLERIC
'—Progress and Mortality.              109
  11.  II. Progress and Mortality.—i. Prog-
ress.—Pestilential cholera first made its appear-
ance in Jessore, a populous town in the centre
of the Delta of the Ganges, and  cut off the
majority of those whom it attacked.  It spread
from  the  town in all directions,  and reached
Jaulnah, on  the Madras side of the Indian pen-
insula, in June, 1818, and Bombay in August of
the same year.  It continued to spread and to
prevail throughout  all  parts of India and the
adjoining countries, and still prevails in many
districts, although in various degrees of severi-
ty,  and with intervals of complete  immunity
from  its presence.  Indeed, it may be said to
have  become naturalized in India, forming one
of the diseases of the country.
  12. During 1818 it visited, in an easterly di-
rection, the Burmese Empire, the kingdom of
Arracan,  and the  peninsula of Malacca.   In
1819  it appeared in the isle of Penang, in Su-
matra, Singapore, the kingdom of Siam, Ceylon,
and the isles of France and Bourbon.  During
1820  it reached Tonquin,  Cambogia, Cochin-
China, Southern China, Canton, the Philippines,
&c.  In 1821 it visited Java, Bantam, Madura,
Borneo, and numerous other places  in the In-
dian Archipelago.  In the years 1822,1823, and
1824 it appeared  at Tonquin,  Pekin, Central
and Northern China, the Moluccas, Amboyna,
Macassar, Assam, and various other Eastern
countries and islands.   During  1827 it pre-
vailed in Chinese Tartary.   In  all these coun-
tries  and places its prevalence and fatality were
unprecedented in medical history.
   13. In July, 1821, it reached, in its western
course, Muscat, in Arabia ; and, during the re-
mainder of the year, visited various places in
the Persian Gulf.   In  the  following month  it
appeared in Persia, and, during 1822 and 1823,
1829  and 1830, it prevailed in several  of the
principal cities of that empire.  It broke out in
Bussorah and Bagdad in July, 1821, and in 1822
and 1823  ravaged  most of the  populous cities
of Mesopotamia, Syria, and Judea.
   14. In 1822 it reached  to within  150 miles
of  the  Georgian  frontiers  of  Russia, and in
1823 appeared at Orenburg and Astrachan, be-
yond which it seems not to have extended un-
til August, 1828 and 1829,  when it  reappeared
at Orenburg, the capital of the province of that
name, situated on the Tartar  frontier, about
400 miles north of the Caspian, and about 1000
miles north  of the places where  it prevailed
extensively in 1822.  Its prevalence and fatality
in this province were great, upward of a tenth
of the inhabitants having been seized, and about
a fourth part of  those attacked having died of
it.  At the same time that the disease appeared
in Orenburg, it was raging in  several Persian
provinces and Tartar tribes in Central Asia,
from  which it was  supposed to have been intro-
duced into Orenburg.  At the commencement
of 1830 the disease had entirely ceased in the
Russian  dominions ;  but  towards  the  begin-
ning  of autumn it broke out  with increased
violence  on  the Georgian frontier of Persia,
having appeared, in June, in the Persian prov-
ince  of Ghilan, on the southern shore  of the
Caspian, from the various  southern ports of
empting those of temperate habits, and who had never been
exposed to the disease until it reached its acme ; then the
malady gradually died away, marked by the same tendency
to bowel complaints which characterized its approach.!
which it extended northward along the west-
ward  Caspian  shore  until it  reached Baku,
Tiflis, Astrachan, and numerous other towns
in its progress into the heart  of the Russian
Empire.  After attacking a number of places,
it has continued to spread westward and north-
ward  through Russia,  Poland, Moldavia, and
Austria ; visiting Moscow, Warsaw, and other
places in Poland, and extending, in May, 1831,
to Riga and Dantzic, and, in June and July, to
St. Petersburgh and Cronstadt; early in Octo-
ber to Berlin  and Vienna, and subsequently to
Hamburgh, &c.
   15.  The  distemper appeared for the  second
time in Astrachan  near the end of July, 1830;
and before  the end of August upward of 4000
persons died of it in the'eity, and 21,270 in the
province.   After ascending the Volga it reached
Moscow, became prevalent there at the end of
September, and continued till February, 1831.
It attacked about 9000 persons in this city, of
which  number more than one half died.  It
reached Riga  in  the middle of May,  and St.
Petersburgh on the 26th of June.  From As-
trachan it extended to the northern coast  of
the Black Sea, and in the course of the rivers
into the central parts  of Russia.  It  reached
Poland in January, 1831, followed the Russian
army in the subjugation of that country, and
proved destructive in Warsaw and many other
places  during  April and May.  At the  end of
the latter month it appeared in Dantzic.   In
June  it  prevailed in  Lemberg,  Cracow, and
other adjoining parts, extending through Gal-
licia and Hungary, and reaching Berlin and
Hamburgh  in August  and September, and Vi-
enna  in  the  same months.   It  appeared at
Smyrna in  September, and soon afterward in
Constantinople.  The pestilence was conveyed
by a caravan  from Mecca  to Cairo in August,
1831, some thousands having died on the road,
and by the middle of  September  10,400 Mo-
hammedans, besides Jews and Christians, had
died of  it in this latter city.
   16.  Pestilential  cholera  appeared  in En-
gland on the 26th of  October, 1831,  at  Sun-
derland, a month afterward at Newcastle-upon-
Tyne,  and in December  at  Hetton,  Hough-
ton-le-Spring, North Shields, Tynemouth, South
Shields, Gateshead, and other places. The first
cases reported in London occurred on the 13th
or 14th  of February, in the immediate vicinity
of the shipping,   In Scotland  the pestilence
first appeared at Haddington about Christmas,
1831, and  in  Leith and Edinburgh about  the
22d of January following.   Although instances
were  adduced of sailors  belonging to ships
which had  arrived from Riga, Cronstadt, Ham-
burgh, and Dantzic, and on board which indi-
viduals had died of the malady on the passage,
being those first affected at the  sea-ports in the
north of England, still there is every reason to
believe, from the information given me by sev-
eral captains of ships who had left these foreign
ports  during  the period when  the distemper
was prevailing there, that the infection was
conveyed to many places in both England and
Scotland in the clothes and bedding belonging
to sailors who had died either in these  foreign
ports, or on the  passage of the ships  back to
this country,  the clothes  and  bedding of the
sick and dead having  been preserved  without
any purification, and given up to the relatives. 
^Progress and Mortality.
 110             PESTILENCE, CHOLERIC

   17.  From this country  the  pestilence was
 conveyed in an emigrant  ship across the At-
 lantic  to Quebec, many of  the emigrants hav-
 ing died of it on the passage.*  It appeared at
 Quebec on the 8th of June, 1832, and on the
 10th at Montreal; and thence it extended to
 Kingston, on Lake Ontario, and all  the sur-
 rounding parts.  New York was attacked by it
 on the 24th of June,  and Albany  on  the 3d of
 July.   About the middle  and end of July it
 spread to Newcastle, on the Delaware, to Phil-
 adelphia and several  other cities, and thence
 to nearly all North and South America.   It ap-
 peared at the Havanna in February, 1833.
   18. The  pestilence  appeared at Calais  on
 the 12th of March, and was believed to have
 been brought from England.  On the 26th it
 broke  out in Paris, where  it carried off about
 20,000 persons by the end of September, no
 precautions having been taken to prevent  its
 extension, a general belief of its non-infectious
 nature having been  erroneously entertained.
 During 1833 and the early part of 1834 it raged
 throughout Spain, and was very destructive in
 Madrid.  It visited several parts  bordering on
 the Mediterranean in 1834, and reappeared in
 London and in some other  places in this coun-
 try, as well as  in North America, in  the same
 year.   It was most  destructive  in  Rome in
 1837, the number of deaths varying, for many
 days, from  200 to 300 daily.  It spread to va-
 rious other  countries not  mentioned in this
 brief sketch, between  the years 1831 and 1837;
 and few places were entirely exempted from it,
 excepting those which were placed under strict
 quarantine.   It still prevails (1845) in several
 parts of the East Indies,
   19. ii. The prevalence of  this pestilence  and
 the mortality among those  attacked varied re-
 markably in different localities, and in different
 races of the species,  and were variously esti-
 mated  by different writers.   The  mortality, as
 well as liability to attack, was certainly great-
 est among the poor and ill-fed ; and among the
 dark  races and those presenting  the  lower
 grades of constitutional power and of vital re-
 sistance to depressing agencies.  The propor-
 tion of attacks to the population, and fatal ca-
 Bes in the whole number of attacked, were dif-
 ferently estimated, according as those  cases
 which  consisted chiefly of  diarrhcea, or of the
 incipient stage, were  comprised in or entirely
 left out of  the account.  Owing  to these  cir-
 cumstances, nothing  can be stated with any
 precision as to this point.   In Arabia one third
 of the inhabitants of the towns which this pes-
 tilence visited was said to have died of it.   In
 Siam,  Java,  and the  Mauritius  the number
 seized  was extremely great,  as  well as  the
 mortality.  In China its fatality was still great-
 er, especially in  the  more densely-inhabited
 places, owing chiefly to the neglect of precau-
tionary measures.  In Persia one sixth  of the
population of the principal cities and towns was
 cut off by it; and from one fourth to one third
 of the  population of Mesopotamia was said to
 have perished.  In Bassorah and Bagdad, sit-
uate in unhealthy localities, and in a humid at-
  [* It is by no means certain that the cholera was convey-
ed across the Atlantic in an emigrant ship, as stated by Dr.
Copland ; all attempts to trace the introduction of the dis-
ease into Quebec in this manner have  proved unsatisfac-
tory.]
mosphere, a third of the inhabitants was car-
ried off by it in little  more than a month.  At
Erivan and Tauris it  destroyed about one fifth
of the population.  But in more elevated and
healthy situations it was much less fatal.  In
Syria its  ravages were extremely  varied;  in
some places one half of the inhabitants were
swept away, while in  others, as in Tripoli, only
one perished  out of every 200.  During the
prevalence of the pestilence  in  the southern
and eastern provinces  of Russia, in 1830. the
mortality  was  also various.  At Tiflis three
fourths of the  sick, at Astrachan two thirds,
were  carried off.  Out of 16,000 attacked in
the province of  the Caucasus, 10,000 died; at
Moscow one half, and  at Orenberg  one  fifth
only perished.   According to the author last
quoted, out  of 54,000 and upward attacked in
the provinces of Russia, in 1830, more than
31,000 died.  In  Hungary alone about 400,000
persons were said to  have been seized, and
more than half the number to have died.
  20. In Astrachan one  third of the cases were
said to have been fatal; among the Don Cos-
sacks two thirds.  At  Moscow  the mortality
varied greatly, being at first  so  high as nine
tenths of the cases, and afterward sunk gradu-
ally to a third.   When the disease first appear-
ed in  India,  the  mortality was also  extremely
high ;  but its prevalence, as well as its fatali-
ty,  gradually abated after 1821.   Exceptions,
however, to this amelioration presented them-
selves in various places ; and at  the same pe-
riod, when the  rate of mortality did not rise
above 8 or 10 per cent, in some parts, from one
fourth to two thirds of the persons seized by it
died in other places.
  21. Of the prevalence and  mortality of the
distemper in this country, Dr. W. Merriman
has furnished the following table  from the Re-
ports sent to the Privy Council Office.  It must
have  been evident, however, to  all  who paid
attention to the matter at the time, that the re-
ports were not even approximations to correct
statements ; for, to my own knowledge, sev-
eral deaths from the disease in my own neigh*
bourhood occurred without having been report-
ed  as  such, and very  numerous cases were
treated successfully during the  early or pre-
monitory stage which were  either not viewed
as cases of the malady or not returned as such,
The prevalence  and rate  of mortality, as  far as
my own observation enabled me to judge, were
remarkably increased by previous ill health, by
debility, and by advanced age.   The number of
cases which occurred before puberty was very
small, and from that age to thirty the propor-
tion of recoveries was  greatest.   From forty
to fifty the proportion of deaths  increased re-
markably, and after fifty years of age but few
recovered.   But much appeared to depend upon
the violence of the attack at the beginning.
England, London, Wales,	Case;.	Deaths.	Recover-ies.
	59,594 11,020 1,436 54,552	14,807 5,273 498 21,171	33,790 5,745 938 33,381
Ireland up to ( March, 1833, j			
  [The following  table, compiled by Prof. J.
Jackson of Philadelphia, exhibits the cases and
deaths in Quebec,  Montreal,  New-York, and 
PESTILENCE, CHOLI
Philadelphia, with the ratios of cases and deaths
to population and to each other.*—(Amcr.Jour.
Med. Sciences, vol. ii., p. 291.)]
Date of report and place.	Popula-t.on.	5	1 ft	Ratio of Cilses tu pop.	c u	Ratio or deaths to pop.
Sept. 2. Quebec, "21. Montreal, Aug.28. N. York, Sapt. 13.PhiJad.	32,1)00 28,000 140,000 160,000	578H 144(1 5814 2314	2218 lin517 lto2A 1904 linGS lto2| 2935|lto24A! 1 to 2 935| 1 to7ll|lto2£			1 in 14.', 1 in 143 1 in 47 linl73
  22.  Ill  Description op Pestilential Chol-
era.—The nature  of this  pestilence is best in-
ferred from a faithful history of the phenomena
manifested by it, during its progress, and of the
changes it produces in the organization, and
from the  means found successful in  limiting
its extension  and in restoring the frame  to
its healthy  state  when  subjected to its at-
tack.   In  conducting an inquiry  fnto the phe-
nomena and nature of this pestilence, I  shall
confine myself to the more important topics of
the subject, and endeavour  to  arrive at  infer-
ences foudded on  careful observation and ex-
tensive experience.
  23. Since the first irruption of the malady in
the Delta  of the  Ganges,  during its various
manifestations in India and other parts of Asia,
and in its different visitations of northern and
western countries, whether  observed in British
India, in Siam, Java, and the adjoining islands ;
in China,  in Tartary, in Arabia, Persia, Syria,
or in Russia, England, and  other countries of
Europe, or in America; whether attacking the
Hindoo, Mussulman, the  Malay, the  Mongul,
the Asiatic, Caucasian, or the European branch-
es of this race, the characteristic features of
the  disease have been uniformly the same ;
modifications as respects  grade, or intensity of
attack, and as regards the severity and the oc-
currence  of the consecutive  fever, being the
Chief sources of distinction.  Age, constitution,
and varying degrees of predisposition frequent-
ly occasion different manifestations of certain
functions, or peculiar forms of disturbance, yet
still the principal  phenomena continue but lit-
tle modified excepting in  degree ; and it  is not
until consecutive  changes  are induced in the
system by  the  morbid actions characterizing
the  disease, that  any marked difference  mani-
fests itself, such  difference evidently proceed-
ing from pre-existing states of the internal vis-
cera, innate vigour of constitution,  and the
remedial  means employed  to remove the at-
tack.  This uniform  character of the malady
indicates  a specific cause, with which, howev-
er, several others may combine, favouring its
action by disposing the frame to its invasion,
by re-enforcing its activity, or calling it into op-
eration after the body has been exposed to its
influence.
   24. The specific cause producing the disease
may be supposed not only  to be thus re-enforced
by other causes, some of them of no mean in-
fluence, but itself may vary considerably  in in-
tensity, producing, cateris paribus, effects of co-
ordinate severity,  yet still acting with a certain

  [* The above table does not include the whole period of
the epidemic, bat may serve to give a comparative view of
the disease  in those cities respectively to the dates men-
tioned.  The population of New-York is estimated not from
the usual ordinary number at  the above period,  but of
those remaining in the city.]
RIC—Description.                      Ill

relation to the predisposition of the individuals
exposed  to  it.   This may be more clearly  il-
lustrated  by taking for granted  the operation
of a certain infectious  product or poison, the
existence of which will be shown in the se-
quel.   This product  or effluvium  emanating
from the bodies of those attacked with the dis-
ease, often in a form  rendered manifest to the
senses of the  observer, necessarily varies  as
respects  concentration and quantity, dilution in
the air, and  rapidity of dissipation by means of
ventilation ; its effects,  therefore, may reason-
ably be supposed to vary equally in  grade, the
state of predisposition to become affected by it
being the same.  Where, however, the predis*
position is great, as after great fatigue, during
mental depression, &c, a  less concentrated
and  abundant effluvium proceeding from the
affected,  will produce a more intense  effect
than this  principle in  its most active and con-
centrated form, acting upon a person but slight-
ly predisposed; while this intensity of  cause
will  altogether  fail of  producing  any marked
effect in  the strong, the unpredisposed, or the
person whose moral confidence and equanim-
ity generally repel the invasion of any form of
infection.
  25. Thus,  therefore, the manifestations of the
malady will be modified chiefly in grade, and
scarcely  at all  as respects its form.  In these
respects  the efficient cause of  the disease is
perfectly similar in its operation to the causes
of other infectious diseases familiarly known,
and frequently  observed in an epidemic form ;
when the poisonous emanation is concentrated
and intense, the subject being also predisposed
to its invasion,  its effects are rapidly produced,
remarkably  severe, and  speedily arrive at a ter-
mination.  On  the other hand, when weak  or
much diluted, or when the predisposition of the
subject is slight, its operation is slow, and the
train of morbid actions of longer duration and
diminished severity.   Thus I have  seen a per-
son  struck  down  nearly inanimate  by the in-
fectious  effluvium proceeding from the bodies
of the  sick,  and concentrated in a close apart-
ment, and death following in a few hours with-
out the energies of life being rallied ; and sim-
ilar results  have been often observed by oth-
ers.   Owing, therefore, to the intensity of the
efficient  cause  of the  disease, to the number of
concomitant causes  which may re-enforce  its
action, and  to  the state of predisposition  of
those  exposed  to them, the  modified results
which  I  am now about to detail  will present
themselves.
  26. i.  A.  Symptoms.—The invading or pre-
liminary symptoms of the disease generally con-
sist  of pallor and collapse of the countenance,
with an expression of  anxiety; slight pain of
the  forehead, noise  in  the ears, and  vertigo;
sickness, heat, and  pain at  the  epigastrium ;
oppression at the chest, with frequent sighing;
nervous  agitation, remarkable loss of muscular
power, general uneasiness ;  colicky pains  in
the abdomen, with slight diarrhoea, at first fec-
ulent,  but afterward  watery or serous ; sick-
ness at  stomach ; slight cramps  of the legs ;
oppressed, weak, small, slow, or creeping, and
sometimes  intermitting pulse,  and  coldness,
clamminess, or humidity of the surface. These
symptoms are  of varied duration—of one, two,
or even three days, sometimes of several hours 
112
PESTILENCE, CHOLERIC—Description.
only, and at other times not of as many min-
utes.   In some cases  they have been scarce-
ly remarked, the patient  having been  struck
down almost lifeless, with a dark or livid state
of the surface, and  all the  symptoms charac-
terizing the fully-formed state of the disease.
  27. Dr. Smith observes, that several of those
about to  be attacked may be seen with a pecu-
liarly dark ring round their  eyes ;* and others
state that the features evidently collapse, and
the expression becomes anxious for a day or
two, or at least for  hours, before they sicken.
At Orenburg, dyspeptic symptoms are stated to
have preceded its attack, and a similar observa-
tion has  been made  in other places.  Various
authors have said that stomach and bowel com-
plaints, of a less serious nature, often preceded
a fully-developed seizure for a day or two; and
that  these complaints  have likewise occurred
in the place where this pestilence has prevail-
ed, and been  removed by  treatment, or  disap-
peared spontaneously, without being followed
by the fully-developed distemper.  This, indeed,
agrees with  my own  experience  during the
prevalence of the malady in London ;  for al-
though but comparatively few were carried off
by the pestilence, yet  very many experienced
severe indigestion,  flatulence,  and diarrhcea,
with marked vital depression, sometimes with
slight spasms ; these ailments being either re-
moved by restorative and astringent medicines,
or successfully  resisted by  the powers of the
constitution.   And I may add, that there were
very few medical men who did not experience
these symptoms in their own persons—at least
the dyspeptic symptoms, if not the diarrhcea—:
during the period of their attendance on cases
of the distemper.
  28. B.  The fully-developed state of the malady
consists  of great  vertigo,  nervous agitation,
oppression at the chest  and praecordia, with
complete loss  of muscular  energy;  cramps,
commencing at the  fingers  and toes, and  rap-
idly extending to the trunk ; slow, thready, and
weak pulse; great collapse of the countenance,
the eyes  being sunk  deep  in their sockets, and
surrounded by a dark circle ; vomiting and
purging of a fluid resembling whey, or rice-wa-
ter, containing whitish flocculi [or green, por-
raceous-like matter]; a peculiar sharp and con-
tracted state of the  features, and wild and ter-
rified expression of  countenance, arising from
a feeling  of  rapidly-approaching dissolution.
The whole surface, particularly the hands, face,
and extremities, assumes a leaden, blue, or pur-
plish tint, varying in shade with the intensity
of the attack and complexion of the person ;
the extremities are  shrunk, shrivelled, sodden,
and the  skin is deadly cold, damp, and raw to
the touch; the nails assume a  bluish-white
hue; the  pulse is either  reduced to a minute
thread, or is entirely lost at the wrist, and often
  [* This is not a dark ring, but an actual dark-blue or
black cavity below the lower eyelid, and the pure result
of the intensely morbid activity of the absorbents every
where, and which here have removed a portion, or all, of
the fatty cushion of the globe of the eye, thus leaving the
blue veins visible through the skin. This blue colour be-
low the eye is frequently seen in the morning, in  nervous
temperaments, from some previous anxiety of mind and
feverishness, and, therefore, quickened action of  the ab-
sorbents, producing the same result to a certain  degree.
The same marked activity of the absorbents, and consump-
tion of the subcutaneous fatty matter, causes the  remark-
able symptom of puckering of the skin in this disease.—T.]
can with  difficulty be felt  in  the neck;  the
course of the large superficial veins is marked
by flat lines of a darker tint than the adjoining
surface ; a burning heat and inexpressible anx-
iety are complained of at the epigastrium ;  the
patient tosses about incessantly, from a feeling
of intolerable weight and  anguish round  his
heart; he struggles for breath, and often lays
his hand  on the  stomach and chest, referring
his agony chiefly to those situations ; his voice
is nearly gone, and his respiration is quick, ir-
regular, most laborious, and imperfect; the in-
spiratory  act being effected by an immense ef-
fort, and expiration being quick and convulsive.
The patient calls frequently  for cold water,
speaks in a plaintive whisper, and utters only a
word  at a time, the lungs  not  containing  air
enough for a sentence.   The tongue is always
moist, often white and  loaded, and generally
flabby and  cold.   A  thermometer introduced
below the tongue indicates an animal tempera-
ture frequently of ten or twelve degrees below
the standard of health.   The sense of touch is
generally  greatly obscured,  and deafness  is  of-
ten present.  If blood be obtained in this state,
it  is black,  flows  by drops, is  thick, and feels
colder than natural;  and the air which is ex-
pired  is cold and raw.  Vomiting and  purg»ig,
which are far from being the most dangerous
symptoms, and are often  the most remarkable
in the least urgent cases, are generally slight,
or at  least not profuse, in those attacks where
the sinking of the vital energies is the  most
rapid  and the greatest, or are readily allayed
by medicine.  The integuments of the abdomen
are often  raised into  irregular folds, while the
epigastrium and hypochondria, with the whole
abdomen, are  commonly, especially in the  in-
tensely severe cases, drawn inward  and up-
ward  upon the chest.*   The spasms are gen-
erally of a more or less passive kind, but they
sometimes, particularly  in the loins, legs, and
thighs, present  a  tetanic rigidity.  They are
often  slight, or nearly absent, in some of the
most  rapidly fatal cases,  or replaced by a con-
stant  tremour.  There is occasionally a low
whine of suffering expressed.  The secretion
of urine  is totally suspended, as well as the
biliary, the salivary, and lachrymal fluids; and
a peculiar earthy odour  issues from the  body,
with  a singular fetor of the  perspiration and
evacuations.
   29.  These are the symptoms in the more se-
vere  attacks,  varying, however, somewhat in
degree, and with the occurrence or non-occur-
rence of previous diarrhcea.  When the intense
attack takes place without  previous diarrhcea,
then the vomiting and purging of watery or rice-
coloured fluid—from  the  escape of the watery
portion of the blood from the digestive mucous
surface—are most marked ; the quantity of this
fluid  thrown out,  both upward and downward,
in a few minutes, being often extremely great.
If the remedial means succeed, the animal heat
is slowly restored, the  pulse  becomes fuller,
and the colour of the surface more  natural;
but if these means fail, rapid extinction of  the
functions  takes  place.   Frictions  even then
may  reduce the lividity of the part to which
they  are applied, but that of the face and  hands
  [* Broussais correctly describes this sensation as sim-
ilar to a band drawn tightly across the epigastrium, a* if
compressing the stomach against the spine.—T.] 
PESTILENCE, CHO
increases.   The  lips and cheeks sometimes
puff out in expiration, as in apoplexy ; and, to-
wards  the close of the scene, the respiration
often  becomes  slow, with a quivering  of the
tendons of the extremities.  The mind is gen-
erally undisturbed, the patient feeling merely a
certain degree of apathy towards the  close, and
a desire to be left to his fate.  At last he is un-
able to  swallow;  he then becomes insensible,
and he dies  after one or two long, convulsive
sobs.   In some cases, when the  patient has
been thus rapidly cut off, without any rallying
of the energies of life, convulsive motions of
the muscles  have been remarked an hour or
two, or even longer, after expiration had ceased.
  30.  Such is the history  of the disease when
it terminates life without any reaction  of the
nervous and muscular systems, the patient gen-
erally dying in from six to twenty-four hours ;
but both in the East  and in Europe, particu-
larly the latter, or among European  residents
in India, a consecutive  state of disease,  at-
tended with efforts at reaction of an  imperfect
or  malignant character, was not unfrequently
observed.  It was rarely evinced in  the weak
Hindoo, or  in  the previously  debilitated, of
whatever race, but sometimes in the stronger
or less predisposed in India, and often in Eu-
rope,  and in England, especially in the robust
and young.
  31.  From  the aggravated state which has
been now described but very few recover, par-
ticularly if that state have existed as long as
three or four hours before  active  treatment has
been resorted to.   A thread of pulse, however
small, is almost always felt at the wrist, where
recovery from  this state is to  be  expected.
Hiccough, coming on in  the intermediate mo-
ments between the threatening  of death and
the beginning of reaction, is a favourable sign,
and generally announces the return of circula-
tion.
  32.  In  less severe cases the pulse  is not
wholly  extinguished, though much reduced in
volume ; the respiration is  less  embarrassed;
the oppression and anguish at the chest are not
so overwhelming, although vomiting, and purg-
ing, and the  cramps may have been more in-
tense.  The  coldness and change of colour of
the surface, the peculiar alteration of the voice,
a greater or less degree of coldness of the
tongue, the character of the liquids evacuated,
are invariably well marked in all the degrees
of violence of attack of this pestilence.  In no
case or stage of this disease have I observed
shivering; nor have I heard, after inquiry, of
more  than one  or two cases in which this feb-
rile symptom took place.
  33.  C. The consecutive phenomena of'this mal-
ady vary considerably.  In the East, when  re-
covery  took place from the previous state, it
was often rapid, and without much subsequent
disease having been experienced.   The numer-
ous writers, however, in the reports from the
medical boards  of the three Indian presidencies
make particular mention of a consecutive fever,
characterized by nervous and malignant symp-
toms, such as  I am about to enumerate, and
which was very commonly observed to  follow
the attack in Europe.  They also state that the
malady often passed into  visceral disease and
dysentery, and  that the danger was  not over,
although they succeeded in rallying the powers
    III              8
jERIC—Description.                    113

of life.  According to Drs. Barry and Russell,
after the  blue or cold period has  lasted from
twelve  to twenty-four, seldom to  forty-eight
hours or  upward, the pulse and external heat
begin gradually  to  return ;  headache is com-
plained of, with  noise in  the ears ; the tongue
becomes  more loaded, redder  at  the tip  and
edges, and also drier.  High-coloured urine is
passed with pain, and in  small  quantities ; oc-
casionally is nearly or altogether suppressed ;
the pupil  is often dilated; soreness is felt on
pressure  over the  liver,  stomach, and belly;
and an offensive odour is exhaled from the sur-
face ; in short, the patient is now labouring un-
der a continued malignant fever.
  34. A profuse critical perspiration occasion-
ally comes on from the second or third day, and
leaves the patient convalescent; but more fre-
quently the quickness of pulse and heat of skin
continue; the tongue becomes brown and parch-
ed ;  the eyes suffused and drowsy, with a dull
flush, stupor, and heaviness of the countenance,
resembling typhus.   Dark sordes collect about
the teeth  and lips ; and sometimes the patient
is pale, squalid, and low, with the pulse  and
heat below natural, but with the typhous stupor.
The urine is suppressed.  Delirium generally
supervenes, and  death takes  place from the
fourth to  the eighth  day, or even later, in the
very person, too, whom the most assiduous ex-
ertions  had barely saved in the  cold  stage.
Dr. Reimer states, that of twenty cases treated
under his  own eye, who fell victims to the dis-
ease, seven died in the cold stage, and thirteen
in the  consecutive  fever.   This  proportion
nearly agrees with that  observed in my own
practice, or among the cases to which I was
called.  In two cases which I attended most
extensive erysipelas complicated the consecu-
tive  fever.  I agree with the observation of
Drs. Barry and Russell, that persons employ.
ed about cases in this  typhoid stage are neve<
attacked with ordinary fever, but with a geuu.
ine cold, blue cholera.
  35. In another class of cases serious disor-
ders of the secreting organs of the abdomen,
particularly of the liver  and of the digestive
tube, supervene, instead of the low nervous fe-
ver now described.   The evacuations from the
bowels  become  of a dark, blackish,  offensive,
and  highly irritating kind,  and attended  fre-
quently with discharges of a bloody fluid, with
mucus, and extremely urgent irritation  of the
rectum, the consecutive   symptoms assuming
nearly the character of dysentery.  Sometimes
an inflammatory or sub-inflammatory state of
the  stomach and bowels  takes  place  either
alone, or accompanied with great tenderness in
the region of the liver, and disorder of the  bili-
ary secretion. In other cases these symptoms
assume very nearly the form of bilious or gas-
tric fever; and in a few this state of disease is
associated with inflammatory congestion of the
lungs.  When these states of consecutive dis-
ease are severe, they not seldom carry off the
patient; and, where recovery takes place, are
frequently accompanied  with tedious  conva-
lescence.
  36. D.  The points of difference between.the
manifestations of this pestilence in India and
in Europe  appear to be chiefly  the following:
1st.  The  precursory dyspepsia  and diarrhcea
appear not to have been  so frequent in India, 
114
PESTILENCE, CHOLERIC—Description.
especially in dark races, as in Europe.  2d. The
evacuations seem to have been  more profuse
and ungovernable in the  violent attack  in the
former°than in the latter, although the char-
acters  of the  evacuations were entirely the
same.  3d. Restoration to health from the cold
state, without  passing through consecutive fe-
ver, was  by far more frequent in India than in
Europe, nor did the consecutive fever there so
generally assume a typhoid  type.   4th. The
proportion of deaths in the cold, compared with
those in the consecutive stage, was far greater
in the former than in the latter country; and,
5th. The proportion of medical men  and hos-
pital attendants attacked seemed greater in
Europe  than in the East.  Relapses, also, in
the  hospital attendants were not unfrequent;
while convalescence was  generally perfect and
rapid elsewhere.  Mr. Jameson states, in  the
Calcutta  Reports, that, although relapses were
not  uncommon, there seemed to  exist an im-
munity from second attacks, but this is not fully
ascertained.
  37.  It  may,  perhaps, be difficult to explain
the  frequency and the modified state of the con-
secutive  disease now described  as it was ob-
served in this  country and throughout Europe.
Much, perhaps, may be owing to the state of
predisposition, the intensity  of the cause, and
the  constitution  of the  affected; something,
also, may be attributed to the effect  of treat-
ment in the early stage of the malady, particu-
larly the  more general employment of blood-let-
ting and large  doses  of  calomel: means  evi-
dently calculated to remove the oppressive con-
gestion of  the vital organs, and reanimate the
functions of the secreting organs and emunc-
tories of the frame, but  which seemed  not to
have been so generally nor so decidedly resorted
to in Europe as in India.   Something, also, may
be imputed to the greater vital resistance made
to the noxious influence exerted by the poison-
ous  miasm causing the distemper  upon the
frame, by the  European  constitution, than by
the more delicate constitution of the dark races.
  38  ii.  The Prognostic Symptoms.—A.  Those
symptoms  which indicate a favourable termina-
tion of the disease are,  increase of the firm-
ness and fulness of the  pulse;  returning ani-
mal heat to the surface ; a  tonic character of
the spasms, or active retchings ; not very ur-
gent feelings of heat and anxiety at the epigas-
trium and  prascordia, or a diminution of these
Bymptoms, and of the pressing desire for drink;
the occurrence of  hiccough ; a more natural
and a livelier state of the countenance and sur-
face of the body ; greater freedom of respira-
tion, and a diminution of the rawness and cold-
ness of  the respired air; a  free evacuation of
the bowels, with  the appearance of a return of
the biliary secretion, and  especially the evacua-
tion of urine and amelioration of the tremours,
restlessness, and general distress. These gen-
erally  indicate a  decrease  of danger  in  the
early stage of the  disease, and  returning vas-
cular reaction ;  but this  state may proceed to
 a fatal issue with all the  symptoms of congest-
 ive and  adynamic continued fever.
   39. Typhoid symptoms, such as low deliri-
 um, black  sordes On the teeth  and  lips, dry,
 parched skin, &c, may, however,  come  on,
 and the patient  sink.   The non-accession of
 these symptoms; the occurrence of a copious,
warm perspiration ; the return of the natural
secretions and evacuations, as of the salivary.^
bilious, and urinary secretions ; the absence ot
serious  affections of any of the viscera con-
tained in the abdomen, particularly of the liver,
stomach, and bowels ;  and a return of the func-
tions of the nervous, assimilating, circulating
and respiratory organs to their natural  state,
are the chief guides of the physician in forming
a favourable prognosis.
  40.  B. On  the  other hand, an unfavourable
issue  must be looked for when the prostration
of strength, the coldness  and blueness of the
surface, the  sinking and  irregularity of the
heart's  action, the collapse of the  counte-
nance, the coldness  and  rawness of the ex-
pired air, the oppression and  difficulty of respi-
ration, the anxiety and restlessness, &c, are
great or, individually, extreme ;  and  especially
if, with great intensity of these phenomena, the
retchings  and spasms  are slight, or  the  latter
consist chiefly of tremours, or irregular clonic
contractions.  An oozing from  the  mouth of
the fluids from the stomach, unconscious evac-
uations or relaxation of the  sphincters, the
breathing consisting of convulsive sobs or being
stertorous, with  puffing of the cheeks or lips,
and inability to swallow, indicate approaching
dissolution in the cold or early period of the
disease.
  41.  The occurrence of low  delirium, or of
coma with collapse of the  countenance, and
all the symptoms of malignant continued  fever,
consecutive of the cold stage, are  extremely
unfavourable, especially when attended by sup-
pression of urine, by great stupor, dark sordes
about the teeth or lips, by convulsive tremours
of the tendons, and restlessness.  These symp-
toms show that the congestion of the nervous
centres, which occurred in the preceding pe-
riods  of the disease, together with  the  thick
and otherwise morbid state of the blood  itself,
has been followed by serious  disturbance of the
capillary circulation  in the  substance of the
brain and of its membranes, probably conjoined
either with effusion  beneath or between the
arachnoid  membrane, or with  continued con-
gestion of the veins and sinuses of the enceph-
alon.   The continued suppression of urine is
manifestly owing as  much to the change pro-
duced in  the  blood, by the  evacuation of the
watery part of it by the bowels, as  to a para-
lyzed state of the kidneys.
   42. The supervention,  also, of tenderness,
pain,  &c, in the  region of the liver, or in that
of the  stomach,  a very morbid and  irritating
state of the alvine  evacuations, with blackish,
bloody, and mucous discharges, attended with
tremours,  &c, all indicate, respectively, the
consecutive appearance of inflammation, or in-
flammatory congestion of the liver, of the stom-
ach, and bowels  ($ 46), and evince a marked
tendency to disorganization,  and call upon the
practitioner for  the employment of the most
decided means of cure.   Although these con-
secutive phenomena show a  most serious state
of disease,  yet recovery  will sometimes take
place from it by the assistance of well-directed
means.
   43. iii. Morbid Appearances observed after  Death.
—The  morbid changes observed after  death
from this pestilence  are in  every respect the
same, both in Eastern and in European coun- 
                        PESTILENCE,  CHC

tries.   When  the  cold  stage  proves  fatal,  or
death takes place within four-and-twenty hours
from the seizure, but little change of organiza-
tion can be detected, although the viscera are
much altered  in  appearance from  the healthy
state.  The surface of the body usually  pre-
sents the same aspect as mentioned when de-
scribing the fully-formed stage of the malady,
being livid, corrugated, constricted, and humid.
The lungs are commonly found collapsed,  con-
densed, sometimes remarkably shrunk, and al-
ways loaded with  black  blood  of an oily  or
ropy consistence, and very closely resembling
tar or treacle.  The cavities of the heart are
filled  with  a black blood, and  they frequently
contain polypous concretions.   Blood of a simi-
lar appearance is generally found in the arch  of
the aorta and other large arteries.  The blood-
vessels of the brain  and its  membranes are
more or less gorged with dark blood, particu-
larly  toward its base.  The arachnoid mem-
brane is frequently deprived of  its transparency.
A serous fluid  of variousquantity is often found
effused between the convolutions  of the brain
and in the lateral  ventricles.  Similar appear-
ances to those detected  in the cranium are also
found in the vertebral column.
  44. The abdomen, upon being opened,  gen-
erally emits a peculiar  offensive odour.   The
stomach and different parts of the bowels are
frequently partially, but considerably contract-
ed ; at other places greatly distended with fla-
tus ; the internal surface of the stomach some-
times seems hut little  affected.  A whitish  or
yellow  fluid matter,  resembling the evacua-
tions, is often  observed  in different parts of the
alimentary canal,  which occasionally contains
much air, but neither bile nor faeces.*   The in-
ternal surface of the intestines is commonly
lined  by a tenacious muco-albuminous matter.
The  colon is frequently much  contracted,  gen-
erally throughout.  The  mucous membrane and
sub-mucous cellular tissue of the digestive ca-
nal present evident marks of congestion, in some
cases approaching to a sub-inflammatory state,
but generally  in  spots  or patches of various
sizes, the colour of these varying from a  very
dark venous congestion to a more roseate hue.
Decided signs of inflammation are always want-
ing, even in the most remarkable of those con-
gested  states.  The glands of Brunner and
Peyer, as well as the solitary glands, are great-
ly enlarged.   Both stomach  and bowels are
frequently of a paler colour than natural,  both
in their inner and outer surfaces.   The liver is
generally  pretty full  of dark-coloured blood ;
the gall-bladder often much distended with te-
nacious ropy bile, of a dark  yellow or green
colour.   The  gall-ducts are  sometimes  con-
tracted, at  other times not.   The appearance
of the pancreas, spleen, and kidneys is various,
frequently differing but little from their natural
state; in other cases  somewhat gorged with
blood.  The urinary bladder is always contract-
ed and  empty.  The vena  porta  and all the
large  abdominal veins  are loaded with black
blood, resembling tar.
  [* The complete suppression, suspension, or extinction,
as it were, of the urinary and biliary functions, is equally
characteristic of  yellow fever.  Not so in typhus; here
the kidneys only are paralyzed, while the liver, though
torpid, responds to aperients or enemata, and even a diar-
rheal tendency is  not unusual.—T.J
LERIC—Description.                    115

   45.  The chief change observed in cases ter-
 minating fatally in the blue stage of the distem-
 per is in the blood, which has lost  the greater
 part of its serum, which, as it has exuded from
 the digestive mucous surface, has left an albu-
 minous  coating over  the  mucous  membrane,
 and that remaining congested, thick and trea-
 cle-like, in the large veins.
   46.  In cases the duration of which extends
 from one to three days, the same  leading ap-
 pearances as  now described are observed, but
 often  with considerable additions.   The ves-
 sels of the stomach in these are found loaded
 with blood, presenting a surface sometimes of
 a pale pink  hue,  sometimes of a deep blue, at
 others of so dark a tint as  to resemble sphace-
 lus of the membrane, from which,  however, it
 was readily distinguished by the  firmness of the
 texture.  Similar changes  are   found  in the
 small intestines, and but very rarely in the lar-
 ger.   In many, evidence of congestive  pneu-
 monia is found, which is usually latent  before
 death.   In those cases in which coma occurs,
 serum  is sometimes effused  in larger quanti-
 ties than already alluded to, but occasionally
 congestion only of a very black fluid or semi-
 fluid blood is found.   Those who die of the con-
 secutive disease show few appearances that
 are different from such as are usually observed
 in other cases, attended with  corresponding
 symptoms.  Those  cases which have evinced,
 during the secondary fever, marked disturbance
 of the brain, generally present, after  death,
 greater vascularity of the substance of this or-
 gan and of the  membranes than natural, with
 the congestion of blood in the veins and sinuses,
 and effusion into the ventricles and between
 the membranes,  particularly between the pia
 mater and the  arachnoid reflected over it.  In
 some cases the brain seems dusky  or mottled,
 and the veins turgid, with dark semi-fluid blood.
 In those terminating fatally, with hepatic dis-
 turbances, the  liver  is generally  of a dark-
 brownish or sodden appearance.  In some ca-
 ses it is of a purplish black, somewhat  enlar-
 ged, its veins filled with dark semi-fluid  blood,
 and the ramifications of the hepatic duct load-
 ed with a dark-green  or greenish yellow bile.
 The stomach and bowels, particularly the lat-
 ter, are contracted and thickened, the  inner
 surface softened, of a dark-red or purplish col-
 our, in patches  or  streaks ; sometimes  exco-
 riated, partially detached  from  the  muscular
 coat, and covered  with a  muco-sanguineous
 fluid, in  those who  have died with consecutive
 gastro-enteric or dysenteric symptoms.
   [The pathological changes observed in sub-
 jects dead of cholera in this country  correspond
 closely with those  described by Dr. Copland.
 Prof. Horner,  however, of Philadelphia, has
 published a very elaborate account of  these
 changes in the Am. Jour, of Med.  Sci. (vol. xvi.),
 in which he maintains the following proposi-
 tions :
   1st.  That  the  vascular  derangements and
 phenomena of cholera, as exhibited in the ali-
 mentary canal, are confined almost exclusively,
 if not entirely, to the venous system.
   2d. That in the earlier stages  a lining  mem-
 brane of coagulating lymph  exists in the small
 intestines at least,  if not in the stomach and
 colon also, and that this lining  resembles the
 membrane of croup. 
116                      PESTILENCE, CH

  3d. That, in addition to the enlarged and tu-
mefied  follicles  described by M. Bocillaud,
and a similar enlargement of the intestinal pa-
pillae described by M. Serres, a copious vesic-
ular  eruption, entirely distinct from both, and
easily  distinguished from them, exists in  the
mucous membrane of the stomach of the small
intestines, and of the larger; and that this ve-
sicular eruption, consisting of small spheres,
seldom more than the sixth part of an inch in
diameter, is probably the essential morbid char-
acter of the disease, as  is the case with the
eruption of smallpox and other affections.
  4th.  That the follicular system of the  ali-
mentary canal is not the principal fountain of
the sero-fibrinous discharges, commonly called
the cholera fluid, but that the latter comes from
the capillaries of the  venous system.  Prof.
Dickson, of Charleston, S. C, remarks, in rela-
tion to Prof. Horner's observations, that he is
" unable to  yield an unhesitating credence to
details  differing in their  alleged  uniformity
from, and  thus  contradicting, all former  ac-
counts, which, until now, agreed in the ascrip-
tion  of extreme  irregularity to the local affec-
tions in  cholera."— (Essays on Pathol., vol. ii.,
p. 84.)   We have made numerous autopsies in
this disease, and have not only found the glands
of Peyer morbidly developed, but  the small,
isolated follicles much enlarged, giving rise to
the appearance of vesicles and vesicular erup-
tion, as described by Prof. Horner.   Was not
the membrane described by Prof. H. probably
the epithelium, and might not its detached por-
tions give rise to the flocculent appearance no-
ticed in the  discharges T]
  47. IV. Diagnostic Characters.—Much mis-
apprehension of its nature and origin has arisen
from viewing the pestilential cholera merely as
a modification of, if not identical with, the form
of cholera not unfrequently met with in India
and other warm climates, and occasionally in
this country, to which the terms spasmodic chol-
era and mort de chien have been applied.  Many
writers,  particularly those who argue against
its infectious nature, have considered this pes-
tilence merely an epidemical occurrence of that
form of cholera.  It is true that, in the spas-
modic cholera, the secretion of bile is either al-
together or nearly interrupted ; or, if it be at
all discharged into the bowels, that it is so vi-
tiated as to  prove extremely irritating to their
internal surface, the spasms, retchings, alvine
evacuations chiefly arising from intense irrita-
tion of the organic nerves supplying the digest-
ive tubes and the abdominal viscera, together
with accompanying congestion  of these  ves-
sels.   In that disease there is every reason to
suppose that the absence of bile is to be im-
puted to spasm  of the common bile duct, rath-
er than to  a suppression of the secreting and
excreting functions ; while, in pestilential chol-
era,  these  functions are altogether  arrested,
and the  discharge of bile is interrupted, inde-
pendently even  of any spasm of the excreting
ducts, the bili arysecretion being suspended as
well as the  urinary, owing not only to a para-
lyzed state of the liver and kidneys, but also to
the state of the  blood being such as not to ad-
mit of circulation through the  extreme capilla-
ries, and to the  loss of its serum.
   48.  In the spasmodic,  or severe form of spo-
radic  cholera, the discharges from the stom-
)LERIC—Diagnosis.

ach  and bowels  are certainly either  not col-
oured  by bile, or but little, excepting at the
commencement, and when the disease begins
to yield ;  but they are accompanied with  a dif-
ferent train  of symptoms.  The spasms are
more tonic, and confined more to the  muscles
of the abdomen, and of the thighs and legs, than
in the pestilential disease ; and, in the former,
the vertigo, deafness, headache, marked affec-
tion of the respiratory function and of the cir-
culation, characterizing the latter, are entirely
wanting.
  49. In  sporadic or bilious cholera the very
dark, thick, and ropy appearance of the blood;
the cold, wet, and shrivelled state of the sur-
face, and its  leaden, dark, or purplish colour;
the almost total absence of pulse at the wrist;
the  very  marked and  rapidly-increasing col-
lapse of the  powers of life; the disagreeable
and earthy odour of the body, even during the
life  of the patient; the burning  sensation be-
tween the scrobiculus  cordis and umbilicus j
the complete arrest of the glandular secretions;
the  cold tongue and mouth ; and the coldness
of the respired air,  which characterize the pes-
tilential disease,  are entirely absent.
  50. In  one  the powers of life are certainly
very much deranged, and the circulation and
functions of the internal  organs greatly dis-
turbed ;  but in the  other all  the derangements
and their attendant symptoms are of a much
more alarming and malignant nature ; the bal-
ance of the  circulation is much more  com-
pletely overturned, the circulating fluid itself
much more sensibly and seriously diseased ; the
respiratory functions infinitely more disturbed;
the spasms of the voluntary muscles more gen-
eral, and more clonic as respects their nature ;
the purging and vomiting slighter and of short-
er duration, and  forming a less prominent fea-
ture of disease ;  the surface of the body  more
deprived of its vitality, of a much darker col-
our, and more collapsed and shrunk ;  and the
powers  of life  are  more  completely over-
whelmed, and  sooner sink altogether, than in
the  severest forms  of cholera observed to oc-
cur  occasionally in warm climates, or in  tem-
perate countries, under circumstances favour-
able to their appearance.
  51. In  this  pestilential  malady the powers
of life are insufficient of themselves,  even al-
though assisted by  the administration  of stim-
ulants, to overcome  the congestion of the in-
ternal organs, and restore the circulation in the
surface of the body and in the extremities  ; and
while the large secreting viscera in the abdo-
men remain  engorged by the thick and viscid
blood thrown in  upon them  from the  external
surface, and  their vital powers  thus  over-
whelmed, their functions of secretion must ne-
cessarily  be arrested; and thus they are una-
ble to remove the load oppressing them by one
of the modes in which congestion of secreting
organs is usually overcome.
   52.  In  the severer forms  of cholera, occur-
ring sporadically, the derangements, being less
malignant than in the present malady, are  more
readily removed  by an energetic  arid appropri-
ate  treatment.  Here the exhibition  of  large
doses of calomel,  opium, and  stimulants is
generally sufficient to allay the inordinate ac-
tion of the stomach and bowels,  to restore the
balance of the circulation, to remove spasm, 
PESTILENCE, CHOLERIC—Diagnosis.
117
 and to excite the secreting function of the liv-
 er   But in this pestilence the lungs are com-
 pletely  paralyzed,  the changes produced  by
 respiration  entirely suppressed, the  blood is
 thick and vitiated, the large vessels, particular-
 ly the large venous trunks, and the cavities of
 the  heart, are so engorged with blood as to be
 unable, particularly in their  state of  deficient
 vital energy, to react upon the distending fluid,
 and to throw it, particularly in its state of mor-
 bid density  and tenacity, into the extreme ves-
 sels of  the  secreting organs and external sur-
 face, unless internal and external stimulants of
 the most powerful kind be employed  ; and even
 these are very often inadequate, of themselves,
 to fulfil the intention with which they are em-
 ployed, and occasionally are productive of mis-
 chief, unless the engorgement of the internal
 viscera be early removed by vascular depletion
 and external medication, which, while they re-
 lieve the heart and empty the large vessels,
 enable them to react upon their contents, and
 recall the flow of blood from the centre  to the
 circumference of the frame.   Hence it is gen-
 erally indispensable, in this very formidable dis-
 ease, to exhibit stimulants and antispasmodics
 internally,  with artificial heat and stimulating
 frictions, in order to rouse the vital energy of
 the system, while we remove the vascular load
 by means of emetics and evacuations of  blood,
 and afterward endeavour  to  excite the  func-
 tions of the liver,  and restore  the  secretions
 generally.
  53. Among the  other  characteristics inti-
 mately connected with the nature of this  pesti-
 lence, and calculated to distinguish it  from  all
 those states of disease to which the term chol-
 era  has been usually applied, may be  particu-
 larly noticed the prevalence  of the  pestilence
 in all seasons, countries, and climates  ; the af-
 fection of the head, nervous system, and  respi-
 ratory organs, characterizing the commence-
 ment of its  attack ;  the uncommon and sudden
 diminution  of the animal  temperature,  which
 often sinks  below the heat of the surrounding
 air,  both on the surface  of the body and  in
 more internal  parts ;  the  remarkably sudden
 and rapid depression of the powers of  life ; the
 continued restlessness and distress referred to
 the  praecordia and  epigastrium; the mental
 apathy and  indifference to  the result;  the ver-
 tigo, stupor, and deafness  ; the blue colour and
 shrunk appearance of the surface of the  body ;
 the state of the respiratory actions, and pecu-
 liar  groan or whine of the  affected ; the un-
 quenchable  thirst and burning at the epigastri-
 um ; the sodden, raw, wet,  and shrunk  state
 of the surface ; the rapid  exudation of  a wa-
 tery fluid from the skin, and  digestive mucous
 surface; the states of disease by which it is
 very frequently followed; the  unprecedented
 mortality, notwithstanding the most energetic
 and  judicious treatment, and the use of  those
 means by the aid of which nearly all  the cases,
 even of the most severe forms of intertropical
 cholera, generally recover ; and, lastly, the ap-
 pearances observed after death, particularly the
 collapsed state of the  lungs, the blackness of
 the blood, the fibrinous concretions in the cav-
 ities of the  heart, the  morbid secretion  lining
 the internal  surface of the intestines, the flac-
 cidity of all the soft solids and of the substance
of the heart itself, and the congestion  of black
 blood on the large nervous centres.  (See § 43,
 et seq.)
   54.  The secondary fever and consecutive phe-
 nomena (33), which  follow upon  the  cold and
 blue stage of the malady, also furnish remark-
 able proofs of dissimilarity between this pesti-
 lence and the severe forms of cholera observed;
 in hot countries, or in temperate climates after
 very hot and moist seasons.  After these lat-
 ter the patient recovers without any consecu-
 tive disease, and frequently the tumult of the
 frame leaves it benefited by the changes it in-
 duces ; but in the present pestilence  the con-
 secutive states of disease are as dangerous  as
 the blue  stage ;  and, even when assuming a
 typhoid or febrile character, they do  not com-
 municate a febrile disease, but the distinct and
 specific pestilence  now treated of.   This im-
 portant feature  was happily insisted upon  in the
 reports of Drs. Barry and Russel, and is one
 of itself sufficient to distinguish this pestilence
 from every form of cholera.
  55. Various  attempts have been  made  to
 trace a resemblance between  this disease and
 some of those which have occurred in former
 ages,  and of which very  imperfect  accounts
 have  been furnished by writers;  but, upon re-
 ferring to the meagre details which have been
 given of them,  I am unable to trace any close
 resemblance between them—far  less  identity.
 Mr. Orton has endeavoured to find out a very
 close  similarity between this  pestilence and
 that which ravaged England and some parts of
 Europe at various periods, between the  years
 1483 and  1551, and which obtained the  name
 Sudor Anglicanus, Ephemera maligna sudatoria,
 Sweating sickness.  In  certain phenomena the
 similarity  is close,  but in others altogether
 wanting ; but as it cannot lead to  any practi-
 cal results, I will not further pursue the sub-
ject.
  56.  It may be  important,  however,  to be
 aware that poisoning from acrid and narcotic
 substances, and particularly tobacco,  or  those
 belonging to the class of animal poisons, occa-
 sions symptoms which, in many respects, close-
 ly resemble  those  characterizing  this  pesti-
 lence.   But the difference will  be apparent upon
 inquiry into the history and premonitory symp-
 toms  of the attack, and  by observing the col-
 lapsed, shrunk,  dark, and wet state of the sur-
 face of the body ; the sodden, shrivelled, damp,
 and raw state of the extremities ;  the spasms,
 the oppressed respiration, the sunk appearance
 of the epigastrium, and of the hypochondria ;
the peculiar character of the matters  ejected ;
the cold, raw state of the expired air, and the
black,  viscous  condition  of the  blood, all of
which  characterize  this  pestilence,  and are
either altogether absent from every other kind
of attack, or never similarly associated.
  57.  After attentively considering its  phenom-
ena and nature, I would conclude, 1st.  That
this malady,  as respects the causes which oc-
casion it, and as regards the pathological states
which constitute its various grades or stages of
intensity, is quite distinct from all the forms of
cholera, whether the common bilious variety, or
the more  severe  form,  usually  denominated
spasmodic,  the  mart  de  ehien,  &c.; and  that,
therefore, the name cholera should be discard-
ed from all scientific descriptions of it.
  58.  2d.  That  the accounts which we possess 
118                 PESTILENCE, CHOLERIC—Causes and Naturb.
of the epidemics and  pestilences which have
ravaged various countries in former  times do
not furnish us with the history of any disease
which may be considered as identical  in its na-
ture with this pestilence;  and that it  must,
owing to this circumstance, and to the uniform-
ity of its characteristic phenomena, be viewed
as being of modern origin, and sni generis.
   59. As it is important that the name of a dis-
ease should  not be such as  may risk its being
confounded with another, different from it in its
nature,  symptoms,  and termination, so I con-
sider that some  other  name than that at pres-
ent applied to it should be given it.   As to the
particular appellation which may be employed,
I conceive that one pointing to its chief patho-
logical states, and  its prominent tendencies,
ought to be preferred.  The intense  influence
of its exciting cause  upon  all the respiratory
actions and  functions, as well as upon the ac-
tions of the heart and state of the pulse, and
its marked tendency to propagate itself, and to
terminate fatally, have induced me to apply to
it the name of Asphyxia pestilentia, or pestilen-
tial asphyxy*
   60. V. Causes and Nature of Pestilential
Cholera.—There are few subjects which have
given rise to greater diversity of opinion, or to
more discussion, than  the causes of this dis-
ease.  Suppositions have  been adduced, and
reasoned  from, as  established and  admitted
facts;  and repeatedly observed  occurrences
and corroborated evidence have been  explained
away or denied, even by those who have given
us merely vague hypotheses  and chimerical
speculations in their place.  It must be evident
that but little truly important can be stated in
respect of the causes  and nature of this mala-
dy, without  previously inquiring into, and com-
ing to some conclusion as to its  infectious or
non-infectious  nature.  I shall, therefore, in-
quire, in  the first  place,  into  the  evidence
which has been adduced as to its possessing an
infectious property from its commencement in
Jessore, and as to the extent and character of
this property.  Its predisposing  and concomi-
tant causes will next come under  considera-
tion ; and, lastly, various topics connected with
its nature will be discussed.
   61. i. The infectious nature of Pestilential Chol-
era demonstrated.—The infectious or non-infec-
tious nature of this disease is one of the most
important topics to which public attention can
be directed ; and one which, owing to the man-
ner of viewing it, adopted both in this country
and on  the Continent, requires the serious con-
sideration of the informed part of the commu-
nity.  Knowing that much important informa-
tion had been furnished by the medical observ-
ers  of the disease in India, which was entirely
overlooked, I carefully examined the  reports to
the Medical Boards of the  three Indian presi-
dencies.  I had also an opportunity of referring
to the  medical  reports at  the  India  House.
From those sources, therefore, and from others
within my reach, I can state that much misappre-
  [* The radical mischief and lesion, no doubt, begins in
the lungs, from the poison inspired, which immediately,
through the pneumo-gastric and other nervous connexions,
simultaneously implicates the stomach ; the respiratory or-
gaus thus can not eliminate  the carbon and hydrogen of
the blood, and the stomach is no longer capable of furnish-
ing to the respiration the elements of ombustion; hence
the entire tram of morbid phenomena.—T.J
hension of this terrible disease had gone abroad,
and been propagated by authorities that should
have  been more accurately informed on the
subject.   I can  truly state that, although my
attention has been much engaged  by this dis-
ease,  since the time of  its eruption in the Del-
ta of  the Ganges, I approached this topic with
my mind  entirely  unbiased,  and desirous  of
adopting that view  of it which well-ascertained
facts  should most fully support.   When, there-
fore,  professional authorities have  stated opin-
ions which have misled, and will  still further
mislead, those who have it not  in  their power
to detect their unsoundness,  it becomes the
duty of those who have detected the true char-
acter of these  opinions to place the particu-
lars within the reach of the misinformed.  One
able writer remarks, as an acknowledged and
proved  fact, " that by an overwhelming major-
ity of the British medical officers, who have
witnessed epidemic cholera in the East Indies,
this disease is not considered to be of a conta-
gious or  infectious nature.   A  few incidents
occurred which excited suspicions in  the ob-
servers that  it  might really,  after all,  possess
this property.   But scarcely a single person has
advocated the doctrine  of contagion with any
earnestness."   The same  writer afterward
stated,  that "the almost  unanimous and ear-
nest  recommendation of British  practitioners
was not to consider the cholera contagious."
In another country an eminent physician, in an
elaborate memoir on the disease, read very re-
cently before the " Academie Royale de Mede-
cine" of  Paris, states,  as a well-ascertained
matter, "that  in India  the  medical men and
attendants on the sick were not  more frequent-
ly seized by the  disease than  others of the
community."   Other instances  of gross mis-
statement, made both  by foreign  and British
writers, may be adduced, but these will suffice.
Now, when we turn to the great authorities on
the subject—to the official depositories of the
origin and rise of this pestilence—we find that
all the  reportSj the Bombay, the Madras, and
the Calcutta,  favour the infectious nature  of
the disease more or less.  It is true that a ma-
jority of  the surgeons  and assistant-surgpons
in India, who sent reports to their respective
medical boards, state that they do not believe
the disease infectious ;  but a large number of
them give a very  different opinion, while the
reasons assigned by many for believing the dis-
ease  to result from other causes than infection
are actually favourable  to the existence of an
infectious property.  Even  where they  have
argued  against its infectious nature, they have
often adduced the strongest evidence, although
unconsciously, of its possessing this property.
   62. When I entered upon the present inquiry,
and commenced with the reports from the three
presidencies, in the order of their appearance,
and before I had seen the disease in this  coun-
try, I had not completely made up  my mind on
the subject of its infectious nature.  But, in or-
der to come to a just conclusion, I had recourse
to the  earliest  and  the  best information, and
read  and noted  every  individual report which
these bulky publications contained ; and so far
are the remarks just quoted wide  of the truth,
so far are the medical men of India  nearly unan-
imously against the belief in cholera possessing
an infectious property, that the members of the 
PESTILENCE, CHOLERIC—Causes.
119
Medical Board of Bombay, in the prelace to the
reports sent to them, and  published at Bombay
in 1819,  state that the disease  had extended
from Poonah to Panwell, a considerable village
in the main line  of communication  between
Poonah and Bombay; that a man who had left
Panwell and arrived at  Bombay, a distance of
about fifteen miles, was soon afterward attack-
ed by the disease, and communicated it to those
attending him ; that it was traced in parts ad-
joining Bombay, and on the island, from village
to village, by the arrival of persons affected
with it from places where it was known to pre-
vail ;  and that there were places  which, from
want of this sort of communication, had, up to
the time of the report, entirely escaped.  From
the foregoing and other data, the members of the
Bombay Board—the first to furnish information
respecting the disease—conclude that " It ap-
pears to them incontrovertible, that this disease
is capable of being transported from one place
to another, as in  cases of ordinary contagion
or infection, and also to possess the power of
propagating itself  by the same means that ac-
knowledged contagions do, that is, by the ac-
quisition of fresh  materials with which to as-
similate."   (Bombay Reports, &c, p. 10,  .11.)
In the  same reports we find Captain Sykes sta-
ting that he ascertained that the disease did not
break out in any village "until that village had
communication with a  neighbouring  place in
which  the disease  existed;" and he  furnishes
several instances  proving this fact.   Besides,
he states that the attendants  on those  first
seized  in his company were  attacked, and  that
it spread from one of his servants to five, while
the gentlemen in the next tent had not one af-
fected  ; and he remarks that he could  add sim-
ilar instances to those now adduced.  (Op.  Cit.,
p. 118  )  Mr. Coats, surgeon, in a letter to the
president of the Bombay Medical Board, states,
that  the  idea  most prevalent was that the dis-
ease was brought  from Jaulna to Aurungabad,
and that  its progress could he traced distinctly
through  the villages on the chief road from
Nagpore to those places  (p. 145).   He after-
ward states that  the information as to the ex-
tension of the disease by infection  was  not
only furnished by Europeans, but that some
Brahmins had given similar information with-
out any particular inquiry on the subject  hav-
ing been made of  them.   From these and  oth-
er facts, he concludes by considering the  dis-
ease infectious ; and that, " If it was occasion-
ed merely  by a  distempered state of the air,
it would have spread over the country with
some regularity ;  but the  epidemic seems gen-
erally to have travelled in lines along  the post-
roads,  and  always to have required a succes-
sion  of subjects for its propagation.   In Can-
deish,  where there is not sufficient population
and but little intercourse between the villages,
its progress was slow.   At Pundergoor it made
its appearance at  the time of the  great Jatra,
and was spread at once in all directions by the
pilgrims returning to their homes."  (Op.  Cit.,
p. 150, 151.)
  63. Dr. Jukes states, that the disease travelled
along the high-road from the Deckan to Pan-
well, and  that he has not  heard of any village
in the Conkan that has had the disease but by
intercourse  with  places in which it had  been
already prevalent.  " If it be something gen-
 eral in the atmosphere," he  remarks, " why
 has it  not hitherto made its appearance in some
 two distant places of the province at the same
 time'   Nothing  of this kind has, I  believe,
 been  observed : it  still seems to be  creeping
 from village to village, rages  for a few days,
 and then begins to decline."  (P. 173.)
  64. Dr.  Taylor reports that, " whenever the
 disorder appeared in any particular spot or fam-
 ily, a considerable proportion of the family or
 neighbours were attacked within a  very short
 period of each other:  on many occasions I
 have seen three or four of a family lying sick
 at once"  (p.  195.)   Dr. Burrell "informs us
 that in the short space of six days every at-
 tendant, in his hospital, on the patients affect-
 ed with cholera had the disease.   (Bombay Re-
 port, p. 9.)  And  Mr. Craw states  that every
 one of the attendants, thirty in number, in the
 hospital of the 65th regiment were attacked.
  65. The next report which issued  from India
 was edited by Mr. Jameson, and was published
 at Calcutta in 1820.  This gentleman, while
 he  reasoned in an  extremely loose manner
 against the existence of an infectious property
 having been evinced by the disease, and with-
 out furnishing proofs of its  absence, actually
 adduces evidence of that property which he is
 endeavouring  to disprove.  Thus, where he is
 stating in general terms, and without any ref-
 erence to  reports from the different medical of-
 fices in the establishment, that the disease did
 not seem to be more prevalent in the tents or
 hospitals of the divisions of the army, in which
 the sick were  treated,  he communicates the
 following important fact in a note:  " A Sepoy
 died of the pestilence.   Five of the corps, who
 had shown no signs of illness, were employed
 to carry the body  to the grave.   They were all
 seized  with the disorder  during the ensuing
 night, and all died."  (Calcutta  Rep., p. 130.)
 Mr. Jameson, instead of appearing as the editor,
 or publishing reporter, of the  opinions  sent to
 the Calcutta Board, states his own  views, en-
 deavours to explain away those which are dif-
 ferent  from them ; and thus  the publication,
 which  in  the title-page professes to be a re-
 port, conveys  not a  single line of information
 from any one on the Bengal establishment, ex-
 cepting this writer himself.  The work, there-
 fore, can not be looked upon as furnishing the
 opinions of the majority of medical men  in this
 part of India,  inasmuch as we find no authori-
 ties or opinions contained in  it  but those of
 Mr. Jameson himself; and these are evidently
 so perfectly at variance with one another, and
 with the ascertained laws by which  those dis-
 eases which are  familiarly recognised  as in-
 fectious are governed,  that we  cannot, even
 although we receive some of  the facts which
 he  adduces, consider him as  an authority on
 this subject.   In all  his remarks he seems to
 suppose that contact is requisite to  the  propa-
 gation of contagious diseases, and that, because
 some  persons in contact with  the sick so fre-
 quently escape, the  cholera is  not contagious.
 He  overlooks  the  influence  of predisposition,
 which is so  remarkably  influential in all mala-
dies which perpetuate themselves ;  and he en-
 tirely forgets  the operation of  those  causes
 which often come in  aid of the poison or efflu-
 vium exhaled from the bodies of the diseased,
even after the exposure of a healthy person to 
120                      PESTILENCE, CHOLERIC—Causes.
it, and which frequently determine its action or
call  it into operation, when, without such  re-
enforcement, it may have failed in producing its
specific and deleterious effects. Could this gen-
tleman ever have had any experience of diseases
admitted by all to he  infectious—had  he ever
seen smallpox, measles, or scarlet fever ?  Not-
withstanding those misapprehensions, and the
evident bias which he betrays in favour of pes-
tilential cholera being non-infectious, numerous
facts escape him  eminently calculated to sup-
port  the opposite doctrine.  Thus he informs
us that the medical staff present with the Han-
si force was "persuaded"  that the infection ex-
tended to it from the Meerut detachment, which
caught the disease on passing through  Delhi,
where it prevailed.  And at another place he
informs us that the centre division of the Ben-
gal army were infected by a detachment which
joined it while subjected to cholera.  He en-
deavours, however, to explain away this  occur-
rence ; but it is evidently shown,  and even ad-
mitted by himself, that the pestilence was  in-
troduced into this division, either by this de-
tachment, or by some of the Rajah of  Sump-
ter's troops, which were  affected, and  mixed
with some regiments of the division.
  66. After  proceeding through  a number of
pages, in which  Mr. Jameson  reasons against
the infectious nature of the disease, what was
my surprise when I found him,  towards the
conclusion of his observations on the subject,
express himself  in the  following  manner :
"This much, however, may be affirmed, from
a review of the whole progress of the epidem-
ic in this quarter, that the infectious medium,
in whatever it consisted, was  confined  within
a very circumscribed circle, and was very slow-
ly extended to healthy parts of the atmosphere.
If, setting aside the circumstances militating
against  it, we take it for granted that the in-
fection  was  truly  received by the centre and
Hansi divisions  from the detachments above
mentioned, we must believe that the disorder,
although not communicable  by  contact from
person to person, was so from one large body
to another large body; and that  whenever the
poison got head among a number of men, it as-
sumed some new quality, so as,  when  mixed
with  the  atmosphere, to become  infectious.
What constituted this additional quality  we
can not pretend to determine; but in support
of its existence, we may quote the predilection
of the epidemic for cities and camps;  the  in-
fection  of the left division, and  the Nagpore
and Meerut troops, immediately after entering
into  the diseased medium at Jubbulpore, Nag-
pore, and  Delhi;  and the similar case  of the
troops and followers in  attendance upon the
governor-general  being attacked  shortly after
communicating with an infected village in the
Gorruckpore  district.  To the same  account
may be placed the progressive  march  of the
disorder from one part of an infected place to
another, as in the centre and  Hansi divisions,
and more particularly the Rajpootana  force, in
which the virus seemed to be regularly propa-
gated from corps  to corps.  In some instances
the suffering body would appear  to have sick-
ened immediately upon coming into the poison-
ous  medium, as was the case with the Nag-
pore troops, who were affected on the very day
in which they encamped at the infected  village
of Gaongong ; but more frequently one or two
days would seem to have  been  requisite  to
bring the virus into action.   Thus the Meerut
detachment entered Delhi on the 29th, and was
not affected till the 3lst;  thus, too, the Hansi
troops  had not the disease till the 6th, the day
after the junction of that detachment.  Again,
by those abetting the opinion of the disorder
being communicated to the centre division by
the Shergur detachment, it  is stated that the
first cases occurred on the 11th, two days after
its junction.  Lastly, the followers of the troops
in personal attendance on the governor-general
in April first  suffered on the 23d, three days
after  encamping near  the  infected  village."
(P. 144-146.)   This surgeon afterward adds,
that the disease recently appeared in a detach-
ment of the Rajpootana force under such cir-
cumstances as  at  first seemed to warrant a
suspicion of the existence of contagion. Now
it appears somewhat surprising that the secre-
tary of the Medical Board of Calcutta, sitting
under the eyes of the governor-general, should
have been allowed to issue his ipse dixit as to
the non-infectious nature of a most devastating
pestilence, then in its full strength, when these
facts were in  his possession, and when many
others  of a still more convincing character of
the infectious nature of the  distemper  had
passed through this very board in  their way to
the India House, in Leadenhall-street, where I
had an opportunity of consulting them in 1827.
  67. The foregoing quotation will be found to
differ but  little from the conclusions which an
attentive consideration of the subject has led
me to entertain.   I have thought it right to be
thus particular in the investigation of this sub-
ject, because upon the adoption of correct ideas
respecting it  will mainly depend  the employ.
ment of successful measures to circumscribe,
entirely to prevent, or counteract  the disease.
And I  hesitate not to maintain that, owing to
the very loose manner in which  this subject
has been  considered,  and to the neglect  of
means which  the due interpretation  of the in-
formation furnished even by the most skeptical
as to the existence of infection, among the re-
porters to  the India medical boards, ought to
have led,  are  to be imputed, in  no  small de-
gree, the propagation of the disease  not only
throughout  India, but also  to other parts of
Asia, to  Europe, and  to  America.   I have
thought it most advisable to go to the original
sources for information as to this and various
other topics, because the opinions of the Indian
reporters  were generally derived  from an ex-
tensive and varied experience of the disease
during a number of years, and they were not
certainly previously biased  in favour  of con-
tagion, that being a property which the diseases
of India seldom present.  While,  also, the in-
formation which they furnish is of a superior
description  to  that which has appeared else-
where, the impossibility of obtaining it in this
country—particularly the reports, the most val-
uable part of it—has  induced me to refer to
them in preference to other authorities. Hav-
ing shown the identity of the Indian with the
European pestilence, the arguments  derived
from facts observed in the one are equally ap-
plicable to both; and, therefore, I pursue the
present topic,  and  farther demonstrate, from
the valuable and voluminous  reports published 
PESTILENCE, CHOLERIC—Causes.
121
by the Madras government, the inaccuracy of
the opinions which  have gone abroad respect-
ing the disease in India, and which have vitia-
ted the doctrines and paralyzed  many  of the
measures, both preventive  and curative, which
have been adopted in Europe.
  68. Mr. Scott, the editor of the reports which
were transmitted to the Madras Medical Board,
«nd were published  at length at that presiden-
cy, has given an able summary of the evidence
which was  furnished to him,  in conjunction
with the results of his own observation.  The
value of the information here conveyed, its ac-
cordance  with the  most accurately observed
facts connected with the manifestation of the
disease in Europe, and the difficulty of access
to the original, will  be a sufficient apology for
the length of the following quotations : " Bodies
of troops in motion have  been attacked, and
have retained  the  disease, while  it  was un-
known to the fixed  inhabitants of the country
through which they passed.  One of two corps
in a camp has been  attacked, and the other has
escaped the disease.   Ships arriving from other
parts of the world  have never suffered under
the assumed epidemic constitution of the at-
mosphere before reaching  the shore."  " Dis-
eases avowedly infectious, such as smallpox,
measles, &c, have  not at  all times the power
of spreading epidemically ; for while it is cer-
tain that their exciting causes are never wholly
extinct,  it is only  at particular periods that
these diseases become epidemic; but we are un-
acquainted with the circumstances under which
this power of epidemic propagation arises.  The
same may be the case with cholera.  All the
atmospheric phenomena, and other circumstan-
ces brought under the head of occasional caus-
es, have, with little or no  interruption, existed
from the beginning of time until now, without
producing cholera ; consequently, the super-
addition of a new cause must be inferred.  An
European, proceeding on  his journey to Tri-
chinopoly, on the 15th October, was taken ill
about a mile from  the Mount, brought  back to
the house where he had  passed the day, and
there died.   On the  17th the wife of that per-
son, on the  19th the owner of the house, and
on the 21st his wife, all experienced attacks of
cholera, but  recovered.  Several of the native
servants also  suffered.  The instances of the
disease  appearing  at  places immediately after
the arrival of  corps  and  detachments  which
were suffering from it are very numerous.   For
example, it  appeared at Jaulnah immediately
after the junction  of a party from  Nagpore,
among whom it prevailed.  It appeared at Au-
rungabad, and at Malligaum in Kandeish, after
the arrival of parties who had left Jaulnah at
the time the disease was  prevalent there, and
among whom it had broken out  on the march
to  these places. It appeared a second time at
Malligaum, after the junction of the 1st battal-
ion of the 5th regiment, in which cholera pre-
vailed.   It appeared at  Secundrabad after the
arrival of a  detachment suffering from it, and
it appeared  afterward in  the villages through
which the detachment had moved.  It appear-
ed at Gooty, where no case had been observed
for  six  months before,  immediately after the
arrival of the first battalion of the 16th regiment
of foot, in which it prevailed with great mortal-
ity.  It is remarkable that  the same formidable
type of the  disease which prevailed in the
marching corps was communicated to the corps
at Gooty.   It also spread on that occasion to
the adjacent villages.   It also appeared in a
detachment of artillery, previously perfectly
healthy, upon their encamping on the ground
which had  been immediately before vacated by
the 1st battalion of the 8th regiment, in which
corps the  disease prevailed.  The bodies  of
several  persons who had died of cholera re-
mained  exposed on the  ground when it was
taken up by the artillery.   The prisoners in a
jail,  enclosed by a high  wall, have  escaped
cholera, while  it prevailed all around them;
and the inhabitants of certain hilly ranges have
also  escaped the disease.  These  have been
said to have interdicted all intercourse with the
people below.   When cholera is once establish-
ed in a marching  regiment,  it continues  its
course in spite of change of position, food, or
other circumstances.  Its approach to a town
has been traced from village to village, and its
first  appearance in a town has  been in that
quarter which was nearest the track of its prog-
ress.  The sudden  appearance and disappear-
ance of cholera, however unlike  the progress
of known  infectious diseases, is not admitted
as being irreconcilable with the doctrine of in-
fection,  especially if the disease be of sudden
invasion after  the application of the  exciting
cause.  The relations  who  have attended  on
people ill of cholera, as well as the nurses ap-
pointed  in  military  corps for that duty, and in
general  those whose employment has led them
to be much with the sick, have been observed,
in very many  instances, to be attacked with
cholera  during, or  shortly  after, their attend-
ance.  The sick  in hospitals  labouring under
other diseases  have likewise been observed to
be attacked with cholera, especially those who
lay near  the  patients  ill  with that  disease.
Sometimes whole families have been swept off
successively.*  Servants have often been ob-
served to sicken after attending their masters."
(Madras Reports, p. xlviii., et seqq.)
   69. This, however, is only  a portion of the
facts and circumstances advanced by Mr. Scott
in proof of the infectious  nature  of this pesti-
lence.   In  addition  to the foregoing, I may add
the opinion  of several able and  experienced
surgeons and physicians, contained in their re-
ports to the Madras government:  Superintend-
ing Surgeon Duncan  states,  that "the 34th
regiment carried the pestilence with them from
Bellary to  Nundydroog, and there was no trace
of the  disease in  any village  on the  road.
Since the regiment  passed, every village on the
road has been  attacked by cholera."  (Madras
Rep., p. 111.)  Mr.  Train adds, that  "the at-
tacks have shown a great disposition  to run in
families, and even among the attendents on the
sick, and have in such cases  been  much more
severe than  usual."  (P.  131.)  Mr. England
observes, that " the disease has been greatly
felt among the attendants on  the epidemic pa-
tients at various places."   (Op.  Cit., p. 170.)
He also notices the extension of the disease
from  troops and travellers to places on the
  [* This rapid transmissibilty and maturity of the disease
in persons to whom it is^omtnunicated is another peculiar
feature in its contagious character.  This extreme rapidity
uf development ism perfect keeping, also, witli the often as-
tonishingly rapid termination of the disease, In death.—T.] 
122                       PESTILENCE, CHOLERIC—Causes.
roads through which they had passed, and other
facts similar to those already recorded in proof
of its infectious nature.
  70. Mr. Chapman, after stating facts perfect-
ly in accordance with  those furnished by the
reporters  already quoted,  adds, that he feels
most confident of  having  experienced  the  at-
tack of the disease,  under which he had with
difficulty recovered, from infection.  Being anx-
ious about a patient,  he remained with  him  for
several hours,  watching the progress  of the
disease.   He felt nausea on quitting him, but
attributed it to the peculiar fetor evolved from
the evacuations.  On the following morning he
was attacked with  cholera, which nearly prov-
ed  fatal.  He  proceeds : In the same  detach-
ment, a woman, anxious  about the safety of
her child, slept in the hospital tent, in which
several choleric cases were present;  in the
morning she was  attacked  with the  disease,
and died.  Three  orderlies, also, slept in the
hospital, and in the morning one of them was
attacked, but recovered.  " Thus it will be seen,
four persons sleep in an hospital containing the
infection of cholera, and that  two are on the
following morning  attacked  with the disease;
whereas from the whole  camp, consisting of
1500  or 1600,  not five cases had occurred."
"That  the  disease  is contagious appears to
have been observed by the natives themselves,
and it thus commonly happens that the  sick are
avoided by those whose duty does not call on
them to attend.  A village in which cholera is
prevailing is usually evacuated for a short  pe-
riod, until the disease  is annihilated; these,
and many others, are the proofs of their opinion
of its contagious nature."   (P. 189.)
   71. Mr. Stokes, in  his comprehensive  re-
port,   states  several  well-ascertained facts,
showing the infectious  nature of the disease.
The case of Mr. Rumbold, assistant-surgeon, is
almost demonstrative of this property.   He
had been visiting  some very bad cases, when
he was  seized with sickness  at his stomach,
and giddiness ; and coming out of the  tent, he
fell down faint, and from that period he  be-
lieved himself infected with the malady.   He
soon became one of its victims.  The sickness
and faintness with  which Mr. Rumbold, in  a
state of high predisposition, " from fatigue of
mind and body," was  affected, may be easily
accounted for  by  the  information which Mr.
Stokes gives in the following page.  He states,
that in the worst cases "a peculiar and offen-
sive fetor was observed to issue from the body,
particularly when  it was covered with much
sweat ;  it was very disagreeable when first
perceived, and seemed to hang about  the nos-
trils, exciting, long after, an unpleasant sensa-
tion."   (P. 211.) In another place, he remarks,
"It was found among many who came to the
hospital, that  some  time previous to their be-
ing attacked, the  disease had existed in  the
family to a greater or less extent, or some one
branch had been ill or died of it.   In others,  it
had spread progressively through the whole, or
nearly ;  and among  those who officiated as or-
derlies or attendants  at  the  hospital, several
were attacked, and some  died."  (P. 217 )
   72.  Mr. Patterson observes as follows : " I
feel convinced that a corps on its march, catch-
ing the exciting cause, will carry it along with
the corps for weeks, and to a very considerable
distance.  Let this corps be halted on the finest
spot of ground possible, let healthy corps join
this, at  short and regular intervals, and I feel
convinced  the  disease  would  attack  those
healthy corps in a few days, and according to
their respective arrivals.  If this be not conta-
gion,  I  do  not  know what  name to give it."
(P. 224.)
  73. Dr. Daun, while he refrains from giving
any opinion as to the contagious nature of the
disease, states the following facts in proof of
it:  " On the 10th, when  in  attendance on
O'Brien, I became indisposed in  such a way as
to lead  me  to apprehend an attack of the epi-
demic.  On the 12th, Mr. Gray  was attacked,
after  having been  up part of the night with
Thomas Flannigan.  Mr. Gray was, during his
illness,  constantly attended by  lieutenants S.
and M'D., who have since had both of them at-
tacks of the epidemic, and no other officers ex-
cept them at this station have been attacked."
(Op. Cit., p. 273.)   And, lastly, as respects the
official reports, Mr. Kellie furnishes both facts
and arguments, many of them similar to those
already adduced  in  support  of  the infectious
character of the pestilence.   (P. 68-77.)
  74. The  above  evidence I consider amply
sufficient to prove that the  disease, even from
the commencement of its ravages, evinced un-
equivocally infectious properties.  If my limits
would permit, I could also demonstrate from
the same sources that the eyes  of many were
shut, by previously entertained dogmas  on the
subject of contagion, against this property;
and that several, even where they were argu-
ing against its existence, were  actually  addu-
cing important facts in  support of what I have
been  cautiously led to believe, namely, that the
disease manifested a tendency to propagate it-
self by means  of a  morbid effluvium exhaled
from the bodies of the affected, similar to what
is evinced  by measles, and fevers whose infec-
tious properties have been well ascertained and
generally admitted.
   75.  It appears extremely singular that, not-
withstanding the evidence which has been now
quoted, in the very words of the reporters to the
different Medical Boards, no means of prevent-
ing the propagation of the malady were resorted
to during the number of years it has existed in
the East.  Surely the doubts even of the skep-
tical  ought to have led to a careful inquiry; and
most certainly the natives of the country, and
the  European population under  the British do-
minion, had even a right to expect that those
placed  to watch  over their health, and to de-
vise measures for its preservation, would have
attended to the unequivocal opinions expressed
by a number of the  best-informed medical offi-
cers  in the service ; and that, although a great
difference  of opinion existed among them, this
very circumstance should have led to more in-
timate inquiry and a careful sifting of the truth.
At all  events, the  error—if error it  could be
called—should have been on the safe side ; and
the Medical Boards, superintending surgeons,
or others to whom the duty appertained, should
have pointed out the importance of preserva-
tive measures to the government, and to civil
or military officers  placed  over districts and
corps,  and have adopted the suggestion of one
of their most  able  medical officers, who has
. stated the  following in one of his reports to the 
PESTILENCE, CHOLERIC—Causes.
123
Madras Board :  "Whether or not the disease
in question be contagious is a subject of infi-
nite importance; but where the slightest gleam
of doubt obtains, it is surely better to adopt the
means usual for the purpose of preventing  its
propagation, by appropriate quarantine of troops
on the line of march, by preventing their imme-
diate entrance into  stations when under the  in-
fluence of cholera.   By these precautionary
measures, I  conceive  it  possible to  preserve
the lives  even  of  thousands  of individuals."
(P. 189.)  That  no  precautions of any descrip-
tion were taken in  India to prevent the propa-
gation of the disease, may be stated  without
any reservation ; and hence, most probably, the
reason of its extension over so very large a
portion of the whole globe.
  76.  Before leaving this part of the subject, it
may be as well  to  take a  hasty glance at the
opinions expressed  by some other authors who,
having observed the disease in India, have writ-
ten respecting it.   Mr. Orton, who published
at an  early period of the epidemic an able work
on it, referred it to electro-aerial influence.  He
now states his belief in its infectious nature.
Mr. Annesley expressed himself in his publi-
cation against the doctrine of infection, and im-
puted the disease to a similar state of the air
to that assigned by Mr. Orton, without being
able to point out in what this  state consisted.
But "de non-apparentibus et non-existenlibus
eadem est ratio."   Mr. Annesley,  however,
appears not to have directed that attention  to
the subject of infection in relation to  the dis-
ease which would impart  much importance  to
his disbelief in its existence.  In  proof of this,
I may merely refer  to the circumstance of his
quoting the letter of a  correspondent, contain-
ing the following remarkable proof of infection,
without  adding  any explanation or  remark :
"We  have, however,  been particularly fortu-
nate till our  arrival at  this station, not having
lost a man, or having  one seriously ill, though
we had been under  canvass above five weeks.
We fell in with  a battalion of native  infantry
who were suffering  from cholera ; the next day
six Europeans were attacked, the number  in-
creased daily, and most of the first cases proved
fatal."  Dr. Kennedy, from extensive  experi-
ence of the malady among both native Indians
and Europeans,  states facts and  arguments in
proof of its infectious nature, and he justly pla-
ces particular stress upon the peculiar odour
exhaled from the bodies of the affected, as in-
dicating the generation of a principle calculated
to propagate  the malady.
  77.  I have now shown, from the chief sour-
ces, that the  disbelief of infection, in respect of
the pestilential cholera, was not general in In-
dia ; that  the productions which issued from
the three Medical Boards  very strongly favour-
ed, and, indeed, proved  the existence of this
property ; that two out of the three  actually
insisted upon the activity of its influence; and
that, therefore, the  dangerous  opinion, so very
generally  propagated,  and  even  acted upon,
both in this and  foreign countries, that the au-
thorities in India did not consider the disease in-
fectious, is entirely without foundation in truth.
  78.  The identity of this pestilence with that
which  has ravaged  the East has  been  proved,
and, indeed,  is  scarcely  anywhere  called  in
question.  Some authors have  supposed that it
 has acquired new properties  and characters
 since its first appearance and early prevalence
 in India, and that its infectious property is one
 of these.  But I am entirely convinced that this
 is not the case.   Even varieties of the disease
 cannot be admitted ; for it  is essentially the
 same, presenting merely gradations of intensi-
 ty, and modified effects according to these gra-
 dations.
   79.  Several writers have supposed that the
 disease has originated in a number of distinct
 and far distant places from those causes  to
 which the disbelievers  in  infection altogether
 impute it, and to which I shall direct a brief at-
 tention (I) 97, et seq.); and that it has, owing to
 the combination  of those circumstances and
 causes which are  generally admitted to be
 productive of infection, assumed this  charac-
 ter ; or, in other words, that the  malady was
 not originally infectious, but that it  has had
 this property superadded to it from the  circum-
 stances of  imperfect  ventilation, neglect  of
 cleanliness,  and  crowding together of the sick.
 There cannot be the least doubt of those being
 fertile sources of an  infectious principle, and
 that they tend greatly to aggravate  all diseases,
 whether infectious or  non-infectious  ; but  I
 have  remarked,  in the course of my inquiries,
 and of my personal observations, and in the
 accounts of various observers, that the  prop-
 agation of the malady from the affected to the
 unaffected frequently took place, although not
 to the same  extent, or with  the same malig-
 nity, in open, and airy, and thinly-inhabited sit-
 uations, and  during opposite  states of the at-
 mosphere as respects both humidity and tem-
 perature.
  80.  I shall next adduce  proofs of the infec-
 tions  nature of this pestilence in other parts of
 Asia,  in Europe, and elsewhere.  But I shall
 be very brief, because, the identity of the  mal-
 ady in both  hemispheres having been fully and
 generally admitted, and its infectious nature  in
 India having been completely proved,  it must
 necessarily possess the same character in Eu-
 rope,  unless counteracted by  powerful means ;
 and, therefore, a minute detail of  facts is not
 required.  Several authors have insisted on the
 proofs which have been furnished of the intro-
 duction of the disease into the Isle of France
 by the Topaze frigate, and  the circumstance of
 about  20,000 of the  inhabitants having been
 seized with it, above two thirds of whom died,
 no precautionary measure having been resort-
 ed  to;  but  that  when  the malady had been
 propagated to the adjoining island of Bourbon,
 a sanitary cordon was established, and  only
 256 persons were attacked.  When the  disease
 appeared in Aleppo, in 1822, the French consul,
 M. De Lesseps, convinced  of its infectious na-
 ture, placed  himself, his  family, and all those
 who wished to join him, in strict  quarantine,
in a place adjoining the town.  This  colony,
consisting of about 200 persons, remained  per-
fectly secure from the disease, although  4000
 persons died  of it in the city.  If it proceeded
from some unknown state of the  air,  as sup-
posed  by the anti-infectionists, to what cause
can we impute the escape of  those who had so
secluded themselves, for they surely must have
breathed the same  air as those who were af-
 fected 1  M. Hubenthal states, that a peasant
having arrived from Arkatal,  on the borders of 
124
PESTILENCE,  CHOLERIC—Causes.
Persia, at the village of Neskutshne, to visit
an uncle, was seized, the night of his arrival,
with the disease.  The persons engaged in re-
storing the heat of the body by frictions, &c.,
four in number, were attacked on the following
day, and three of them died.  Precautions were
taken by the police to arrest the progress of
the pestilence in the village,  and it spread no
farther.   If the causes of the  seizure had ex-
isted in the air, or state of the locality, how
came all the  inhabitants, excepting those who
had been exposed to the inhalation of the efflu-
vium from the affected person, to escape I
  81.  According to the reports of the Medical
Board of Ceylon, the disease  made its appear-
ance in 1819, in Jaffnah, in Ceylon, imported
from Palamcottah, with  which  Jaffnah holds
constant  intercourse, and thence it was  propa-
gated over the island.  In August, 1820, the
Leander is stated to have called at Trinquama-
lee from Pondicherry, and to have landed sev-
eral of her crew affected with cholera.  Trin-
quamalee, soon afterward, was infected, and
the pestilence was again propagated over the
island.  The Island of Sumatra was believed to
have been infected  in 1819,  from the  inter-
course carried on between Achem and Malac-
ca, across the intervening strait; and it seems
to have reached Penang and Singapore towards
the end of the same year, in the same manner.
Dr. Labrosse states that the  prisoners  in the
jail of St. Denis, in the Isle of Bourbon, who
were employed in the removal of the dead bod-
ies, all died  of it;  that, at the  lazaretto, two
servants alone escaped ; and that in the hospi-
tal it was communicated to the attendants and
other patients.  M. Moreau de Jonnes  states
that it was imported into Muscat, in Arabia, by
the English East India ships ;  and Dr. Salinas
says that it was carried into the port of Basso-
rah, in 1821, by a vessel from  India, and that it
spread from this port, extending from town to
town, even as far as  the coast of Syria.  When
the pestilence reached Manilla in 1820, where
It was believed to have been  imported by ships
whose crews had been, or were infected, those
vessels in  the harbour which abstained from
intercourse  with the shore entirely escaped.
At Bankok, the capital of Siam,  it was said to
have been introduced by the ships trading there
from British India.  It was supposed that 40,000
persons were attacked in this city and vicinity.
Its appearance in  Java, in 1821, was likewise
considered to have  been  owing  to the unre-
stricted intercourse of infected vessels,  partic-
ularly the junks trading to Samarang, whence
the pestilence spread over the island, carrying
off upward  of 100,000 of its inhabitants.   Its
irruption in Canton in 1820, in Macao in 1823,
in the Moluccas in  the same  year, and in va-
rious places in the Persian  Gulf, and on the
coast of the Arabian peninsula, was generally
attributed to vessels which had arrived from in-
fected places.
   82. Dr.  Meunier  states,  that at Bagdad,
where a third of the inhabitants was attacked,
none were affected but those who approached
the sick.  Dr. Reimann says that there was not
a single instance of a town or village in Rus-
sia which contracted the malady without  pre-
vious communication with houses or persons
affected.  Drs. Russell and Barry, who were
sent by the British government to St. Peters-
burg, in order to investigate the nature of the
disease, state that the number of medical men
and  hospital attendants attacked with cholera
in that city was  extremely great, particularly
in lll-ventiladed hospitals ;  and they, as  well
as Dr.  Walker, who was sent to Moscow, ex-
press  their belief in its infectious  property.
The report from these gentlemen to the Privy
Council, dated the 20th of September, at St.
Petersburg, has been  kindly allowed me for
perusal by Sir William  Pym, and  it abounds
in proofs, remarkably in accordance  with the
quotation  from Mr. Scott's  report ($ 68), dem-
onstrating the infectious nature of the disease.
  83. The director of sanitary police at Peters-
burg, Dr.  Reimann, after expressing  his  con-
viction that the Russian pestilence is entirely
the same  as that which has been so fatal in In-
dia, states that most decisive proofs have been
furnished  him  that it has not been of indigenous
production, but has been  introduced by persons
who have arrived from infected places on the
borders of the empire.  He farther states that
he is convinced of its being less active and less
fatal, according as the place in which it is in-
troduced is more airy, elevated, clean, and free
from the  usual cause of insalubrity ;  while its
increased fatality  in low, moist, thickly inhab-
ited, and  dirty places has been demonstrated
on numerous occasions.   The personal and do-
mestic cleanliness of the inhabitants has also
a most remarkable effect upon the infectious
property  of the  malady  and its fatality.  In
proof of this, Dr. Reimann states, that in a vil-
lage almost entirely peopled by Jews, 700 deaths
occurred  from among few more than 800 who
were attacked. These conclusions are perfect-
ly in accordance with the laws of all infectious
diseases,  and  are  entirely such as d priori rea-
soning would lead us to adopt.
  84.  In  September, 1823, the  disease first ap-
peared at Astracan, and the Russian govern-
ment resorted to preventive measures in order
to arrest  its progress.  Whether or not those
measures were the cause of its disappearance
may be difficult to determine, but it did disap-
pear, and it was not until 1830  that it showed
itself  again in that city.  In  1828 the pesti-
lence broke out in Orenburg, and was  supposed
to have been introduced  either  by the caravans
which arrive there from Upper Asia,  or by the
Kirghis Cossacks, who are adjoining this town,
and among whom it was said to have  prevailed
at this time.   During the winter the number
seized was not great; but in the spring of 1829
it raged severely,  and extended to the villages
in the  province.   During its prevalence in this
part of the Russian Empire, many of the phy-
sicians, who at first did not believe in  its infec-
tious properties, were induced to change their
minds, chiefly owing to  the circumstance of
its appearing in places very soon after the ar-
rival of persons affected with it.  Several in-
stances of this description have been  recorded
by Dr.  Lichtenstadt  among the official docu-
ments  published by him.  Another circumstance
evincing  the  infectious  nature of this pesti-
lence was the peculiar irregularity of its course;
and to this may be added its extension in the
lines of the  principal  roads and channels of
traffic.
  85.  The introduction of pestilential cholera
into Astracan, in  1830, was traced to a vessel 
PESTILENCE, CH
which arrived from Baku, a town on the shore
of the Caspian, and at that time affected with
cholera.  This vessel lost eight of her crew on
the voyage, and  the sick were brought to the
lazaretto ; a day or two after which  the pesti-
lence first  appeared  in  this  populous town.
According to  Dr. Solomov, it attacked the sub-
urbs on the 27th of July, and gradually extend-
ed to the nearest villages, and thence over the
whole government.  It proceeded through the
Cossack stations and towns on the highway to
Moscow, and up the streams of the Volga, at
the mouth of which Astracan is situated.  Its
extension was attributed to the fugitives from
the places successively attacked.  After visit-
ing the  principal towns,  and  committing un-
heard-of ravages on the high roads to Moscow,
the pestilence reached that city at the end of
September.   Towards the end of 1830, or soon
afterward,  a body of troops from  Koursk,  a
province at that time  affected with  the pesti-
lence, was marched against the Poles.  These
troops carried this  scourge along with them, af-
fecting the places in their line of march through
Podolia and Volhynia.   In this way the towns
of Astrog, Zaslaf,  and Luck became infected ;
and from the last  of these places the  disease
passed the Bug into Poland.   Here it appeared
with the invading Russian army, and was com-
municated to Lublin, Siedlec, Praga, the Polish
 army, and Warsaw.
   86. The following is an extract from a letter
written by a clergyman, who witnessed the dis-
ease in  Saratoff, and published in  the Quarterly
 Review  for November, 1831: "Scarcely had
 we heard of the breaking out of cholera in As-
tracan, than the news came to us  like lightning
 that it was coursing the Volga, and that it was
severe,  and had  already reached  Zaretzin.
Without a dread of the presence of the angel
of death, the vice-governor, the  medical  in-
spector, and the  government as well as the
hospital surgeon, at once went into the infected
places of this province.  On the evening of the
6th of August we  heard that three persons had
been seized with cholera who had left Astracan,
 and were carried to  our hospital.  On the 7th,
 others were  reported to have  been carried off
 by this malady with such frightful rapidity as
to have impressed all minds with deep conster-
nation, especially  those who dwelt in the sec-
 ond division of the town.  The disease soon
appeared in  the third division, and seized so
 many that the hospital could  no longer contain
the sick, and killed so rapidly that they scarce-
ly survived six hours.  The  evil came so sud-
 denly on us, that  we  had no time  for taking
precautions ; our  governor  and  our surgeons
 were gone to meet it afar off, in order to pre-
 serve cur city, but it was already among us be-
 fore any regulations  could  be  made, or any
 means  of  opposing  it could  be  devised.   It
 could scarcely be reckoned  an  epidemic, de-
pending on some change in the atmosphere, for
many places were left untouched in  our neigh-
 bourhood, while in Saratoff there was scarcely
a family who had not to lament the loss of some
of its members.
   87. " In the very commencement of the epi-
demic, all our four surgeons were seized with
it; two died on their journey to Zaretzin, and
one here.  From this moment fear and anguish
took possession of the public mind.   They who
OLERIC—Causes.                       125

could flee from the city, fled ; and, as the mal-
ady was not considered  contagious, servants,
labourers, Tartars, and Russians were permit-
ted to rush into the country.   My congregation,
which consisted  of 550 individuals, was re-
duced to 150.  Many of the  fugitives died on
the' road, and spread the malady whithersoever
they went.  From the 10th of August the mal-
ady increased in virulence ; the daily mortality
of 4 rose to 5, 12, 20,  80, 120, 200, and  one
day to 260, and decreased in the same gradual
mode.   Up to the 30th of August, 2170 persons
died.  While all around was infected, Sarepta,
in which the quarantine regulations were most
strict, escaped, and yet this disease is not called
contagious."
  88.  From  among other evidence—indeed, I
may say a mass  of evidence—that furnished
by Dr. Reimann,  of  St. Petersburg, as to  the
extension of the  disease through Russia, may
be adduced  : " The  cholera  was  brought to
Astracan by ships, and it has spread itself over
Russia from Astracan by the emigration  of the
inhabitants,  principally those of the lower or-
ders.  This  is the chief cause of its propaga-
tion in Russia ; it has never shown itself  in  any
place except where it has been brought by trav-
ellers who  came from infected  places.  We
have not a single  instance of a town or village
which, without communication with houses or
persons affected,  has contracted the disorder.
Several places surrounded by the disease have
preserved themselves from it by a rigid insula-
tion."
  89.  The  introduction of  the pestilence into
St. Petersburg  is referred by Drs. Barry  and
Russell to the arrival of vessels from placea
on the Wolga where  it prevailed.  In that cap-
ital the infectious nature of the disease was
shown,  not only by the  mode in which it was
propagated in various quarters, and by its intro-
duction into, and extension through, the prisons
and hospitals of the city, but also by its exclu-
sion from some  places by a rigid  insulation.
Among numerous other instances the follow-
ing may be  mentioned : Up to the 13th of
July, fifteen hospital physicians were attacked
by the disease; and "the proportionate num-
ber of attendants of all descriptions on  the
sick who  have been taken  ill with cholera is
fully greater than that of the medical men."
"There were 150 pupils on  the officers' side
(Military Academy at Cronstadt), which is kept
perfectly distinct from the school for petty offi-
cers and sailors.  The gates were shut on  the
19th of June, and  as strict a quarantine as pos-
sible maintained to the 6th of August (O.  S.).
No case occurred among the pupils, who  are
from nine to twenty years of age."
  90. In a letter from  Dr. Russell (Medical
Gazette for November 11th, 1831), the follow-
ing remarkable fact  is communicated:  "The
son of a villager in the government of Pensa,
who was coachman to a nobleman at fifty versts'
distance, died of  cholera ; the father went to
the place to collect the effects of the son,
and brought home with him his clothes, which
he put on and wore a day or two after his arri-
val at his native village.   He was shortly there-
after seized  with  cholera, and died of it: three
women, who had watched him in sickness, and
washed his body after death, were also seized,
and died of the disease.  The doctor arrived in 
HOLERIC—Causes.
 126                      PESTILENCE, C]

time to see the fourth case ; and, finding that
the disease spread on that side  of the village,
he had the street barricaded on the side where it
had not reached, and interdicted all communi-
cation to the two sides of the village.  In that
side in which the  disease first,  broke out, up-
ward of 100  cases  of cholera occurred,  of
whom forty-five died, but it did  not appear on
the other  side of the  barricade."  And  Drs.
Barry and Russell report, that " the Navari-
no  corvette, Captain Nachinoff,  200 men, had
been placed two miles to the eastward of Cron-
stadt during the epidemic, to question and ex-
amine all craft from St. Petersburg.   She had
eleven severe cases of cholera, of whom eight
died.   Her first and second cases occurred  on
the 26th of June (O. S.).   These two men be-
longed to the  boat that examined the vessels
coming from St. Petersburg, on board many of
which they had been.   The next men who fell
ill were of those who carried the two first cases
to the hospital in town."   These are but a very
few from the many facts of the  same descrip-
tion now before me.
  91. With regard  to  the appearance of the
disease in Berlin, the following extract of a let-
ter from Dr. Becker of that city, dated the 29th
of  September,  1831,  furnishes  information:
" I am a most decided contagionist, and  it is
the force of facts which  has made me so; for
on the authority of your Indian practitioners I
formerly believed the  cholera not to be conta-
gious.   The appearance of the disease in  Ber-
lin, and the manner in which it  has  spread, is
also very remarkable, and  affords supplement-
ary evidence in favour of contagion.  The con-
clusion at which I have arrived is, that the  ef-
ficient cause of the Asiatic or malignant cholera
is always a virus, the production  of human  efflu-
via, and which, according to  common medical
language, undoubtedly deserves  the name of a
contagious principle; but that this virus, in or-
der to produce the disease, requires, first, like
the contagion of the small pox, measles, typhus
fever, and even the plague, a disposition of the
atmosphere favourable to its development; and,
secondly, a peculiar disposition of the animal
economy in every person who is exposed to it.
This  disposition appears  to  be  brought on  by
previous disease, particularly bowel complaints,
by excessive fatigue, cold, errors in diet, drunk-
enness, fear,  &c.  One young physician  has
been one of the first victims of  the cholera, a
decided anti-contagionist; he  carelessly ex-
posed himself, died, and, as if his case was to
be a warning proof of the fallacy of his opin-
ions, his death was immediately followed by
that of his  landlord and two  children, and the
illness of the  servant-maid in the house, the
only instances of the disease in that street."
In a report subsequently given by Dr. Becker
(Medical Gazette, 12th of November, 1831),  it is
stated  distinctly that the  disease was intro-
duced by the vessels navigating the River Spree,
which runs through the city.
  92.  The introduction of the disease into this
country was certainly owing to the clothes and
bedding of  sailors, who died of it at Riga, and
other northern continental ports, or during the
voyage from these ports, having been too gen-
erally  preserved  and  delivered up  to  their
friends, upon the return of infected vessels  to
British  ports.   Of this fact,  already adverted
 to ($  16), several proofs of an  incontrovertible
 nature were furnished me by  two masters of
 vessels,  on board of which several cases of
 cholera  occurred  during  the voyage  from in-
 fected ports.  These masters were at the time,
 conformably with  the  then  prevailing opinion,
 persuaded that the distemper could not be prop-
 agated by the clothes of those who had died
 of it; but facts soon afterward occurred which
 demonstrated to them the  propagation  of the
 malady  in this  manner as  well  as  by direct
 communication with the affected.  Soon after
 the opening of the first cholera hospital in the
 vicinity of London, near Bermondsey, I passed
 a considerable time with the patients first ad-
 mitted, and was present  during the  inspection
 of two fatal cases.  I drove thence in an open
 carriage, and saw two relatives, residing in an
 airy situation in Pentonville, a  distance of from
 three to  four miles ; and yet the persons whom
 I visited, after so long a drive in  the open  air,
 complained to me, instantly upon  my entering
 their  apartment, of the offensive  odour which
 proceeded from my clothes.   I was cautious In
 not mentioning the source of this odour, and
 no  suspicion was  entertained  by  them of  the
 cause.   But  the following day I was called to
 them, and found them both in an early stage of
 the distemper, from which  they ultimately re-
 covered  with difficulty.  Precautions were ta-
 ken against the farther extension of the malady
 in this house, and no case  occurred in the vi-
 cinity until  some  months  afterward.   Other
 proofs of infection occurred to my observation;
 but it is  unnecessary to advert to  them at this
 place. I shall hereafter state  briefly the con-
 clusions  at which  I have arrived after the clo-
 sest attention I could devote to the subject.
  [There have  been various hypotheses sug-
 gested in relation  to the nature of the agent to
 which cholera owes its origin, each of which
 numbers its ardent supporters, and  is  main-
 tained with all the  array of facts and arguments
 that can  be summoned in its defence.  Some,
 for example, regard the disease as entirely  at-
 mospheric, depending on changes in  the pon-
 derable or imponderable elements of  the air,
 without  the addition of some new ingredient.
 Others, again, consider the  materies  morbi to
 be a  modification of vegetable miasma, pro-
 duced by peculiar causes of heat, moisture, &c,
 acting on the productions of the soil.   A third
 sect believes that the agent  is some latent
 matter, evolved from  the crust of the earth,
 and produced by volcanic and  other changes,
 according to the views of epidemic causes, as
 laid down by our countryman, Noah Webster.
 Another  party, still, regard  it  as strictly  an
 agent, depending for its spread, like the virus
 of smallpox, on  canine rabies, or direct  conta-
gion ; understanding by this  some morbid ele-
 ment  eliminated from the human  system, and
 propagated by actual contact or close proxim-
 ity.  This party, of which Dr.  Copland may
 well be  regarded  as the leader, believe that
other  causes, such as endemic  influences,  at-
mospheric vicissitudes, &c, have but a limited
effect, and are not essential to the develop-
ment and action of the materies morbi.  Its trans-
missibility, if they are to be believed, is only
possible  through human intercourse.   Lastly,
Dr. Holland and some others have attributed
the origin and spread of cholera to insect life, 
PESTILENCE, CK
existent in the atmosphere under certain cir-
cumstances ;  while others, still, have traced it
to eating  bad rice.  Every medical  man who
has devoted any attention to the  subject must
be aware  of  the numerous  and  almost insur-
mountable  difficulties with which it is beset.
The agents about  which we are inquiring are
subtile, invisible, uncognizable by any methods
known to  science.   We are able to form but
very vague conceptions of the various condi-
tions in which the bodies receiving these agents
are placed, either  by changes in themselves,
or by physical alterations in surrounding me-
dia.   Anomalies meet us  on every  hand ; and
when we have flattered ourselves that we have
arrived at a general law, we unexpectedly find
so many exceptions that we are  obliged reluc-
tantly to  abandon  it, and seek  for another.
The views we shall  take of this disease, as
well as of yellow  fever,  may not find favour
with the advocates of either of the exclusive
hypotheses above  mentioned, but as they are
those which we honestly entertain, after a care-
ful investigation of the subject, we  shall pro-
ceed to state them as briefly as we are able.
   I. The  disease—we speak of it as it  prevail-
ed in this country—was essentially atmospher-
ic ; in other  words, it was  an  epidemic,  de-
pending chiefly on  certain unknown atmospher-
ic causes  for its extension.
   This is  proved  by its history and progress.
In the fall of 1831,  influenza  prevailed to a
great extent, appearing first in November and
continuing until January,  1832,  proving very
fatal to the  old and infirm.  This  complaint
was characterized by very great  irritability of
the digestive organs, so that antimonials and
purgatives were badly borne ; and the scarlati-
na, which  prevailed during the same season, was
marked by the same  intestinal irritability, and
often  presented instances of collapse  and un-
expected  death, similar to what was afterward
observed  in  cholera.  Cases, also, of cholera
morbus, and  dysentery of an aggravated type,
were  extremely common during the  winter,
many of which  terminated fatally.   The com-
 mon cholera, which is generally endemic  in
 Montreal in  summer, made  its  appearance in
 April.  Diseases  throughout Canada  and  the
United States were characterized by a low ty-
phoid type,  essentially different  from  that of
former years.
   The epidemic cholera first made its appear-
ance on this continent at Quebec,  on  the  8th
of June, 1832, when  eight cases  occurred, and
fifteen on the subsequent day;  and so rapid
was its stride that it reached its acme on  the
 15th day of June,  seven days after  its  first ap-
pearance.  During the latter part of May and
the  first week in  June, according to Dr. Rob-
ert Nelson, diarrhcea was a common and pre-
dominant  symptom in every form of disease
that prevailed  at  Montreal; and on the ninth
of that month  cholera, in  an  epidemic form,
burst upon that  city ; and so rapid was its pro-
gress, that in nine days it reached  its height,
a fact, perhaps, difficult  to explain upon  the
doctrine of contagion alone.  The same intel-
ligent physician informs  us that,  during the
same night of its  first appearance, it attacked
numerous persons, in various parts of the city,
remote from the port and from each other, and
having no communication with the  port or
OLERIC—Causes.                       127

place of landing.  In two weeks eight hundred
persons had died of it. It continued its progress
from one place to another, along the St. Law-
rence and the lakes, outstripping the  progress
of travel and emigration, and appeared in De-
troit early in  July.   With  respect to the ap-
pearance of cholera in Quebec, which  Dr. Cop-
land  says was conveyed  in an emigrant ship
(I). 17), it  was stated in the Quebec Mercury,
at the time, and the statement  was afterward
confirmed by  the testimony  of the  most re-
spectable physicians of that city, that, although
the first  cases were among emigrants, all at-
tempts to trace it to any vessel had been un-
successful, and that the sickness on board the
Carrick and other vessels suspected, was ship-
fever, small-pox, &c.  In the first two weeks of
its prevalence there were one thousand deaths.
  The cholera first appeared in the city of New-
York on the  26th day of June.  The patient,
an intemperate Irishman, had not been out'of
the city for some weeks, but was attacked af-
ter a debauch and  falling into  the dock.  He
came under our care, and died  at the medical
mansion in Greenwich, more than two miles
from  the place (Cherry-street), where other
cases occurred  the  ensuing day.—(See Com-
mercial  Advertiser of June  28-9,  1832.)  The
disease reached its climax in this city twenty-
seven days after its commencement.   The dis-
ease  broke out at the almshouse establish-
ment at Bellevue soon after its first appear-
ance  in this city, 27th  of June.  The patient
first attacked had not been  out of the house for
some time previous, and of course could not
have  been exposed  to any foreign causes of
the disease.   The same remark will  apply to
its first appearance  among  the inmates of the
state prison at Sing Sing, where it broke out
on the 17th of July, and proved extremely fatal.
We are authorized in stating that  the disease
originated in the establishment, not only  from
the rigid discipline which is there enforced, and
which renders it highly improbable that  any
foreign communication should take place which
could escape  detection  ;  but especially  from
the testimony of the superintendent and physi-
cian of that institution that the disease was not
introduced from abroad, but originated within
the prison*
   It is worlhy of remark, in this connexion,
that the cholera made its appearance in New-
York sixteen  days  after the  first case occur-
red in Quebec, and  without having shown it-
self at any intermediate spot between Canada
and this city, all the intermediate cities on the
sea-board of the provinces of New  Brunswick,
Nova Scotia, and of the states of Maine,  Mas-
sachusetts, and Rhode Island, remaining whol-
ly exempt.  The first case of  the disease at
Albany occurred on the 3d of July, having been
preceded  for  weeks by the general prevalence
of diarrhcea.
  According  to the best  authorities, the first
case of the disease in Philadelphia was observ-
ed as early as the 5th of July; but, according
to Professor Jackson, it did not  assume an epi-
demic form until the 27th of the month, when
the epidemic  influence acquired its full sway,
  [* See Reports of Hospital Physicians and other Docu-
ments in relation to the Epidemic Cholera of 1832. p. 26,
(Published by order of the New-York Board of Health,
1832.)] 
128                       PESTILENCE, CHOLERIC—Causes-
and cases were daily developed.  The epidem-
ic obtained its acme  about the 6th of August,
from which time it rapidly declined.  " Taking
the 27th of July as the proper commencement
of the epidemic," says Professor J., "in  Phila-
delphia, and the 1st of July as the  same epoch
in New-York, we have twenty-seven days for
the transmission  of the  epidemic.   The dis-
tance in  a direct line is between eighty and
ninety miles."  (Am. Jour. Med. Sci., vol. ii., p.
291.)   The  same writer remarks, that "the
routes or lines of communication leading from
the St. Lawrence to  the  United States do npt
appear to have been  the  means of conducting
it into  our territories, or infecting  our  cities,
notwithstanding the number of emigrants and
others who penetrated into the country in those
directions."—(Loc. cit.)   The cholera did not
make its appearance  in Boston until about the
middle of August, and then  only in a sporadic
form ; the whole number of cases of it, as sta-
ted in the annual report of deaths,  being 78.
  During the same month it appeared at Balti-
more, Washington, and various other places in
the United States.   About the 1st of October
it suddenly broke out at Ciffcinnati, and  nearly
at the  same time at Madison, Louisville, and
St. Louis.   It  reached  New Orleans late in
the month of October.   Leaving  the Ohio,  it
visited Tennessee, Illinois, Indiana, and Ken-
tucky,  Lexington, Maysville, and other  towns
suffering very severely.
  It  would  not be  difficult to show that the
cholera appeared in many places besides those
above  mentioned,  without  the  possibility  of
tracing it to any foreign source, as at Grenville,
on the Ottawa River (C. E.)—(Bost. Med. and
Surg. Jour.,  vol.  ix., p.  55.)  Such are some
of the  reasons which induce us to  believe that
this disease was an epidemic depending main-
ly on some unknown distemperature of the at-
mosphere, whose laws have  never been satis-
factorily investigated or explained.
  II. Cholera is, under certain circumstances,
hereafter to be pointed out, contagious or infec-
tious; using these terms, with Dr.  Copland, as
synonymous.  We see no incompatibility what-
ever in attributing its spread to both of the above-
mentioned causes, and we think that physicians
have unnecessarily taxed their ingenuity in at-
tempting to limit its spread  to a single  cause.
All admit that the typhus or ship fever is gener-
ated by confining many persons in a small com-
pass without due regard to ventilation, cleanli-
ness, and proper food, and that it is, moreover,
contagious;  that is, capable of propagation to
those who have not been under the influence of
the same predisposing causes.  Scarlet fever,
measles, and  hooping-cough are instances of
epidemic  diseases,  being also propagated by
personal contagion, while they owe their origin
and general prevalence to some unknown con-
stitution of the air.   Cholera, yellow fever, and
plague belong, in  our judgment, to the same
category.   It  is idle to attempt to account for
their spread upon one principle only.   There
is nothing, moreover, unphilosophical in our po-
sition.  One cause,  doubtless, might be suffi-
cient to produce equally devastating effects ;
although we know of no simply contagious dis-
ease  which bears any analogy in its rapidity
of extension  and  fatality to that  of cholera ;
but the question at issue  is, are  the facts of
the case reconcilable  upon either hypothesis
singly?   We  repeat that  they are not.   In
the operations of nature, we not unfrequently
find the same  results brought about by several
causes ; as heat and light  by the rays of the
sun, by friction, and electrical and chemical
action.  We shall quote a few examples, where
the disease  was propagated, beyond all  ques-
tion, by contagion.
  On the 31st of October, 1832, the brig Amelia,
bound to New Orleans from  New-York, was
wrecked on Folly Island, about twenty  miles
from Charleston.   Some of the passengers la-
boured under cholera, which prevailed at New-
York when she sailed.   They were all landed
safely, and  lived in the few buildings on the
island and in tents.  There they continued to
sicken with the disease.   A  boat's crew of
wreckers had  gone  to the stranded vessel to
save her cargo, and, on their  return to town,
one was seized with cholera  and died.  The
rest of  the crew were  ordered to the island to
perform quarantine  with the  persons landed
from the brig, and one was taken on his way
and died in the boat.  There were four negroes
on  the  island.  Three physicians  were sent
from the city to attend the  sick, and a detach-
ment of the  city guard was detailed to enforce
the quarantine.  Of the wreckers, thirteen in
number, several were attacked, and eight died
of cholera.  One of the physicians was seized
with it, but recovered.  The nurse of the wreck-
er, above mentioned as dying in the city, him-
self sickened and died, after being sent to the
island.  Of  the four negroes  residing  there,
three died;  of the guard sent down, eighteen
in number, ten were sick, and one died.*
  On the 17th of  July two females left New-
York in a packet for Newport, where they ar-
rived well the  next day.  After being detained
a week  at quarantine,  they were permitted to
land on the 25th.   They were both sick with
cholera  when  they landed,  of which they both
died on  the same day.  On the 30th, Mr. Fos-
ter, who had  assisted in burying them, was at-
tacked with the same complaint, but recovered.
Immediately after  this his wife and three chil-
dren were attacked with cholera, of whom the
wife and two children died.  (Reports on  Chol-
era, &.C., N.  Y., 1832, p. 19.)  The disease was
also communicated to two  persons at the hos-
pital, where  two of the  above patients had been
removed, both  of  whom died.   The town of
Newport was, at this  time, perfectly healthy,
and there was no ground to suspect the opera-
tion of any general or local cause.
  Dr. Ellwood, of Rochester, states that a man
who had attended some friends sick of cholera
in that  city, went  to Mendon, a small village
sixteen  miles east of that place.  He died of chol-
era the following night.   There had been no
case of the disease there before this.  Of six
persons who attended him during his sickness,
and buried him, not one escaped an attack, and
four died within a week.   There were after-
ward thirteen  deaths by cholera in a population
of only one hundred and fifty  persons.  (Loc.
cit., p. 20.)
  At Manchester,  Ontario  county, New-York,
a similar fact was observed.   A lady arrived
there, and died five days after leaving New-
  [* Essays on Pathology and Therapeutics, &c, by SAM-
UEL Henry Dickson, M.D., vol. zi., p. 9'J.J 
PESTILENCE, CHOLERIC—Causes.
129
York.  Her sister, who resided at Manchester,
and was with her during her illness, died two
days after.  (Loc. cit., p. 20.)
  In Oneida county, New-York, some  Indians
were  employed to  bury a person  who had
died of cholera in a canal-boat, six of whom
died of cholera very soon after.   In all the
above  instances there had been no cases of
cholera previously within  many miles of the
places mentioned.
  The above, and  numerous facts of a similar
kind, oblige us to adopt the doctrine of contin-
gent contagion, with the full conviction, more-
over, that contagion per se is utterly inadequate
to  account for the  phenomena attending the
prevalence of this disease.  It is a malady, we
believe, propagated, as a general rule, by oth-
er agency than that of reproduction by the hu-
man system ;  and yet at times, and under par-
ticular circumstances, by no  means fully un-
derstood, it is so reproduced, and acquires con-
tagious or infectious properties, so called.  At
any rate,  the  fact has been, in our judgment,
fully  established that the  disease cannot  be
localized and restrained by quarantines ; theory
 and experience both demonstrate  the  inutility
 of preventive measures of this kind.  The chol-
 era is contagious  just as typhus fever is con-
 tagious, in crowded,  unventilated dwellings,
 amid  filth,  intemperance, and  poverty; rarely
 in cleanly, airy  apartments,  the  inmates  of
 which are regular and temperate,  well-fed and
 well-clothed.]
   93.  ii. The Infection of pestilential Cholera, as-
 sisted by predisposing, concomitant, and determin-
 ing Causes.—It may be briefly premised, that
 this  disease  is never produced  without the
 presence  of a certain leaven, or morbific mat-
 ter, which, emanating from the bodies of the
 affected, and  floating in the air, is respired by
 those about to be attacked.  This is the clear
 and only inference connected with its trans-
 mission that can be deduced from the body of
 evidence now placed before the reader.  Those
 who argue against its transmissible nature can-
 not show, since the irruption of the pestilence
 in India, down to its  arrival in this country,
 and transmission thence  to America, a single
 instance of its appearance in any place with-
 out the  previous communication  with an  in-
 fected place  or persons, of a nature to propa-
 gate the malady.*  The non-infectionists place
 great reliance  upon the  circumstance  of the
 disease having,  in several  places,  spared a
 large number of those  who have come within
 the sphere of its  influence.  But they must be
 aware that a similar circumstance is  uniform-
 ly met with during the  prevalence of ali dis-
 eases acknowledged infectious.   All  who are
 exposed to them are not equally, and many are
 not at all  liable  to be  affected by them; and
 the person who may not have been susceptible
 of the infection to-day may be susceptible  to-
 morrow,  owing, very frequently, to the causes
 about to be noticed.  This pathological fact is
 familiar to every observer in  respect of small-
 pox, measles,  scarlet fever, and the  true  ty-
 phus—diseases whose infectious nature is very
 generally  admitted;  and  wherefore  should it
 be otherwise in  respect of the present pesti-
 lence 1  The same fact,  moreover,  has been
  [* This statement can by no means be borne out by facts
as observed in this country.]
    III.              9
remarked of all pestilences of which we have
any  accurate  information in medical  annals.
In illustration of this I may notice what has
fallen under my own observation.  During the
dry easterly winds  which occasionally prevail
on the  west coast of Africa, it is frequently
impossible, and always difficult, to infect the
system  with smallpox, even by inoculation;
and when the operation succeeds, the  disease
is usually mild  and the  eruption  distinct;
whereas,  during the moist, close, and sultry
weather following the rainy season, it  spreads
with the  utmost rapidity; the  effluvium from
the bodies of the affected appears to be carried
to considerable distances, and transmitted read-
ily by means of various media,  the disease be-
ing generally confluent,  and  most fatal.
  94. The circumstance of so many  persons
escaping, besides being referable to  this non-
predisposition, may likewise be explained by
the circumstance of free ventilation, the per-
flation of currents of pure air, by modes of liv-
ing calculated to oppose the invasion of the in-
fectious effluvium,  and by being habituated  to
the influence of this principle.  We frequently
observe that persons constantly present in pla-
ces contaminated by an infectious effluvium are
less liable to be attacked than those who are
suddenly introduced from a purer air, but  at
the  time predisposed to infection.  This has
often been demonstrated by the experience  of
others as well as of myself.   Thus, on the first
occasion  of my visiting the cholera hospitals
and cases of the disease, a sensible effect was
produced upon my respiration, pulse, and di-
gestive functions, that was less and less mani-
fested on each successive exposure to  the con-
centrated emanations from  several of  the sick
placed  in one apartment.  A similar fact was
observed by others ; and, although it was very
remarkable in this distemper, it has  also been
noticed in respect of other infectious maladies.
 Thus, a person confined in a close apartment
 with the true typhus fever was visited by a
 friend;  the visiter, upon entering the apart-
 ment, [smelt] a  peculiar, disagreeable odour,
 which  occasioned a slight faintness and nau-
 sea, followed by headache, indisposition to ac-
 tion, &c.  This slight indisposition  continued
 for  several days,  when,  about eight  or nine
 days afterward, typhus fever was fully devel-
 oped.   The person thus infected was kept in
 an airy apartment, and directions given as to
 ventilation, &c, with the view of preventing
 its extension ; and the means employed suc-
ceeded as far as regarded the members of the
family;  but, when  convalescent, a friend was
admitted, and this  person caught the  disease.
What the ultimate  progress of  the malady was
in respect of this third person I had no means
of knowing; but  I have no  doubt that the dis-
ease was communicated, in these two instan-
ces, if not  in the  one  first referred  to, while
none of the constant  inmates  of the  families
were infected.
   95. Another circumstance showing the op-
eration  of a  specific cause in producing the
pestilence is  its  uniform and  specific charac-
ter in all climates, seasons, and localities ($ 112).
 [The cholera is no more specific and uniform
in its character than many diseases acknowl-
edged to be epidemic, and caused by some con-
ditions of the atmosphere.]   If the  efficient 
130
PESTILENCE, CHOLERIC—Causes.
causes of the disease were diversified, or con-
sisted  of the contingent combination  of sev-
eral, we  should  naturally expect a similar di-
versity of effects and a constantly-varying mal-
ady, both at its commencement  and during its
advanced progess;  but  such has been shown
not to be the case (§ 53, et seq.).   The efficient
cause is  specific, the disease itself is specific,
and only modified as respects severity or grade,
and  the  manifestation  of certain subordinate
phenomena, by the intensity of  this cause, by
certain predisposing, concomitant,  and deter-
mining influences, and  by  the habit and tem-
perament of the affected (§ 97-101, et seq.).
  96.  Having stated that the pestilence  is not
communicable to any excepting to those who
are circumstanced or disposed so as to  allow
the invasion of its exciting or specific cause, it
will now be necessary to notice those circum-
stances which co-operate in this manner ; and
this is the more necessary, as those who deny
the infectious nature of the disease refer it al-
together to  certain influences which predispose
the frame to the action of the  specific  cause,
which re-enforce or accompany it, or which, ow-
ing to their presence after exposure to  it, de-
termine  its  operation, or bring  it more rapidly
or more efficiently into action,  when  it might
otherwise have failed of its effect.
   97.  Many of the earliest reporters  and wri-
ters on  this pestilence, who disbelieved in  its
infectious nature, had recourse  to  the state of
the  seasons in India to account for its  occur-
rence.  Some  referred it to the prevalence of
easterly winds, with long-continued or heavy
falls of rain, by which the air was rendered
moist and  vitiated ; others, to  sudden  or ex-
 treme variations of the electrical conditions of
 the atmosphere, which variations were mere
 suppositions, and not matters  of corroborated
 observation ; not a few, to the extrication of
 some peculiar terrestrial  miasm, projected in
 distinct or remote places from one another, and
 proceeding in  singular currents, so  as to  in-
 volve a part of a  village, or a  detachment, or
 even  company of a regiment, while the vicinity
 was intact; and several could detect no other
 cause for  it  but  exhalations proceeding from
 low, moist, and swampy situations, and other
 sources of malaria, rendered peculiar by some
 unknown cause, or productive  of  this peculiar
 disease from errors in  diet or incautious expo-
 sure.  Now it should  be kept in recollection
 that the existence of all, or any of these, was
 merely  supposititious ;  that proofs were never
 adduced, and that  the commonest meteorolo-
 gical observations were  generally  wanting.
 There was no uniform  relation observed, either
 in this  country or in  the eastern  and western
 hemispheres,  between  the appearance of the
 malady and marked variations in the barome-
 ter, thermometer, or  hygrometer, even in the
 few places where these were  registered; but
 the irruption  of the pestilence was  often ob-
 served  in states of season, weather, and atmo-
 sphere  opposite to those to which it has been
 confidently imputed.   Even admitting  that all
 the above-mentioned  causes were actually in
  existence  (and I believe they were frequently
  present), particularly during the severer irrup-
  tions of the disease, they merely  show the
  truth of a  part of my doctrine,  viz., that the in-
  fectious nature of the disease was more stri-
kingly evinced during conditions of the  situa-
tion, season, and atmosphere, of acknowledged
insalubrity ; that whatever tended to lower the
energies of the frame, as such  causes indispu-
tably do, favoured the operation of the  infec-
tious effluvium issuing from those affected by
this pestilence, and rendered it more prevalent
when they were concentrated or uncommonly
active ; and that, in this respect, as well as in
many others, the infection of pestilential chol-
era observes the same laws as other infectious
maladies, as  scarlatina,  measles, &c,  mani-
festing  itself in isolated  cases  only during
healthy states of season and atmosphere,  and
spreading to a greater or  less extent during
seasons of marked insalubrity, and during pe-
culiar constitutions and vicissitudes of the air.
   98. So far, therefore, from disputing the in-
fluence of many of those causes to which some
highly-respectable  authors have imputed this
malady, I fully admit their operation, even al-
though their existence  is more a matter of in-
ference than of observation. I deny, however,
that they are  sufficient for the production of
the destructive effects characterizing  this pes-
tilence, and  contend that  as  no such effects
 have, in the history of our species, been known
 to result from them, so we cannot with justice
 admit that they are alone capable of producing
 them so as to generate this pestilence : I view
 them merely in  the  light of predisposing and
 concomitant causes coming in aid of a more
 powerful agent, which,  emanating  from the
 bodies of the affected, contaminates the  pre-
 disposed in such a manner as to give rise to
 the same  morbid actions as those which gen-
 erated it; that these imputed causes favour the
 operation of this infecting agent, 1st, by predis-
 posing the frame to its influence;  2d, byre-en-
 forcing or assisting its action  ; and, 3d, by de-
 termining or calling into operation the infecting
 principle.   The  predisposing and re-enforcing
 influence of the different causes already referred
 to  cannot be  denied.  We know, or, at least,
 observe too much  of their influence in respect
 both  of contagious  and  infectious diseases
 which are familiar to us to doubt their opera-
 tion as regards this distemper; indeed, their
 action would be a matter of undoubted infer-
 ence to the well-informed physician, independ-
 ently of the results of observation.
    99.  But, besides the predisposing and  concur-
 ring causes noticed above ($ 97), there are oth-
 ers not yet enumerated, of equal influence, not
 only in favouring the operation of the efficient
 agent  of the malady, but  also in calling it into
 action after the frame has been exposed to its
 invasion.   The  chief of these are, anxiety and
 depression of the mind ; fear of the disease;
 physical and moral debility ; low living and un-
 wholesome diet; constitutional debility or lax-
  ity of the bowels ;  previous disorder of the di-
 gestive  organs; neglect  of personal and do-
 mestic cleanliness; deficient or filthy clothing;
 exposure to cold ; the immoderate use of in-
  toxicating liquors, or excess  of any descrip-
  tion ;  sleeping on the ground, or in low, ill-
  ventilated apartments, or in the open air; the
  use of cold, indigestible,  or unripe fruits ; cold
  drinks when the body is overheated  ; fatigue;
  sudden  arrest of the cutaneous exhalations,
  however produced, &c.  Either of these, wheth-
  er acting shortly before, or at  the time, or even 
PESTILENCE, CHOLERIC—Causes.
131
soon after the body is exposed to the invasion
of the infectious effluvium, will favour the pro-
duction of the malady, particularly  if several
of them act in conjunction, and if, at the same
time, those causes,  whether proceeding from
the state of the locality or of the air, to which
allusion has been already made, are also present.
   100. One of the most remarkable of predis-
posing causes to  an attack is advanced age, as
well as one of the most unfavourable circum-
stances as respects  hopes of recovery.   In-
stances of attack previously to  puberty were
comparatively few ; but the  frequency of the
seizure after 40 years of age increased in pro-
portion to the advance in age, and the mortali-
ty in a still greater proportion (see  § 21);  so
that after 55 years recovery was  rare.
   101. It has been  already stated that a great
number of the medical men called upon to treat
this pestilence have imputed it chiefly to atmo-
spheric causes, denying altogether the influence
of infection ; and the chief arguments  which
they advance, in order to show the absence of
this property, have been and are about to  be
referred to (9 97-99, and 102, et seq.). I verily
believe, nevertheless, that this malady is in-
fectious in a similar  manner to  measles  and
scarlet or typhus fever ;  that is, not by contact,
but from  the inhalation  into the  lungs, along
with the air, of the morbid  effluvium given out
from the body or bodies of the affected.   We
know that the mere contact of persons suffer-
ing from the diseases now mentioned will not
communicate  them even to the  predisposed ;
while the  presence in the air which is breathed
of a scanty portion of the effluvium  given off,
during  their progress, from the  affected, will
often produce them; and such, I am convinced,
is the  case with the pestilential cholera.   We
farther  know, that it is not easy to  communi-
cate these acknowledgedly infectious diseases
by inoculation when access of the morbid ef-
fluvium to the lungs  is prevented.  It, there-
fore, can be no matter of surprise to  learn that
M. Foy, and others of the young physicians
who visited Warsaw, failed  to propagate  the
malady by inoculation,  or by tasting the mat-
ters vomited  by  the  affected; even although
the tasting matters vomited, under any circum-
stances, might well have turned  the stomachs
of many.   Indeed, though cautiously  convinced
of the existence of the infectious  nature of the
pestilential cholera, I would have inferred that
inoculation, or the introduction of the morbid
secretions into the stomach of healthy persons,
even were they predisposed to an attack of the
malady, would have failed, in accordance with
the laws which infectious diseases observe, to
communicate  it,  provided  the  effluvium  pro-
ceeding from the  bodies of the affected be pre-
vented from passing into the lungs.  I as firm-
ly believe that it is the inhalation of this efflu-
vium into, and its influence on, the lungs of the
predisposed, that  paralyzes the nervous energy
and functions of this very important and vital
organ,  occasions the singular collapse of it ob-
served after death,  and  evinced  during life by
the state of the hypochondria, epigastrium, and
respiratory organs, prevents the changes which
the blood is destined to undergo  in  the lungs
from taking place, and gives rise to all the con-
secutive phenomena of the attack, as I am con-
fident of any fact in pathology.
   [While in attendance upon  the  Greenwich
 Cholera Hospital, in 1832, a medical gentleman,
 Dr. C, from Vermont, called on me and request-
 ed the privilege of seeing some  of the cases.  I
 accordingly accompanied him through the  dif-
 ferent apartments, in which there were about
 70 patients in all stages of the disease.  This
 occupied about twenty or thirty minutes ; and
 on reaching the door, after completing a hasty
 examination of the cases, he  suddenly com-
 plained of faintness and nausea ; in a moment
 more I  perceived him staggering, and likely to
 fall.   I accordingly supported him in part while
 he sunk upon the floor, apparently in a perfect
 state of asphyxia.  By the application  of cold
 water, stimulants, &c., with the aid of a hori-
 zontal posture, he soon revived sufficiently to
 be removed in a carriage to his  hotel, where he
 was immediately seized with cholera in its worst
 form, and barely escaped with his  life.   This
 gentleman had reached town only an hour pre-
 vious to his  call at the hospital, had not been
 previously exposed  to the disease, nor had he
 any  fear of  an  attack.  I regarded it, and still
 do, as a very striking example of the influence
 of cholera effluvium, when intense, in affecting
 the human system, even if not predisposed.]
   102.  iii. Arguments of those who contend that
 the Disease is not Infectious, farther noticed.—I
 have adduced above (§ 61, et seq.) sufficient ev-
 idence  of the  infectious nature of this pesti-
 lence, and have stated, under the head of con-
 current causes, those to which  solely the anti-
 infectionists  impute the disease.  I have now
 to notice, more particularly than I  have yet
 done, certain arguments on which they rely in
 favour  of their doctrine ;  and,  first, they con-
 tend that, having had sufficient and admitted.
 proof that cholera has not hitherto been an in-
 fectious malady, either as occurring in warm
 or temperate climates,  wherefore should  it
 change its nature,  and become infectious at
 the present  time 1  The  ready  answer to this
 is, that it is granted that the common cholera,
 whether that connected with a vitiated state
 of the biliary secretions, or that more severe
 form of the  disease most frequently met with
 in warm countries, and denominated spasmodic
 cholera, or mort de chien, is not  infectious ; but
 that this can be no reason why  this pestilence,
 which is distinct  from cholera,  occurring from
 other causes and under  other  circumstances, •
 possessing also very different characters, among
 which those  of cholera are merely a part, and
 the least important  part, should present  this
 very important feature.
   103. Secondly, they contend that, if this mal-
 ady were infectious, a greater number of those
 who come near the affected would be attacked ;
 and  because, under circumstances already al-
 luded to ($ 93, 94, 95), so many do escape, that
 therefore the disease is not infectious.   This
 is the chief argument on which Mr. Searles,
 referring to what took place in his own hospital
 at Warsaw,  relies, in support of his opinions
 as to the non-infectious nature  of the disease.
But as respects the escape of a large propor-
tion of those  who  are exposed to the infection,
this pestilence resembles all other known  in-
fectious diseases,  not excepting even the most
virulent.
  104. Much stress, also, has been laid upon the
fact of the disease not having been  communi- 
132
PESTILENCE, CHOLERIC—Causes.
  cated by inoculation, and by tasting the ejec-
  tions ;  but this proves nothing, and is merely
  an illustration of what ought to be known to
  every medical man—that diseases which do not
  generate a specific virus cannot be easily prop-
  agated  in this way.   Who, I would ask, would
  expect  to communicate measles, scarlet fever,
  or typhus fever in this way?  Who would ex-
  pect to be affected by even a concentrated mor-
  bid virus on receiving it into the stomach'?  It
  is well known that the matter of smallpox and
  the  poison  of serpents may be thus  applied
  without effect.  That so many, or that all even,
  of the attendants in an hospital  should escape,
  is only  what most medical men  of any consid-
  erable range of observation  would expect, rea-
  soning  from their experience ; this point, how-
  ever, has already been disposed of ($ 93,  94,
  95, 101).  But the facts are, even on this point,
  as respects this pestilence, opposed to the doc-
  trine of the non-infectionists ;  for it has been
  proved  on  numerous  occasions, several  of
  which have been noticed when demonstrating,
  by direct proofs, the infectious nature of the
  disease, that a very large  proportion  of the
  medical men and  hospital attendants were at-
  tacked, notwithstanding the absence of all dread
  with which medical  men and  their attendants
  view disease, and their habitual exposure to
  animal  and other insalubrious effluvia.
    105.  Thirdly, the non-infectionists argue that
  numerous  instances of the true pestilential
  cholera have  occurred, which  could  not be
  traced to exposure to communication direct or
  indirect with those  previously affected.  This
  may be the case in a few instances ; but how
  difficult is it to prove mediate infection, or that
  which takes place through the  medium of fo-
  mites ;  and it may be asked, on  how many oc-
  casions are persons liable to be  affected by an
  infectious principle, without .being able to  ac-
  count for the manner in which it took place, or
  to refer to the individuals whence it emanated,
  or to the media through which it was conveyed ?
  We know that infectious diseases  may occur
  almost  immediately after the impression of the
  exciting cause, or not until after many days, or
  even weeks,  according to the state  of predis-
  position in  relation  to  the  intensity  of the
  cause, during which interval certain latent or
  almost  imperceptible changes are going on in
. the frame ; therefore, during so indefinite a pe-
  riod of  interval between exposure to the cause
  and the development of disease, how can all
  those attacked refer to the particular occasion
  on which they were exposed to infection ?
    106.  Fourthly, the anti-infectionists refer to
  the occurrence of epizooties, in proof of a nox-
  ious emanation from the earth, which, floating
  in the air, affects both man and  beast, and oc-
  casions this  pestilence.  I grant that  emana-
  tions may, and sometimes do, arise from the
  soil, and affect man as well  as  the lower  ani-
  mals ; and that, when this phenomenon takes
  place, it may be a  concurrent cause of the pes-
  tilence, so far as to increase the predisposition
  to infection, and the fatal tendency of the dis-
  ease.  But, from a careful review of the occa-
  sions on which epizooties have  been observed
  contemporaneously with the prevalence of this
  pestilence, I can state that they have been few,
  and merely coincidences, which by  no  means
  affect the question at issue.   It  should be kept
in recollection that several of the seasons pre-
ceding and during the prevalence of pestilen-
tial  cholera have  been usually wet, and  that
increased mortality among the lower animals
is often  observed  at such  times.   Many even
of the instances of such coincidences on rec-
ord are so vague, and  so deficient in accuracy
of details and  dates, as to  deprive them alto-
gether of importance in the discussion of the
subject.   Besides, during the very long preva-
lence of this malady over the whole globe, it
would have indeed been wonderful if the coin-
cidence of epizooties with it had not been ob-
served.
  107. Fifthly, another circumstance made use
of by the non-infectionists is that of so  many
who have observed and treated the disease
having espoused their side of the question.  To
this  I may reply, that a very large number of
those who have enjoyed this advantage have
not had,  even in India, as may be ascertained
by referring to the reports  of the Medical
Boards, and  to the  documents  at  the  India
House, that extensive experience  which we in
this country suppose.  It should be recollected
that  a large proportion both of natives and na-
tive  troops were treated by their native  doc-
tors.  Besides, are we to expect those compre-
hensive  views  of the history and modes of
propagation of a disease from those who have
seen but a little, and described only what they
have seen ;  or  from those who dispassionately
investigate the  origin, the causes, the phenom-
ena,  and the relation of all  that has been  ob-
served and recorded, and cautiously weigh the
evidence on either side of a disputed topic con-
nected with it ?  The captain of a company, or
even a colonel, performs an important part, in-
dividually, in an army during a general engage-
ment ; but he can know little, personally, of the
disposition, changes, and evolutions of all its
parts, and of the plan of strategy, according to
which  it first acted, or was led to change its
operations, in order to meet or counteract those
of its opponent.  Like the commander-in-chief
of the whole army, we, who  collect, compile,
arrange,  and digest facts, on both the one side
and the other of a disputed subject; who ob-
serve closely what has occurred within the
sphere of our own experience ; who compare,
weigh, and meditate upon the whole evidence,
personal as well as testimonial, with our minds
uninfluenced  by prematurely conceived  ideas,
are the best suited to  investigate, and to con-
clude respecting them.  Placed, by the number
of accumulated facts, and by minds accustomed
to view and to  investigate the difficult opera-
tions of nature, on the elevated table-land of
human science, we may be admitted to be more
able  to  take  in a  comprehensive  view of the
causes and nature of disease, and to come to
accurate  conclusions respecting it, than many
of those who, as observation has shown, have
drawn  hasty inferences from a few  and very
imperfectly investigated occurrences.
  108.  Sixthly, the non-infectionists also argue
that if the disease had been infectious, its prop-
agation would  have  been  prevented by the
measures resorted  to.  To this argument I re-
ply, that  the disease, during its prevalence in
the East, was never expected to be confined by
sanatory measures ; that it was not until it
reached Astracan that any such measures were 
PESTILENCE, CHOLERIC—Causes.
133
attempted, and then only imperfectly ;'and yet
these succeeded for eight years in preventing
its entrance  into that place;  and that, where
rigorous  quarantine  has been  adopted,  the
measure has succeeded, several  instances of
the success of such measures having already
been adduced.
  109. The non-infectionists farther state that
several continental states and authorities, con-
vinced of the inutility of quarantine, have re-
linquished it.  Granting this to be the  fact, it
merely shows, what any thinking person must
admit, the impossibility of preventing the intro-
duction of the disease into a populous town,
situate in the vicinity of others, and of a thick-
ly-inhabited  country,   between  which  there
must necessarily still be, even under the most
strict  quarantine,  a  constant intercourse of
some kind or other, either by land or water,
and perhaps  by both.  There  can be no doubt,
if the testimony of several  well-informed per-
sons, cognizant of the  facts,  are to be relied
upon, that the distemper was introduced at sev-
eral seaports of  this country by the bed and
body-clothes of those who died on board mer-
cantile ships, that had been  preserved and giv-
en up to the  relatives of the deceased.   But a
strict quarantine and  purification of these ef-
fects only could have prevented  this mode of
communicating  the distemper; and in no in-
stance  were  these observed. Indeed, many
ships arrived, during the latter part of 1831, in
British ports, from infected  places, having lost
 individuals from among their crews on the voy-
 age home, and the fact was often  either con-
 cealed or not attended to, the infection  either
proceeding farther, or not, as circumstances
concurred to favour it.
   110.  But let me turn for a moment to the
causes which the  non-infectionists substitute
for an infectious principle.  Some  argue in fa-
vour of a certain distemperature,  epidemic con-
 dition,  or altered  state of the air, being the
 cause of the disease.  Now these are mere
 suppositions.  But grant them  to exist, how
 would  they explain the progress and propaga-
 tion of the pestilence ? The air is a very mo-
 bile fluid, sweeping along frequently at the rate
 of seventeen and  eighteen miles an hour, and
 being constantly renewed, both in  a horizontal
 and in a  vertical direction,  unless in situations
 where it can be confined.   But the disease has
 not been propagated in the  course of winds, or
 with the rapidity  which such a source would
 suggest: it  has  advanced  slowly, and at the
 rate at which human intercourse  takes place,
 in the  lines or  channels of such  intercourse,
 and in the quarters where intercourse with pre-
 viously infected parts has occurred.  It has
 usually spread in a town, visited  prisons or se-
 questered places  the  last,  but  affected them
 severely  when introduced ; and it  has entirely
 avoided those who placed themselves altogeth-
 er apart from the  rest of the community.
   111.  If the constitution of the air were the
 cause, how came isolated places, in the middle
 of infected towns,  or in the track of the prog-
 ress of the disease, to escape ?  How could
 the disease be barricadoed, as it was  in some
 towns in Russia, and shut out from certain dis-
 tricts and streets ?  How could  it spread and
 travel along one side of a river,  in the line of
 public intercourse, and never  appear on the op-
posite  side, or, if it did appear, wherefore  did
it, either  first  or merely, at the  point  where
communication with the opposite banks takes
place ? When introduced into a country, where-
fore should it break out first in seaports having
intercourse with previously infected places, or
in towns  having inland communication with
parts thus circumstanced ?  If the air were the
source, how was its noxious property retained
after passing hundreds, or even thousands of
miles, as in the case of the appearance  of  the
disease in the  Isle of France;  or wherefore
did it, after this passage, respect the adjoining
islands?   How came the disease never to  ap-
pear in any place without previous intercourse
with a previously infected part, if it arose from
a generally diffused state of the atmosphere ?
  112. Others,  again, impute the pestilence to
the exhalation  from the bowels of the earth
of some  peculiar miasm.  But the above  ar-
guments  are equally weighty when directed
against this supposition ; for, independently of
such exhalation being a mere assumption, as well
as the foregoing, and putting out of the ques-
tion the fact that not a vestige of evidence has
ever been adduced of  any peculiar change of
the atmosphere from its usual condition, or of
any miasm, exhaled from the interior parts of
the earth, having been observed simultaneously
with the appearance of the malady, these caus-
es, even if they did exist, could not account for
the specific and uniform characters which it has
always presented, in every situation, tempera-
ture, and  elevation above the level of the sea,
in all latitudes and longitudes,  and from its
commencement constantly up to  the present
time.  A  distemperature of the air, whether
from foreign gases, electrical states, or what-
ever other cause, surely could not for  such a
period, or under such a variety of circumstan-
ces, be so uniform  and specific.   Exhalations
from the  interior  of the globe, whether  pro-
ceeding from a great internal fire, from the ac-
tion  of circumambient agency, solar or lunar,
or both, or from the electrical changes taking
place in the more interior masses and constitu-
ents of our planet,  surely could not, in all pla-
ces,  at  all periods  of  this  epoch, at all eleva-
tions, and under every combination of circum-
stances, be so uniform in their effects, so spe-
cific in their action, as  the character of this
pestilence shows its exciting cause to be.
   113. If a noxious exhalation, proceeding from
the more  interior parts of the globe, caused the
disease, it must on some occasions have risen
through the depth of the ocean to have affected
the  crews of  ships.   Could this  have taken
place without it being changed by  the medium
through which it passed ?
   114. Where we find a distinct agency—a spe-
cific effluvium, exhaled from the bodies of the
affected, of which  we have certain proofs, not
merely as respects the  manner of its operation,
but also as regards its impression on several
of our senses—wherefore should we have re-
course to supposititious essences  and  to  vain
imaginings to  account for the propagation of
the disease ?
   115. It may be supposed that more space has
been devoted to this part of the subject than it
deserves.  It  is, however,  of the most tran-
scendent  importance;  for upon accurate views
respecting it altogether depends  the success of 
134                        PESTILENCE, CH

measures to prevent the extension of the pes-
tilence, and even to remedy it where preventive
measures have failed.  Besides,  as this pesti-
lence is placed in the same category with true
yellow fever and the plague, both by those who
argue for and  by those who argue against in-
fection, the evidence for or  against this prop-
erty in  respect of it applies also to the others.
   116.  Having devoted much attention to the
phenomena of this  pestilence, and to the  cir-
cumstances characterizing the dissemination of
it, and  having  had extensive  experience in it
during  its  prevalence in  this  country,* I pro-
ceed very  succinctly to state the conclusions
at which I arrived as to its causation and prop-
agation.
   117. (a)  The distemper was caused by  in-
fection, which  was  traced in  many cases—in
most of those which I saw in private practice :
it  was  manifestly infectious according to  the
definition I have given  of Infection, in the ar-
ticle devoted to the  consideration of this topic
(see <J 3, et seq.).
   118. (b) It was not caused or propagated by
immediate or mediate contact—by a consistent,
manifest, or palpable virus or matter;  but by
an effluvium or miasm, which, emanating from
the body of the affected, and contaminating the
air more immediately surrounding the affected
person, infected  the healthy  who  inspired the
air thus contaminated,  especially  when predis-
posed in the manner above shown (§ 99).
   119.  (c)  This morbid effluvium or seminium
of the distemper—this animal poison emanating
from the infected—was often made manifest to
the senses of smell, and even of taste ;  it attach-
ed itself to the body and bed-clothes ; remain-
ed so attached for lengthened periods, if these
clothes were shut up in confined places;  and
reproduced  the disease when the air respired
by predisposed persons was contaminated or
infected by the clothes  imbued by the effluvium
or poison.
   120.  (d)  The disease was  thus  propagated
in numerous cases ; and,  as I was convinced
in my own person, even by  the clothes of the
  * On the introduction of the pestilence into this country,
I was desirous of observing it in the cholera hospitals with-
in my reach, especially in those first established ; and my
friends at the Privy Council Office furnished me with every
facility in accomplishing  my intention.  I saw also many
cases in private practice, both in my own vicinity and in
various parts of the metropolis and suburbs.
  [The editor  may also be allowed to refer to his own op-
portunities of witnessing this disease.  At the commence-
ment of the cholera in New-York, 1832, he was  appointed
by the " Board of Health" to organize a cholera hospital in
the northwestern part of the city, then called Greenwich,
which he did, and was connected with the same during the
prevalence of the epidemic.  The cases treated  from July
G to September 5,1832, were 350, of which 204 were cured,
and 146 died ;  of these there were 193 cases of collapse,
of which 66 were cured, and 127 died ; 135 of these  occur-
red in intemperate persons, of whom 109 died, and 26 were
cured ; 58 cases of collapse occurred in temperate persons,
of whom 40 were cured, and 18 died.  Of the whole numler,
204 were intemperate, and 146 either temperate or their
habits  unknown.   Seventeen nurses were attacked,  of
whom 2 died, and 15 were cured ; 52 died of consecutive
diseases ; 3 puerperal women died ; and 42 died within six
hours from admission.   Of the whole number, 50 were
children, 37 blacks, 91 Americans, and 222 foreigners.  In-
cluding hospital and private patients, in 1832 and 1834, we
have treated or watched the treatment of more  than 1000
cases of cholera ; made numerous autopsical examinations ;
and for forty days  and nights ate and slept among the sick,
the dying, and the dead.  We state these facts that  the
reader may judge whether we act presumptuously in ques-
tioning on some points the doctrines of our author in rela-
tion tu the character, treatment, &c, of this disease.]
OLERIC—Causes.

 physician, without himself becoming affected.
 An  infected or contaminated  air—infected in
 the  way just shown—caused  an  attack, with-
 out  immediate or mediate contact, which was
 entirely innocuous, provided the air contamina-
 ted  by the affected person was not inspired.
   121.  (e) Placing the hand upon any part of
 the  surface of a person in the cold or  blue stage
 of the distemper was often followed by a pecu-
 liarly unpleasant or tingling sensation in the
 course  of the nerves of a  healthy person, but
 this would not occasion infection, if breathing
 the  contaminated air surrounding the affected
 was avoided.
   122.  (/) When the poisoned air was breath-
 ed by a healthy  person for the first  time—es-
 pecially the unpleasant air in the wards of a
 cholera hospital, or that surrounding the dead
 body, or that contaminated by  the evacuations,
 a  morbid impression was often felt and refer-
 red  to the chest and  epigastrium, giving rise to
 frequent forcible inspirations or expansions of
 the  chest.   This impression and its immediate
 consequences generally disappeared after a re-
 course  to  stimuli, or  full  living; but were fol-
 lowed by some grade or other  of the distemper
 if other depressing agents, as fear, &c, or high
 predisposition, favoured their development.
   123.  (g) On  occasions  of  subsequent ex-
 posure  to the efficient cause of the malady—of
 breathing the infected air—this morbid impres-
 sion was  somewhat less manifest;  and each
 successive exposure was  followed by less evi-
 dent effects,  unless the morbid effluvium was
 more concentrated in the respired air.
   124.  (h) The operation of the morbid efflu-
 vium or animal poison was violent  in proportion
 to the  concentration of it  in the  air respired,
 and to  the weakness of the person inspiring it,
 and to the grade of predisposition.
   125.  (i) There is no evidence to account for
 the  generation of the choleric poison in the first
 instance, and there is as  little of  its  reproduc-
 tion  de novo, on subsequent occasions.  It is
 also impossible to form a correct idea of the
 period  during which  the  infectious miasm or
 seminium may be retained by clothes closely
 shut up from the air, or by the  dead and buried
 body, and be still  capable of infecting the
 healthy.
   126.  iv. The  Disease considered in  relation to
 its exciting Cause, and the Effects of this Cause on
 the  Vital  Functions and Blood.—The  intimate
 relations and nature of this pestilence can only
 be inferred from a careful examination of symp-
 toms or phenomena,  in connexion with their
 exciting cause,  and with its effects, both direct
 and consecutive, upon the  frame.   The uni-
 formity of the symptoms,  under every circum-
 stance of locality, climate, and constitution of
 the  affected,  would  point,  as  stated above ($
 53, 95), to  one specific or principal cause.  But
 in what does  this consist ?   The manner of the
 attack,  the selection observed in its victims,
 the  circumstances connected with the seizure,
 the  characteristic symptoms which it presents,
 and  various other considerations, strongly indi-
 cate, independently of the evidence adduced in
 proof of it, the existence of some animal poison
 or effluvium proceeding from the diseased and
 infecting the  healthy.   But in what  way this
 poison, or leaven of the disease, first originated,
 there are no certain data from which to venture 
PESTILENCE,  CHOLERIC—Causes.
135
 an inference.   Did it originate about the period
 of the first irruption of the pestilence in the
 Delta of the Ganges,  and propagate itself by
 extending its influence to the predisposed ever
 since,  without any subsequent generation of
 the principle de novo, assuming more destruc-
 tive features under circumstances which pre-
 dispose to, or facilitate  its transmission,  as
 moist, unhealthy, or epidemic states of the air,
 &c. ?  Or does this disease arise in distant and
 unconnected places at  nearly the same time,
 from some peculiarity of the air, or of its  elec-
 trical states, or from some foreign material ex-
 tricated from the earth, or floating in the at-
 mosphere ; and, having produced the fully-form-
 ed disease, an effluvium emanates from the af-
 fected body, capable of inducing the same train
 of morbid actions as those in which itself ori-
 ginated, the infectious principle being thus gen-
 erated de novo on numerous occasions?  That
 an infectious property is evinced by the disease
 cannot be doubted  by any one  who  intimately
 examines its phenomena, particularly in  con-
 nexion with their origin,  or who has attended
 to his own sensations during and after respiring
 air contaminated by the effluvium from the sick,
 or after inhaling  the miasms from the  excre-
 tions or from the bodies of the dead; but wheth-
 er this principle originated with the first erup-
 tion of the malady, or has been  reproduced on
 numerous occasions subsequently, the disease
 which reproduces it proceeding  from a very dif-
 ferent cause, is a difficulty which will not read-
 ily be solved.   It cannot be believed, however,
 that, where the symptoms  of the disease are
 uniformly the same, the causes which occasion
 it should be so entirely opposite as are aerial
 influence and an animal poison generated in the
 bodies of the diseased ;  or, in other words, that
 very different and very  opposite causes should
 be uniformly followed  by the same  effects on
 every occasion and combination of circumstan-
 ces, the disease at  the same time  generating a
 cause which shall perpetuate it, of a very dif-
 ferent nature from those  in which itself origi-
 nated.  Indeed, we have no evidence of the re-
 production of this  principle in distant and un-
 connected  places,  from causes  different  from
 itself, inasmuch as there is no evidence of the
 disease having ever appeared under such  cir-
 cumstances, or, in other  words, without com-
 munication with  previously infected  places ;
 and hence we have no right to infer that a con-
 tingent combination of causes will  reproduce
 this principle, until we have evidence to show
 that it does.
   127. But in whatever way this question may
 be answered, if, indeed, it be ever satisfactorily
 answered, is not very material,  as  respects the
 nature of the malady.   Whatever may be the
 exact origin of the efficient cause, there seems
 little doubt that it is inhaled into the lungs with
 the inspired air, where it  acts as a poison, de-
 pressing the  energy of the  nerves  supplying
 this organ, destroying the expansile actions it
 performs during respiration, and impeding those
 changes which the blood  undergoes  in the
 lungs.  That the vital  energy  of the nerves
 distributed  to the respiratory, the  circulatory,
 and the secreting  organs is either uncommonly
depressed or entirely annihilated, is shown by
the nature of the characteristic symptoms con-
stituting the malady.  The state of the respi-J
 ratory function, particularly the laborious in-
 spirations and rapid expirations, the coldness
 of the expired air, the involuntary and forcible
 retraction of the epigastrium and hypochondria,
 and the  inexpressible  oppression  and anxiety
 referred to the chest, all indicate that the vital
 actions of the lungs are nearly suspended, and
 that the state of collapse and congestion, pre-
 sented by them soon after death,  had  actually
 commenced during life.  The impaired actions
 of the heart, the small, weak, and nearly abol-
 ished pulse, and the black colour of the blood,
 evince a suspension of those changes produced
 upon this fluid during  respiration, and demon-
 strate not only a paralysis of the nervous en-
 ergy of the lungs, but  a  marked diminution of
 the nervous power actuating the heart and ar-
 teries ; the loss of vital or nervous power being
 necessarily  followed  by a  suspension  of the
 changes produced  upon the  blood in the lungs,
 by congestion of the abdominal viscera, by an
 exudation of the watery or  serous part of the
 blood from the digestive mucous surface, and
 the discharge  of it from the  stomach and bow-
 els,  and  by a  total cessation of all circulating
 and  secreting actions,  owing to the loss of or-
 ganic nervous power, and to the change in the
 state of  the  blood.   The vital or ganglionic
 class of nerves (which forms a sphere of inti-
 mate union with each  of its parts, supplies the
 lungs, the heart, and blood-vessels, and all the
 digestive, assimilating, and secreting  viscera,
 and  when powerfully impressed in  any one part
 experiences a  co-ordinate effect throughout the
 whole) is primarily and chiefly affected.  Hence
 the alteration  of all the  natural secretions so
 rapidly supervening upon the  morbid impres-
 sion made by the efficient cause of the disease
 on the nerves of the lungs; hence the almost
 total abolition of circulation, assimilation, and
 secretion ; hence the congestions  of the large
 vessels and vital organs ; and hence, also, the
 rapid extinction of voluntary power, as a neces-
 sary consequence  of the suspension of those
 changes which, being produced in the blood,
 support the nervous energy  and all the volun-
 tary and vital actions.   The retchings, evacu-
 ations, and spasms so  generally observed, fre-
 quently follow upon  any  sudden diminution of
 vital power, and upon  congestions of the ner-
 vous centres, and seem to answer wise purposes
 in the economy, inasmuch as  they tend, by
 their influence on the circulation, to bring about
 a natural restoration of the vital  actions, and
 to throw off the injurious  load by which the
 springs of life  are oppressed.  They are efforts
 of nature to expel what is injurious, or to rally
 what is sinking.  Where the powers of life are
 not too far reduced, these efforts will be ener-
 getic, and often successful, as very frequently
 remarked in respect of the less dangerous cases
 of this pestilence ;  but when the vital energies
 are far sunk, or where the serous portion of the
 blood is so far drained  off by the digestive mu-
 cous surface as to render the blood unfit for
 circulation in the capillaries, these efforts will
 generally prove weak and inefficient, even when
 assisted by rationally devised means.
  128.  Whatever may be the exact nature of
 the exciting cause, and whatever may be its
 mode of operation on the frame—whether this
cause primarily affects the organic nervous  sys-
tem, and the blood consecutively through the 
136
PESTILENCE,  CHOLERIC—Causes.
agency of this system, as now maintained—or
whether it passes at once into the circulation
from the air-cells of the lungs, and affects the
organic nervous system secondarily, there can-
not, at least, be any doubt of the very remark-
able  changes  produced  on  the  blood in  the
course of the distemper.   The analyses of the
blood, of the bile, and of the evacuations by M.
Le Canu, Dr. O'Shaughnessy, and others, show
that, at an advanced period, the blood has lost
one half of its  serum, a considerable portion of
its fibrin, and  most of its carbonate of soda;
while the rice-water-like  evacuations consist
chiefly of the  serum of the blood, containing
albumen  and carbonate  of soda, and other  sa-
line ingredients which are deficient in the blood.
When the disease has gone on to the febrile or
reactive  stage, then urea accumulates in the
blood, and even in  the bile, owing to the par-
alyzed state of the kidneys.   It is not improb-
able that a considerable  change is going on, in
a latent manner, in  the blood before the serous
portion of it is discharged from the digestive
mucous  surface; and that this  change takes
place chiefly in the  lungs, and affects the vital
relations subsisting between the serum, fibrin,
and colored globules, as well as between the
capillary vessels and blood circulating through
them; and that the fully-developed period of
the malady  is the result, 1st, of this change,
and, 2d,  of the  evacuation of the serum and
other ingredients of the blood ; capillary circu-
lation in  vital organs thereby becoming arrest-
ed.   This state of the blood, in connexion with
the impaired functions of the lungs, of the kid-
neys, and of the liver, is evidently  the source
of the consecutive fever.
  129. It has  been  now shown, both by refer-
ence to  the appearances displayed  by investi-
gations  after death, and by connecting these
with the phenomena presented by the disease
during life, that the requisite changes are  not
produced upon the blood by respiration ; and
that the  emunctories, which remove from  the
circulating mass those materials which would
prove highly injurious and irritating to the frame
if they were allowed to remain in it, have their
functions entirely suspended ;  while, at  the
same time, the serous portion of the blood es-
capes from  the digestive canal in  so large  a
quantity as to change the physical condition of
the blood in the vessels, and thereby to inter-
rupt the  circulating functions in vital  organs'.
Can it, therefore, be a matter of surprise that,
when reaction of the vital powers of the system
is brought  about, very  great  disturbance,  not
only of the circulating system, owing to the al-
tered state of the blood, but also of the enceph-
alon, and of the  different emunctories, is  im-
mediately manifested?  Indeed, these consec-
utive states of disease,  which have been well
illustrated by  observation, are entirely in  ac-
cordance with a priori inferences in pathology.
  [Whether we suppose the cause of cholera
to consist in  a  contagious  miasm, emanating
from the bodies of the  sick, or  some peculiar
morbid principle, or change in the elements of
the atmosphere, the manner in which it oper-
ates upon  the human  organism  is  purely  a
matter  of hypothesis.  We fully  agree with
Mr. Copland that the disease is an infectious
one, but then  it is only  so under peculiar and
rare circumstances, and when some conjunc-
tion of causes, or elements which we do not as
yet understand,  is brought  about.   We have
known the disease apparently originate de novo
in many places  where it  could  not  be  traced
from abroad, and hence we conclude that, like
typhus fever,  its prevalence is  owing to two
distinct causes,  although its phenomena are
identical.   It  is not certain, however, by any
means, that  the aerial poison  which causes
cholera produces its effect by a direct impres-
sion on the respiratory nerves ;  it is far more
likely to be attracted into the circulation, and
produce its effects upon the solids of the sys-
tem, and the large secretory  and  excretory
organs, through the medium of the blood. ^ We
incline to the  latter hypothesis.   Prof. Paine,
of New York, in his very able  work, entitled
"Letters  on  Cholera Asphyxia" (1842), ex-
presses the opinion that  the proximate cause
of cholera consists in a simultaneous modifica-
tion of all the organic powers  and  functions,
produced  by some  unknown morbific poison,
acting either directly on the properties, or trans-
mitted indirectly through  the nervous system.
He supposes the primary impression to be made
on the organs of sensation and sympathy, and,
perhaps, through the organic properties of that
system.   This change, so produced, he consid-
ers not merely a depression of the vital powers,
but that there is probably an alteration of their
specific character, as seems to  be denoted by
the  remarkable  derangement of some of the
functions.
  Although there is  abundant  evidence  that
the organic system of nerves is profoundly af-
fected in all its ramifications,  there is  equal
reason to believe that the cerebro-spinal system
is but slightly influenced by the choleric poison.
Spasms occasionally occur in places during the
prevalence of cholera, and this, too, without any
other symptom denoting the epidemic influence,
but  there are evidently  fewer  lesions of that
system through the whole progress of the dis-
ease than of the organic and sympathetic.  The
brain and the nerves issuing from it undoubt-
edly serve to transmit the impression  which
they receive to other parts of the body, but if we
look at the mind we shall find it " sitting unim-
paired and serene  amid  the ruins of organic
life."  " Respiration  is only performed by the
voluntary muscles, pulsation has  long ceased
in the extremities,  the heart has become inau-
dible to the  stethescope, yet the integrity of
the mind  remains undisturbed, and the indiffer-
ence with which it  contemplates the  wreck
over which it presides proves that at least its
peculiar and  last abode in the body is still its
own undivided possession."]
   130.  I  conclude this part  of  the inquiry by
stating the inferences which  may  be  drawn
from an extensive  view of what  is known of
this pestilence, as it has appeared in Asia and
in Europe, and from intimate observation of its
phenomena, as they lead  to various considera-
tions calculated  to arrest its progress  and to
remedy it, when an attack  has  not proceeded
too far in the  destructive  processes in which it
has been  shown to  terminate.
   131.  A. The  pestilential  cholera  seems to
have been propagated by an animal miasm or
effluvium of" a peculiar kind, emanating from
the bodies of the affected ; and  this effluvium,
being inhaled  with  the airjnto  the lungs, par- 
PESTILENCE, CHOI
alyzes  these  organs, and acts as a poison on
the class of nerves which supplies the respira-
tory, the assimilating, the circulating and se-
creting viscera, vitiating also the whole mass
of blood, and  thereby occasioning a specific dis-
ease, which in its turn gives rise to an effluvi-
um, similar to that in which itself originated ;
which,  also,  in  like  manner  perpetuates its
kind, under  the favourable  circumstances of
predisposition, aerial vicissitudes, &c, and thus
a specific form of disease is  propagated far and
wide, as long as predisposing, concurrent, and
determining causes favour its propagation.
   132.  B.  The morbid  impression  of this ef-
fluvium or poison upon the nerves of organic
life, and probably the effect of its introduction,
also, into the current of the circulation, are of a
sedative kind, rapidly destroying  the vital en-
ergy of the former, and vitiating the latter, and
thereby giving rise to the  characteristic phe-
nomena of the malady.
   133.  C.  The impression of this effluvium on
the organic  class of nerves, and  the vitiated
state of the blood, may be viewed as the prox-
imate cause, not only of the disturbance evinced
by the respiratory, the secreting,  the assimila-
ting, and the circulating functions, but also of
the morbid actions of the stomach and bowels,
and the copious serous discharges from these
organs, as well as of the muscular spasms, the
sinking of all the vital  and  animal powers, of
the shrunk and collapsed state of the surface of
the body, of  the black, thick state of the blood,
 and of the rapid depression of the  animal tem-
perature.
   134. D. The states of the perspiration and
skin, and the discharge of  the serous portion
 of the blood by the stomach  and bowels, im-
parting the peculiar  appearance of the evacua-
tions,  proceed from the alteration primarily
produced in  the vitality of the frame and in the
condition of the blood ; and it is chiefly through
the medium of the  cutaneous surface, of the
liver,  of the  kidneys, and of the mucous mem-
branes, assisted, perhaps, also by the other se-
creting viscera, that the morbid change of the
blood  is   remedied,  and  impurities removed
from it.
   135. E. The  advanced stages, or the con-
secutive  or  febrile  symptoms  of the disease,
 whether those chiefly depending upon the state
of the nervous functions, or of the  circulation
within the brain, or proceeding from the con-
dition  of the abdominal viscera, arise partly
from the shock received by, and the  depression
of, the vital  energy of  the  frame in the early
 stage, partly from  the  congested condition of
 the large veins and important viscera,  and
partly, if not chiefly, from the alterations which
 had taken place in the blood during the early
stages of the malady.
   136. F.  The effluvium or seminium, which
propagates the distemper, is generated in the
progress of the changes produced in the blood,
and is  emanated or discharged from the mucous
surfaces of the lungs and digestive  canal, and
from the  cutaneous surface, along  with their
respective exhalations and excretions ;  and
this seminium, by contaminating the surround-
ing air, or woollen cloths and animal products,
capable of attracting and retaining  for  a time
animal effluvia, as shown above (§ 92), affects
those of the healthy who are predisposed, either
LERIC—Treatment.                    137

constitutionally, or by antecedent, concomitant,
or determining influences, or on whom this ef-
ficient agent acts in an intense or concentrated
form, of is  aided by accessory or concurrent
causes.
   137. VI. Treatment of Pestilential Chol-
era.—The means of cure which should be em-
ployed, in order to  secure even a  moderate
share of success, ought to be appropriately pre-
scribed,  and strictly directed  to the  various
pathological states and stages which  the dis-
ease presents in different habits and constitu-
tions, and in its various grades of severity.  It
is, in some measure, owing to a neglect of this
strict appropriation of the numerous plans and
means of treatment  recommended,  and to the
empirical manner in which they have been ad-
ministered, that  opinions have been so differ-
ent as to the utility  of the greatest number of
them, even  at  an early period  of the malady ;
at a far-advanced stage, very few remedies, in-
deed, have hitherto been employed with any re-
markable benefit.  In order that the  means
chiefly depended upon by the numerous writers
on this malady may be more strictly referred to
the circumstances under which they seem to be
indicated, and often  to have really proved ben-
eficial when early employed, I shall first suc-
cinctly state the chief forms and stages  of the
disease,  with reference to various grades of in-
tensity, and existing pathological conditions ; I
shall next briefly notice the methods which have
been employed by various authors ;  and, lastly,
detail, with strict reference to these different
states and stages, the treatment I venture to
recommend, according to  my own  experience
and observation.
   138. i. Grades and Stages of the Malady, with
reference chiefly to Curative Measures.—The mode
of attack, as well as the severity of the disease,
vary materially, according to  the intensity of
the exciting cause,  the nature of the concur-
rent causes, the state of predisposition, and the
 strength of the patient's constitution.
   139. A. The invasion of the disease gen-
 erally presents itself in three different grades,
 owing to the above causes.—a. The first and
 least dangerous grade or  state of  invasion is
 the most gradual, and is usually that of a com-
 mon diarrhcea, varying in duration from  a few
 hours to one or two or even more days, accom-
 panied with oppression in the  chest, and anx-
iety at the praecordia, and collapse of the coun-
tenance  and  surface  of  the  body.  If these
symptoms be  neglected,  they  soon pass into
those characteristic  of this malady, viz.,  mark-
ed and sudden loss of pulse; oppressed and diffi-
cult respiration ; muscular spasms or tremours;
shrunk, wet, and leaden appearance  of the sur-
face and extremities; sunk eyes, and watery
vomiting and purging, with great distress.  This
is generally the least severe form of the malady,
and is commonly met with in the younger and
more robust class of subjects.  For the sake
of distinction, I shall term it the slighest grade,
or that characterized by premonitory diarrhcea,
&c.
   140. b. The  second state of invasion  is the
most frequent, and  is generally ushered in by
cerebral symptoms,  such as giddiness, noise in
the  ears, by  a remarkable oppression of the
chest, weight at the epigastrium, and a great
depression of the pulse and of all the vital en- 
138                PESTILENCE, CHOLERIC—Treatment—Stages.
ergies, rapidly followed by spasms, commencing
at the farther parts of the extremities, and ac-
companied with watery purging and vomiting,
and  all the symptoms described above (§ 28).
This is the common form or degree of severity
of the malady.
   141.  c. The third state or form of invasion is
the most sudden and fatal.   The patient is sud-
denly seized, as if struck by lightning, or by a
severe blow on the epigastric centre.  His vi-
tal powers are  immediately laid prostrate ; in-
ordinate discharges  of serous fluid take place
from the bowels and stomach, with cramps and
spasms of the  voluntary muscles; and he is
usually found without pulse at the wrist;  with
most laborious respiration ;  shrunk,  purplish,
raw, wet, and cold condition of the surface of
the body; and  collapsed, terrified  state of the
countenance.   This severest grade of the mala-
dy generally seizes on the  old, the debilitated,
or most  highly-predisposed persons, and often
terminates life  in a few hours, with a most rap-
id and  continued sinking of all the functions.
   142. This last form or state of the disease is
generally beyond the reach of medicine; it is
chiefly in the two former that medical means
avail.   These  three  modes of invasion  and
grades  of the  distemper should  be distinctly
borne  in  mind, as requiring very distinct and
decisive modes of  cure.   Besides attending
strictly to these states of the disease, as indi-
cated chiefly by the modes of its invasion, the
practitioner is required to notice attentively,
   143. B. The  periods or stages which mark
its course.—a.  The first or premonitory stage,
or the incipient state of diarrhcea, during which,
in addition to  much vital depression  and im-
perfect discharge of the vital and natural  func-
tions, the serous portion of the blood is being
effused from the digestive mucous surface, con-
stituting, as well as the more sudden and rapid
effusion of serum, a serous haemorrhage from
the digestive canal.
   144. b.  The second, or the cold and blue stage,
is that of extreme depression, the symptoms in-
dicating the utmost sedative effect of the exci-
ting cause of the  disease  on the vital powers,
with a morbid  state of  the circulation.  The
extreme degree of this period constitutes the
third, or severest  form  of the malady  (§ 29,
141), it being  so  marked  as to entirely over-
whelm life  in  a short time, without any other
period or stage supervening.
   145. c.  The  third period is that of morbid re-
action, and is evinced by returning warmth and
pulsation, and  diminution of the  leaden  state
of the surface.*  It passes either into conva-
lescence, or into exhaustion  and disorganiza-
tion.  This period, as stated above (§ 29), may
not appear in the severest forms of the disease.
But when it does supervene, it presents the
symptoms already described, when treating of
the  consecutive phenomena of the malady (<$
33).  In many instances, life is not destroyed
by the morbid state forming the first period of
the disease ; nor is it so completely overwhelm-
ed as to prevent all reaction ; but the reaction
which is produced, being accompanied with the
morbid state of the blood,  the principal part of
its serum being lost, and  with a  considerable

  [* But in objection to the classification of the author the
very first invasion is frequently that of marked inflammato-
ry symptoms of general fever and violent, painful spasms.]
share of the congestion of vital organs charac-
terizing the preceding period, is necessarily im-
perfect, and readily passes into an adynamic
state of sub-inflammatory action, affecting chief-
ly important and vital organs, and often assu-
ming the form of malignant fevers complicated
with visceral disease.
   146. d. The last stage, or that of exhaustion
and  disorganization, is always a consequence
of attempts at  reaction, which are,  however,
often imperfect, and extremely morbid in their
nature (<j 33, 34), owing to the marked impres-
sion made by the exciting  cause on the vital
energies, and chiefly to the very evident dete-
rioration of the  blood.  This stage takes place
more or less rapidly, and, when once  present,
the fatal tendency is great, and is very rarely
arrested by treatment.  In  a very large propor-
tion of cases, the febrile symptoms arising from
reaction are accompanied with more or less of
congestion, or of a sub-inflammatory state  of
some vital organ, frequently  of several, as  of
the  encephalon, alimentary canal, liver, lungs,
&c, and when  the consequent  collapse  termi-
nates in death, these organs manifest the na-
ture and extent of their disturbance.
   147.  It should be kept in recollection that the
third stage, or that of reaction, as well as  its
consequences,  namely, exhaustion and  disor-
ganization, can  only occur in the first and sec-
ond  grades of the disease, or  in those cases
which  have not proved fatal from the  second
or cold stage.   The third stage is identical with,
and presents the phenomena described as form-
ing  the consecutive  states of the disease ($
33).  Owing to the important features it often
assumes, it requires a more particular notice:
1st. A  congestive  and sub-inflammatory state
of the encephalon and spinal marrow, assuming
the characters of typhoid, or malignant nervous
fever, and proving the most frequent and fatal
form of the second  period ; 2d. A bilious or
bilio-nervous form of fever ;  3d. A sub-inflam-
matory state of the stomach  or of the bowels,
and frequently  of both conjoined ;  and, 4th.
An  irritative  or sub-inflammatory state, with
congestion of the lungs, accompanied with op-
pression and pain in the chest, cough, and vis-
cid expectoration.
   148.  The exhaustion into which these stages
gradually pass,  and which forms the fourth or
last stage  of the malady, is generally attended
by symptoms indicating more or less conges-
tion, particularly of those  organs which mani-
fested the chief disturbance  during the period
of reaction.  Its accession is often rapid. It re-
quires to be accurately recognised and prompt-
ly met, in order to ensure any share of success
in combating it; and  even then success very
rarely results.
   149.  When death occurs in the first  stage,
as it often does in  the highest grade of the dis-
ease, the  chief changes  are observed in the
blood, the  lungs, and vascular system  (§ 43,
45), the vital  functions being so  rapidly abol-
ished, from the impression of the exciting cause
of the malady, that the  morbid influence can
be evinced only on this system, and there chief-
ly as respects the state of the circulating fluid,
a sufficient length of time to produce disorgan-
ization to  any very remarkable extent not hav-
ing elapsed between the invasion and termina-
tion  of the disease.  But  when death takes 
PESTILENCE, CHOLERIC—Grades or Stages op.
139
place after the  period  of reaction,  organic
changes are observed in various important vis-
cera ($ 46), which,  however, with the disturb-
ance  of vital  functions,  and  in which  they
chiefly originate, only partly account for the
fatal result.  The thick and venous states of
the blood, owing to the remarkable loss of se-
rum and to the arrest of the changes produced
by respiration on the blood,  manifestly inter-
rupt the capillary circulation in  vital organs,
and occasion the phenomena of the advanced
stages of the distemper, and ultimately death.
  150. It will  be necessary to acquire precise
ideas of the foregoing forms and stages of the
malady, in order to  devise appropriate means
for counteracting their fatal tendency.
Synopsis of the Forms and Stages of Pestilential Cholera, depending upon the severity of attack.
                              'First stage, or preliminary diarrhcea, which may be readily
                                    arrested without farther disturbance beyond indigestion,
                                    &c.
                               Second stage, or that of extreme depression or failure of the
                                    circulation (§ 28), often quickly passing into dissolution,
                                    but sometimes followed by the
                               Third stage, or reaction, or febrile affection, with suppres-
                                    sion of the urinary and biliary secretion (§ 33).
                                 A.—Reaction with typhoid, or maligno-nervous febrile  af-
                                    fection ($ 34).
                                 B.—With gastro-enteric affection, &c. (§ 35).
                                  C.—With bilious affection, &c. (§ 35).
                                 D.—With pulmonary affection, &c. (§ 35).
                                 E.—With two or more of these conjoined.
                               Fourth stage, or that of vital exhaustion and disorganization,
                              ^.     often terminating in death.
                               Most frequently consisting of the stage of depression only,
                                 rapidly terminating in death,  and more rarely followed by
                                 reaction and the stages and states above enumerated.*
 151. ii. Notice of various Modes of Treatment | ses of calomel, with  moderate quantities  of
  First grade.—With marked pre-
monitory symptoms, particularly
diarrhcea, &c. ($ 26, 139).
  Second  grade.—Commencing
with giddiness, faintness, &c, rap-
idly followed by the characteristic
features of the disease (§ 28,140).
  Third grade.—The seizure sud
den and intense (§ 29, 141).
employed  in  different  Countries.—M.  Benoit
states that he found the combination of camphor,
laudanum, and sulphuric ether, with the exter-
nal use of sinapisms to the epigastrium and ex-
tremities—means employed by numerous prac-
titioners—successful in the visitation of the
pestilence at Manilla, in 1820.  Mr. Craw (Bom-
bay Reports)  speaks very favourably of large
doses of  ammonia  and  musk.   Dr. Peitsch
(Fodere, p. 261) states that his practice in Java
showed the uncommon efficacy of two parts of
spirits of mint, one  part of spirit of lavender,
and one of laudanum, taken in doses of a spoon-
ful, until the vomiting ceased.   Mr. Milward
(Bomb. Rep.) informs us that he found magne-
sia, in doses of four  scruples, remain in the
stomach and procure natural evacuations, oth-
er means having failed.   Dr.  Mahir, of the
Polish army, employed large  doses of opium
and prussic acid, with lavements of asafoetida.
Several physicians in Russia, Poland, and  Ger-
many had recourse to moxas,  or the actual
cautery applied  either along the  spine or  on
the scrobiculus cordis, but with as much  ben-
efit as may rationally be  expected from  such
means.   Many of the physicians at Warsaw
ascribed good effects to  the magistery of bis-
muth, while others stated it to be more injuri-
ous than beneficial.
  152. The treatment which was recommended
by Mr. Corbyn, and very generally adopted in
India, consisted of from fifteen to twenty grains
of calomel,  washed  down with sixty drops  of
laudanum, and twenty drops of the oil of pep-
permint, in two ounces of water. He prescribed
full blood-letting in  Europeans, and repeated
the above medicines every three hours  until
relief was obtained.   The oils of peppermint
and cajeput were very generally used in India,
and they seem to have been frequently service-
able, but as adjuvants merely.
  153. Mr. Annesley confided in blood-letting
employed early in the disease, and in large do-
opium, followed by warm, stimulating purga-
tives.  His  object in prescribing these medi-
cines was to remove the tenacious muco-albu-
minous matter lining the internal surface of
the intestines, which he viewed as obstructing
the canal.  But he ascribed undue importance
to a change contingent upon the advanced stage
of the malady,  the  existence  or removal of
which  could but little affect its course.
  154. Mr.  Searle advised the patient to be
placed between very warm blankets in an airy
apartment;  and, as  he considers a deranged
state of the stomach  is  generally connected
with the origin of the attack, the free evacua-
tion of this  organ to be among the earliest in-
tentions to  be fulfilled.   For this purpose ho
recommended, whether the patient has vomited
or not, that he should drink freely of warm
water  in which common salt has been dissolved
—about a table-spoonful of  the salt to half  a
pint of hot water;  that bleeding should be
practiced, and, after the stomach  is evacuated,
that a  full dose—about twelve grains—of calo-
mel  be exhibited, and  washed down  with hot
brandy and water, and that this be  repeated
every hour or two, until an improvement is ob-
served, when it may be given in smaller doses,
and  either in conjunction, or alternately, with
some mild aperient.   For the sub-inflammato-
ry states of the encephalon, or abdominal vis-
cera, frequently supervening  during  reaction,
or the  third stage of the malady, he recom-
mends the employment  of moderate, general,
and  local depletion,  with injections and coun-
ter-irritation, by means of sinapisms.  He found
the cramps relieved by compression.
  155. Mr. Goss, of the East India Company's
  * [Professor Jackson, of Philadelphia, makes_/iue grades
or periods of the disease, viz.:  1st. Of incipient irritative,
or the premonitory stage ; 2d. Of confirmed irritation, or
forming stage ; 3d. Of incipient concentration, commencing
collapse, or algid stale; 4lh. Of complete concentration,
confirmed collapse, or perfect algid state ; 5th. Of reaction,
or febrile state.—Am. Jour. Med. Sci. (vol. ri., p. 306).] 
140
PESTILENCE, CHOLERIC—Modes of Treatment.
service, states, that hearing the patients com-
plaining of the excoriating nature of the fluids
evacuated, he  suspected  this property to  de-
pend upon the presence of some acid, and that
he, therefore, exhibited about a drachm of the
carbonate of soda with fifteen grains of the car-
bonate of ammonia; the patients, who were
very few, and their cases slight, all recovering
under this mode of treatment.  He likewise
had recourse to full blood-letting, occasional
doses of  calomel  and  jalap,  to  frictions  and
counter-irritants applied  to the  abdomen  and
lower extremities.   He states that emetics had
failed in some instances in which he had  em-
ployed them, but had succeeded in others.  He
appears to have employed the ipecacuanha pow-
der merely, without combining it with  diffusi-
ble  stimuli,  and therefore his  failure  in  the
most severe cases was to be expected.
  156. Dr. Raimann, of St. Petersburgh, states
that blood-letting, with calomel and opium, and
external heat  and irritation,  were among the
most  successful means employed  against the-
disease in Russia.  Warm baths were of equiv-
ocal service, unless at the very commencement
of the seizure, or in the slightest cases.  They
generally exhausted the patient instead of re-
storing  the  circulation to the surface in the
more severe cases.
  157. M. Vos, who practiced in Batavia, found
blood-letting of service among Europeans only :
it was injurious  in the natives.   The remedies
from which he derived the greatest advantage
were  calomel with opium, followed some time
afterward by warm stomachic purgatives and
injections.  M.  Margeot, who  observed the
disease in the Isle of France, prescribed, every
two hours, two drachms of the sulphate of soda
in a glass of  honey-water, until bilious evac-
uations appeared.   He gave diluents liberally,
and administered emollient injections frequent-
ly, with the view of promoting the  action of
this salt.  M.  Robert, who adopted this prac-
tice, added to  it the occasional exhibition  of a
draught with ammonia ;  and M. Galdemar em-
ployed a draught with olive oil, sulphuric ether,
and camphor.
   158.  Mr. Boyle, who treated the disease in
India soon after its first appearance, finding, in
the post-mortem  examination  which  he  first
made, that the gall-ducts were obstructed  by a
thick viscid  bile rather than by spasm,  was led
to exhibit emetics and procure full vomiting, in
order to  remove  this  obstruction  of the  pas-
sage  of bile to the duodenum ;  and the advan-
tages which he obtained from  the practice in-
duced him to recommend it in preference to
other means which he considered subordinate
to it, and requiring to be varied according to
the circumstances of individual cases, the use
of emetics being always requisite.   To this gen-
tleman the  credit is due of having been the
first to*recommend emetics for  the disease.
   159.  Several  of the American practitioners,
who  had visited  India  and China during the
prevalence of the pestilence, prescribed  pow-
dered carbon and  burned cork in milk, and con-
ceived  that benefit resulted from the practice.
This substance, however, as well as many oth-
ers to which a certain degree of credit was at-
tached, only seemed of advantage, it being ap-
parently successful in the slighter  cases of the
disease, in  which the morbid actions  induced
in the frame operated their own cure, through
the aid of the powers of the constitution.  This
practice, however, was strongly recommended
by  Dr. Jackson, an  authority of the greatest
weight in dysentery  and chronic diarrhceas, in
which  affections  it appears to have been ex-
tremely serviceable.
  160. When the disease appeared in Persia,
the native  practitioners had recourse  to cold
affusions, and cold acidulous, or iced fluids, of
which  the  patients were  allowed to  drink at
will.  At Bussorah, M.  Morando  prescribed
cold applications over the  organs chiefly affect-
ed, at  the  commencement  of the attack, and
blood-letting, both general and local.  M. Meu-
nier, at Bagdad, treated the disease by means
of venesection, leeches applied to the pit of the
stomach, mucilaginous and  opiated draughts
and injections, and hot fomentations.  A sim-
ilar practice to this  seems  to have been very
generally adopted by  medical men in Syria,
Mesopotamia, and Aleppo. Of the effects, good
or bad, of the cold affusion  as adopted in Per-
sia, I  can  find no precise  information.  But,
judging from the great benefit I have  seen de-
rived from the cold affusion on the head, in
cases of poisoning by opium, even when  life,
apparently, is nearly  extinct, this practice seems
to me  not  so irrational as many may suppose.
It is, at least, one of the most energetic means
with which I am acquainted of removing con-
gestion of  the vessels within the head.
   161.  When the disease appeared at Astra-
chan, in 1823, the medical commission prescri-
bed the following practice:  A large blood-let-
ting ; a dose  of calomel, with  sugar  or gum
Arabic, and  followed  by  from  forty  to  sixty
drops of laudanum ; twenty drops of the oil of
peppermint, given in two ounces of the aqua
melissae ; frictions of the  epigastrium, with an
ammoniacal liniment; scarification and cupping
over the abdomen ;  frictions of the limbs and
surface generally, with camphorated spirit; mu-
cilaginous  injections, with about thirty drops of
the tincture of opium, and calomel in doses of
from ten to twenty grains. This practice, which
was altogether based on that  very generally
employed  in  India, was likewise adopted when
the disease invaded  Russia in 1830 ; but on this
occasion blood-letting was found less beneficial
than formerly, and  warm sudorifics,  and  the
external application of heat, were more depend-
ed upon.
   162. Dr. Keir, who had great experience of
the disease at Moscow, derived advantage from
 blood-letting in the  young, plethoric, and well-
 fed, and in the common or intermediate grades
 of the malady, particularly when employed ear-
 ly, or  before the pulse left the wrist.  In  the
 most  intense grade, or when resorted to late,
 or when the pulse  had   disappeared  from  the
 arm, it  often seemed prejudicial.  Full  doses
 of calomel with opium, followed by stimulants,
 purgatives, and injections, and accompanied by
 the external and other means usually employed
 by the Indian practitioners, formed the princi-
 pal part of the treatment  adopted by him.
    163. When the pestilence appeared in War-
 saw, the medical authorities there had recourse
 to very nearly the same treatment  as stated in
 the preceding paragraph ($ 162).  Subsequent-
 ly, many adopted, and several afterward relin-
 quished, the plan of Dr. Leo, which was to give 
PESTILENCE,  CHOLERIC—Modes of Treatment.
141
three or four grains of the sub-nitrate of bis-
muth every two hours.  According to M. Bois-
seau, the hydrocyanic acid, the hydrocyanate
of zinc,  oxygenated  water, and oxygen  gas
were all tried in this city without benefit;  and
I may add, that laurel-water, phosphorus, both
internally and externally, moxas, and the ac-
tual cautery to the spine and epigastrium, were
also  made trial of without any remarkable ad-
vantage.  M.  Briere  de  Boismont  recom-
mended (when vomiting continued urgent) the
cuticle to be removed by  means of liquid  am-
monia, and the denuded surface to be sprinkled
with one or two grains of the acetate of mor-
phine.
  164. Mr. Finlayson derived advantage in one
case in Ceylon from passing a galvanic current
through  the  lungs.   Galvanism certainly de-
served a fair trial in this  disease ; but the in-
stances in which it  was resorted to in this
country did not furnish evidence of its success.
  165. Dr. Barry, having very frequently ob-
served congestion, inflammation, and softening
of the spinal marrow, in a greater or less de-
gree, in his examination of fatal cases of the
pestilence, was led to recommend the applica-
 tion of the actual cautery to the back, opposite
 the  lower dorsal and upper lumbar vertebrae :
 it had been employed on the  Continent with
 some success.   He also advised full vomiting,
 and for this purpose preferred a strong solution
 of common salt  and water, given in doses  of
 six ounces.  Warm, dry applications to the skin,
 and continued friction, he considered very bene-
 ficial, while vapour and hot-water baths he be-
 lieved to be worse than useless.  Bleeding,  as
 well as large doses of either opium or stimu-
 lating liquors, he believed to be dangerous  in
 the  utmost state of depression, when the pow-
 ers  of life are  reduced to the lowest ebb, and
 consequently easily annihilated ; but previous
 to this state, or when reaction is supervening,
 he considered blood-letting beneficial to the pa-
 tient.
   166. The following account of the experience
 of several physicians  at Warsaw, abridged from
 that given by M. de Boismont, is important, as
 showing the results of different kinds of prac-
 tice :
   Dr. Janikowski treated sixty-six cases.   He
 bled the robust and those with evident  con-
 gestion, and gave every three hours two grains
 of calomel, with one of opium, with warm stim-
 ulating diluents, sinapisms on the epigastrium,
 and frictions of the  limbs with irritating lini-
 ments.  In some cases he gave the nux vomi-
 ca  in doses of half a grain, every fourth hour,
 in an emollient  decoction, and, he conceived,
 with some advantage.  He lost twenty, chiefly
 old  persons, of the  number treated.  Dr. Koeh-
 ler had sometimes  recourse to blood-letting,
 but  depended  more upon the  preparations of
 ammonia.  He also prescribed  calomel  with
 opium, and in some  cases large doses of the
 sub-carbonate  of potash.  The farther results
 of his experience are not given.  M. le Brun
 treated about sixty cases, of which he lost near-
 ly  one half.  The disease was, however,  far
 advanced before they came under treatment.
 He  confided chiefly in blood-letting, warm dilu-
 ents with opium, and camphor combined with
 calomel.  Of twenty cases treated in private
 practice  five died.   The  remaining forty were
hospital cases.  Dr. Enoch treated forty-three
cases, of which five were hospital patients.  He
lost  only  seven cases, chiefly  aged persons.
The  most of his patients  were blooded, and
treated  with  calomel and opium at first, and
afterward  with calomel and rhubarb.   He di-
rected  sinapisms  to  the  epigastrium and  ex-
tremities.  Dr. Jasinski treated  thirty cases, of
which ten died.   In  his earliest cases he em-
ployed blood-letting when he thought it  indica-
ted, or leeches to the painful part  of the epi-
gastrium, with small doses of calomel and opi-
um, and the infusion  of valerian.  In the cases
which occurred subsequently, and which were
generally more intense, he prescribed leeches
to the abdomen, the  magistery  of bismuth in-
ternally, and sinapisms and frictions to the ex-
tremities.  Dr. Kaczkowski, physician-in-chief
to the Polish armies, had  recourse in the most
severe cases to large blood-lettings, to calomel
in doses of three or four grains, with half a grain
of opium every two  hours, with the external
use of sinapisms, stimulating cataplasms, mox-
as, &c.  He also frequently prescribed, every
two hours, small quantities of Dover's powder
with mint ptisans, and large doses  of magne-
sia ;  and states that he derived advantage from
the nux vomica, given with the mucilage  of
gum Arabic  and sugar or sirup. He lost one
sixth of his  patients, among whom, however,
he seems to have included several cases which
evidently either did not belong to this disease,
or consisted of the slight  form, or of the incip-
ient stage.
  167.  Most of the individual means and plans
of cure noticed above were had recourse to
when the disease appeared in this country, but
generally with that want of success, especially
in the severer and more advanced cases, which
led to the relinquishment of them, and to the
trial of other medicines and different combina-
tions.   Blood-letting, which had been  advised
both by Indian and  European  physicans, was
resorted to, but with very equivocal benefit;
for it was only in slight  cases, or  in an early
stage of the  disease, and in young, plethoric,
and  robust persons, that it seemed to be of
service ;  and in these either equal advantage
would have been derived from other means, or
recovery would have been  brought about  by
the powers of the constitution.   The same re-
marks  apply also to the use of opium.  This
remedy could only be viewed  as an adjuvant
of other means, and it was often a valuable one,
in aiding to check the diarrhcea, in the slighter
cases and earlier stages.  But when  the  at-
tack was violent, and when the collapse was
great, it either failed of  producing any effect,
or occasioned an injurious one.
   168. The failure of the more usual means led
to the adoption of warm emetics  by several phy-
sicians, especially of those consisting of large
doses of mustard, or of the substances  usually
employed  with this  intention,  conjoined with
powerful stimulants.  But in the more violent
seizures, or at an advanced period of the dis-
ease, they did not appear to me to be produc-
tive of any benefit.
  169. Indian practitioners, owing to their pred-
ilection to the use of calomel, especially at the
period of the outbreak of the pestilence in In-
dia,  and to the absence of bile in  the evacua-
tions, had recourse to this medicine, generally 
142                     PESTILENCE,  CHOLERIC—Treatment.
in large or very frequent doses, and in conjunc-
tion with  opium.   They imputed too much im-
portance  to the absence  of bile, looked upon
this as the chief source of mischief,  instead of
viewing it as a part only of the general circle
of consecutive  disturbance,  and aimed merely
at removing a  symptom without directing at-
tention to more general and important morbid
conditions.  In certain states, however, of the
malady, hereafter to be noticed, and  in certain
combinations, it was often of more or less ser-
vice.
   170  Dr. Graves, impressed with  the little
efficacy of the means previously recommended,
and with  justice believing that  it was  of the
first importance to arrest the  discharge of the
serum of the blood from the  digestive mucous
surface, recommended full doses of the acetate
of lead to be given with opium, varying the quan-
tity and frequency  of the dose with the severity
of the case.  Previously to the publication of
this method, I had been employing the sulphate
of zinc, with opium  and extract of logwood,
and sulphate of alumina, in similar combinations,
with this  intention ;  but my experience hardly
enables me to decide as to the comparative mer-
its of either, for each was efficacious  in the less
violent cases, and inefficient when the collapse
was extreme.
   171. The saline treatment advised by  Dr.
Stevens  for malignant fevers, with a confi-
dence  which subsequent experience has  not
justified,  was  sufficiently tried in this pesti-
lence, and in several cases by myself.   The as-
certained  deficiency of the saline ingredients of
the blood, in the fully-developed distemper, he
proposed  to restore  by giving every half hour
or  hour half a drachm of sesquicarbonate of
soda, a  scruple of muriate of soda, and seven
grains of  chlorate  of potash, in half  a tumbler
of  water.  The trials which I  made of this
medicine did not furnish greater success than
that derived from others.   The state of vital
action ;  the complete arrest put to the function
of  absorption  from the alimentary canal,  and
the general relaxation  of the capillaries and of
the digestive mucous surface, with the conse-
quent serous exudation, did  not admit  of the
passage of saline  solutions  or fluids from this
canal into the circulation.
   172. Knowing the deficiency not only of the
saline ingredients of the blood, but also of the
serum, and believing that the deficiency could
not, in the existing state of vital action, be sup-
plied by  the  alimentary canal, Dr. O'Shaugh-
nessy was thereby induced  to propose the in-
jection of saline solutions into the vascular sys-
tem.  The solution most generally used  con-
sisted of half an ounce of muriate of soda, and
four scruples of sesquicarbonate of soda in ten
pints of water, at  a temperature varying from
104° to  112° or 118°; and the whole was in-
jected slowly, and generally during somewhat
more than half an  hour.   Several cases which
I attended were thus treated, two of them of
medical men; but  none recovered ultimately.
Dr. Mackintosh, of Edinburgh, treated many in
this way ;  and, in the institution to which he
was attached,  of  156  patients in whom  this
plan was  employed, twenty-five recovered.
Most probably these were all hopeless cases ;
but, as far as I could learn, this plan was  not
much confided  in  generally in the metropolis,
and  was  employed  only as a  last resource.
When recovery did  follow after a recourse to
it in these circumstances, the event could not
fail of attracting particular notice ;  yet, as re-
covery did also occur,  although  in rare instan-
ces,  even in the worst cases, apparently from
the powers of the constitution rather than from
the  means  employed, the degree  of success
evinced by this method was more or less ques-
tioned.   Phlebitis, which always proved fatal,
supervened  in some cases.
  173. The  effect of the injection of the above
solution into the mass of blood was always re-
markable  on the disease.  All  the symptoms
subsided,  or entirely disappeared, except  the
excessive evacuations.  These, however,  re-
turned, or became still more profuse ; until a
very short time after the injection, the whole
of the fluid  had passed off by the bowels, and
all the phenomena  reappeared,  generally with
increased violence  and extreme vital  depres-
sion, often  rapidly  passing into  dissolution.
This circumstance shows that the disease  did
not merely consist in the loss of the serum of
the blood, but in an alteration of the blood still
more materially affecting its  vital constitution,
and  most probably originating, as I contended
in the work published in 1832 on this  distem-
per,  in the altered vital  condition of the gan-
glial or organic  nervous system, and implicating
the vascular system and circulating fluids con-
secutively.*
  174. iii. Treatment chiefly  confided in by  the
Author after observing the Effects of various Means
and  Methods.—When the disease is prevailing
in any locality, disorder  of the stomach  and
bowels should  receive early attention, and be
treated with great  decision.  Strict attention
to my own sensations during and after the im-
pression  of the morbid  exhalations from the
evacuations, and from the bodies of the sick or
dead, and the experience of many of my friends
when their attention was directed to the mat-
ter, convinced me that the morbid impression
first made upon  the organic nervous system
was characterized by depression ; and that the
consequence of such depression, and of such
other change in the  state of this system as may
have taken place in addition, were soon after-
ward manifested in the vascular system, and
in the several  digestive, assimilating, and ex-
creting  functions, if the  primary morbid im-
pression  was not removed by powerful stimu-
lants and tonics.  It is necessary, therefore,
not only to develop vital resistance and action
by these means as soon as the earliest indica-
tions of depression appear, but also to restrain
frequent  or increased evacuations  from  the
bowels, as being the most prompt modes  of
preventing these changes from taking place in
the blood, which soon  induce the most serious
and fatal results.
  175. When the disease is  more fully devel-
oped, it is necessary to combine our means ju-
diciously  and  energetically,  to  bring  several
agents into  action at the same  time, to direct
them to different organs  and  opposite parts of
the  frame, and  thereby  to  fulfil, directly and
contemporaneously, several  intentions  and in-
  [* We tried the injection of saline solutions into the vascu-
lar system, after the plan recommended by O'Shaughnes-
sy, in 13 cases, with the effect above described ; the pi
tients were all in a state of hopeless collapse.  Of these
one only recovered.] 
PESTILENCE, CHOLERIC—Treatment.
143
dications.   In all circumstances it is requisite,
even to a moderate share of success in the
treatment of this pestilence, to prescribe the
means of cure appropriately to existing mor-
bid conditions—to the pathological states and
stages of the malady—and not empirically, or
without reference  to  the known  operation of
these agents on the diseased  actions which we
employ them to remove.
   176. A. Treatment in the mildest Form and ear-
lier Periods of the  Distemper.—(a) It has been
stated above ($ 27) that the attack in its mild-
est form, and in young, robust, or previously
healthy persons, was very frequently ushered
in by diarrhcea and general  depression of the
vital powers, with or without nausea, vomiting,
or spasms ;  and that, if these symptoms were
removed by energetic means, the disease gen-
erally proceeded no  farther.  In  most cases,
however, in  connection  with diarrhoea and
depression of vital power, there was also more
or less congestion of vital organs, especially of
the lungs,  liver,  and  large  venous trunks;
 and hence it became  necessary to remove this
 congestion, while  we  endeavoured to restrain
 inordinate discharges from the alimentary ca-
 nal, and to allay spasm when present;  the in-
 tentions of cure being thus—1st. To arrest purg-
 ing and vomiting ; 2d. To remove congestion
 and oppression of the viscera, and to determine
 the circulation to the surface and  extremities ;
 and, 3d. To restore the secretions and excre-
 tions  to a healthy state.,
    177. The first of these indications should be
 fulfilled  by exhibiting  warm astringents and
 stimulants, conjoined with the remedies usual-
 ly prescribed for  Diarrhcea (see  that article, §
 26, 30);  of these means I have found the sul-
 phate of zinc, with  capsicum and opium, the
 most efficacious, especially when exhibited in
 frequent closes.  The opium should be given in
 small or moderate doses, so as to support, but
 not to depress, the powers of life, and always
 with  aromatics  and  astringents—with capsi-
 cum, aromatic  confection, confection of black
 pepper, extract of logwood, sulphate of alumi-
 na, acetate of lead, &c.  The sulphate of zinc,
 when conjoined with cayenne or black pepper,
 or with  other  aromatics  and opium, will not
 readily excite vomiting.  But if an emetic ef-
 fect be produced by the quantity thus prescribed,
 the circumstance will not prove  injurious ; but
 will tend to  remove internal congestions, and
 to fulfil the second and third indications, with-
 out increasing the intestinal discharges.
    178. In cases where vascular plethora exists,
 a moderate blood-letting may be instituted, so
 as to bring the mass of the circulating fluid
 more nearly to the state  of the  moving pow-
 ers ;  but it should be prescribed  with caution,
 and »nly for young, robust, or plethoric persons,
 and either at an early stage or in the slighter
 form of the  malady.  If  these  means  do not
 speedily arrest diarrhcea and other symptoms,
 they  should be aided by the application of dry
 warmth and frictions to the surface of the body.
 Dry warmth may be applied by placing the pa-
 tient instantly  in bed, and  elevating the  bed-
 clothes around him  by two or  three common
 hoops, or pieces of whalebone, and then intro-
 ducing one end of a wide tube, at the other ex-
 tremity of which the flame  of a spirit-lamp or
 candle should be made to pass ;  or bags of hot
salt, or  of hot bran or oats, may be placed
around him.
  179  The removal  of congestion and the
equalization of the circulation will be promoted
by employing  assiduously,  at the same  time
that external heat is being applied, frictions of
the abdomen, chest, and thighs, with a liniment
composed of two ounces each of liquid ammo-
nia,  of olive-oil, and spirits of camphor, with
three ounces of spirits of turpentine, and from
three to six of hard soap and cayenne  pepper,
to which about two or three drachms of cajeput
or lemon oil may be  added.  Or  hot  flannel,
soaked  in  a mixture  of these, may be  applied
over the abdomen and over the insides of the
thighs, and renewed until warmth is restored.
If the attack  be attended  by spasms of the
muscles  of the  abdomen or thighs, this mix-
ture may be used either as a liniment or  as an
embrocation, as now  advised.  The external
applications should be assisted by the internal
administration of ether, camphor, ammonia,
calomel, opium,  aromatic spirits, and essential
oils, either singly, or in such forms and combi-
nations as the circumstances of particular ca-
ses may point out.
   180. If the  irritability of the  stomach con-
tinue, and if the attack  be  severe,  flannels
wrung out of hot water, and  immediately soaked
with the embrocation  just now described  ($
179), or with warm spirits of turpentine,  ought
to  be instantly applied, as  warm as possible,
over the stomach and  abdomen, and retained
there, or renewed, until a decided effect is pro-
duced.   This  is the most powerful means I am
acquainted with,  and  the  most successful  in
procuring  reaction and restoring  the heat of
the body.
   181.  The foregoing means frequently accom-
plish the last  of the intentions of cure enumer-
 ated above (§  176), by fulfilling those which pre-
 ceded it.  But we should  never consider the
 patient to be  placed  in a fair way of recovery
 by bringing about reaction  merely, unless the
 suppressed secretions be  also  restored.   It
 should be  kept in recollection that an early ef-
 fect of the exciting cause  of the  disease is to
 vitiate the whole mass of  blood, and that this
 morbid  state can be removed only by supplying
 the loss of the serous parts of the blood exuded
 from the mucous surfaces, and by exciting and
 calling into active and healthy action the func-
 tions of the secreting organs, particularly those
 of the  abdomen.  In order to attain this end,
 large doses of calomel, followed by purgatives
 or aperients,  are required.
   182. Calomel was commonly employed in In-
 dia, and generally in  conjunction with opium,
 in some form or other, and certainly few reme-
 dies succeeded better, either there or in Europe,
 in allaying the vomiting, when the disease was
 neither unusually severe nor too far advanced.
 In cases of moderate severity, and when given
 early in the attack, it seems to have  been re-
 markably  beneficial in restoring the secretions
 of the abdominal viscera, particularly  of the
 liver;  and in these, in conjunction with bleed-
 ing, it  seems to  have had  no  mean  share in
 preventing the  consecutive states of disease,
 into which this pestilence so frequently passed,
 more particularly the  nervous, congestive, or
 malignant state of fever sometimes superven-
 ing.  Mr. Ogilvy (Bomb. Rep., p. 210) remarks, 
144                    PESTILENCE, CHC

that where the calomel affected the mouth, the
consequent symptoms of bilious fever were not
observed.  Its good effects will be promoted by
combining it, as above ($ 179), with camphor,
carbonate of ammonia, and small, or at least
moderate, doses of opium.  Large doses of this
last medicine are injurious in a disease, one of
the chief characters of which is  great depres-
sion of the vital energies.
   183. If the  means here detailed arrest the
malady, or bring about reaction, the treatment
must be greatly modified or altogether changed.
If they fail of producing either of these effects,
the additional means about to be recommended
for the third form  of the disease must be  re-
sorted to (§ 200, et seq.).
   184. (b)  The third stage,* or  that of reac-
tion, being brought about, the chief intentions
of treatment are,  1st. To prevent it from pro-
ceeding  too far ;  2d. To promote the secre-
tions, particularly  those  of the liver and kid-
neys ; 3d.  To guard internal viscera from the
congestive, sub-inflammatory,  and  disorgani-
zing states often attendant on this stage;  and,
4th. To  promote  the  return  of  the healthy
functions of the alimentary canal.
   185. The above objects are obtained by the
cautious employment of blood-letting, either
general or local, but more frequently the latter,
in this  stage  of the disease, particularly if it
have  not previously been resorted to, or when
it is clearly indicated, and when the pulse is not
very soft, broad, and open—states which forbid
blood-letting; by calomel exhibited in the states
of combination already noticed, or with ipecac-
uanha ; by aperients or  purgatives, combined
with gentle tonics and antispasmodics, and by
vapour baths.   If cerebral, typhoid, or nervous
affection supervene, opium, unless in small do-
ses, and combined with camphor, or with calo-
mel also, seems to be contra-indicated.
   186. In  the stage of reaction  attended  by
cerebral symptoms, particularly if  the vessels
of the conjunctiva be loaded, leeches should be
applied  to the posterior parts of the head  and
temples, and purgative medicines be employed
with the view of removing the  congestion  of,
and the determination to the  head, and of in-
creasing all the abdominal secretions and ex-
cretions ; and external derivatives  resorted to,
in order to relieve the internal viscera from the
load which oppresses them.  In  this particular
state of the  disease, as well as in its early
stage, active enemata are especially indicated.
They should be  repeated, without being dis-
couraged by the circumstance of their not  be-
ing retained.  The end will be obtained at last,
if we persevere in a judicious manner.  I have
frequently seen marked  advantage derived, in
this state  of the  disease, from the subjoined
formulae :
  No. 308. ft Asafcetids, 3ij. ;  camphors rasse, gr. xii. tere
cum decocti avenaj, Jviij. ; deinadde olei terebinth. 5ss. ad
5jss. Misce, et fiat enema,                    /
  No. 309.  R Olei terebinth.,  5j- i olei olivse, f jss. ; cam-
phors  rasae, gr. iv.; decocti avente,  fviij.  M.  Fiat en-
ema.
   187. Derivatives are  of the utmost  advan-
tage in the state  of reaction with dangerous
cerebral affection.   Belonging to this class of
means,  blisters and sinapisms have been most
commonly resorted to, the former  applied  be-
tween the shoulders, the latter over the epigas-
             * See note, p. 124, supr.
LERIC—Treatment.

trium  and insides  of the  thighs.  M. Ranqcs
has strongly recommended certain rubefacient
and irritating applications  to the abdomen, and
M. De Boismont has approved of them.   They
are required equally during the first stage, par-
ticularly when  the  vomiting and  spasms are
very urgent, and during this period when the
head is much affected.  Of this class of means,
the warm turpentine embrocations  applied to
the abdomen  and insides  of the thighs, as no-
ticed above (v 180), are to be preferred, as be-
ing most quick and decided in.their  operation.
The liniment already mentioned ($ 179), or the
former of the two prescribed below,* may like-
wise be assiduously rubbed over the spine and
lower extremities ;  the latter on the insides of
the thighs only, as it is more apt to remove the
cuticle than the former.  When the turpentine
fomentation is not used to the abdomen, the
liniment  may be applied to this situation.  In
this period  of the malady  the kidneys may not
sufficiently  discharge  their functions, although
this is not so frequently or constantly observed
as in the severer grades, where this condition
is one of the  most dangerous that presents it-
self, and the most difficult to remedy.  When,
however, it does occur, the embrocations and
liniments already  mentioned  should then bo
applied to the loins.
   188.  When  the stage of reaction is accom-
panied with gastro-enteric affection, or with the
additional complication of marked affection of
the liver, or disturbance of its  functions, or if
it assume the nearly allied form of  bilious fe-
ver, the  external medicaments recommended
above are also requisite.   If the stomach and
bowels are  chiefly affected, the application of
leeches to  the epigastrium will be  necessary
previous to the employment  of these,  or of
other external or internal means; and  emoll-
ient injections  should be  occasionally thrown
up.  Small doses of opium, combined with cam-
phor and the blue-pill, or the hydrargyrum cum
creta, may also be given from time to time.
   189.  Very nearly the same treatment as now
stated is required when the symptoms indicate
a congested or sub-inflammatory state  of the
liver.   The application of leeches to the epi-
gastrium and right hypochondrium ;  full doses
of calomel  given at  bedtime,  combined with
small quantities of camphor, and an aperient
draught the following morning, or a few hours
afterward;  the use  of warm  diaphoretics at
short intervals ; aperient  and  emollient injec-
tions, and the  external means recommended
above (§ 187), will generally be requisite.
   190.  If the  consecutive affection  assume a
dysenteric character, leeches to the  perinaeum
or sacrum, emollient and diaphoretic medicines,
and mucilaginous injections will be  found ex-
tremely serviceable.   As  the dysenteric form
of the stage of reaction is frequently either as-
sociated with, or dependent upon, a very acrid
and otherwise  morbid state of the secretions
poured into the bowels, and sometimes on an
affection of the liver, the occasional  exhibition
of a dose of calomel with  James's powder, and

  * No. 310. R Linimenti saponisco. ; linimenti canvphora
co., aS, f jss.;  olei terebinth., Jij. ; saponis duri, 3ij.; olei
limonis et olei cajeputi, 55, 3jsg.   M.  Fiat linimentum.
  No. 311. R Camphora, 3ij. ; solve in tinct. cantharid. et
Tinct. capsici, 55, 3ij-; dein adde linimenti sapon.  Co., Jss.
et gradatim, miscendo, liquoris  ammon., 3vj. ; olei olivs,
3x. Misce, bene ei sit linimentum. 
                         PESTILENCE, CHC

the use of aperients, will be indispensable, in
addition  to the  other  internal and external
means of cure already particularized.
  191. When the stage of reaction is attended
with  pulmonary affection, local depletion, and
the exhibition of those medicines which, while
they increase  the secretions  of the skin and
the abdominal viscera, occasion a derivation of
the blood from  the congested  organ, will then
be  necessary.  The most energetic of those
are calomel, or the blue-pill, with ipecacuanha,
camphor, and hyoscyamus,  followed by active
purgative draughts and injections, and the ap-
plication to the  insides of the thighs of the lin-
iments or embrocation already prescribed.   In
these cases the  decoction  of  senega may  be
given  with emollients  and  aromatics,  or the
ammoniacum mixture, with liquor  ammoniae
acetatis, the camphor mixture, the  spiritus
aetheris nitrici,  and the vinum ipecacuanhae.
   192. Upon the whole, the treatment  of the
stage of reaction in its various forms of mani-
festation, as well as the  state of collapse into
which it so rapidly passes, must be directed ac-
cording to sound views  of morbid  actions,  of
therapeutical indications, and of the operation
and appropriate application  of remedies, as in
similar or analogous cases and circumstances
of disease.  As to  the treatment of the last
period of the malady, or that of collapse, it will
be preferable to defer any remark until some
notice has been taken of the treatment of the
more violent forms of attack.
   193. B. Of the Treatment of the severer Grades
of the Disease.—The same objects or intentions
of cure  as  have been  recommended for the
slighter  grade  of the  malady  (y 176) will  be
applicable to the early periods  of the severer
grades, and very nearly the same agents will
be required to fulfil them.
   194. Here, also, I recommend astringents
and stimulants, and upon the  same grounds,
with  the same views, and in the same or simi-
lar forms of combination as those already de-
scribed ((}  177).   If the astringents chiefly con-
fided in, more  especially the sulphate of zinc,
occasion or increase  vomiting, the circum-
stance is not to be regretted.   In some cases
it may even be  promoted,  with the view  of
equalizing the circulation and overcoming vis-
ceral congestions.  In young, robust, or pleth-
oric  persons I would  even  propose a moder-
ate venesection, at the same time that vital re-
sistance and reaction  are promoted by stimu-
lants and external  derivatives ; by  it the load
which oppresses the springs of life, and pre-
vents their reaction, is lightened, and the mass
to be moved is thereby brought to a nearer re-
lation to the state of the moving power.  But
while the mass  to be moved is thus reduced,
care must be taken to rouse the moving power
by a judicious administration of stimulants,  of
which full vomiting, excited by the  means al-
ready noticed, the application  of external heat
($ 178), hot epithems  and fomentations on the
abdomen ($ 179), and  frictions  with hot lini-
ments or warm cloths (y 180), are  among the
most efficacious.
   195. Blood-letting, however, should not  be
attempted in persons who are advanced in life,
in the debilitated, the previously  ill-fed, the
drunken, and in those inhabiting low, marshy,
and unwholesome situations, or who live chiefly
    III              10
!—Treatment.                     145
  * No. 312.  R Phosphon, gr. j. ad ij.; solve in sether
sulphur., 3iij.; olei terebinth., 3ij., et adde olei olivas, 3H
ss.; pulv. gum. acaciie, 3j.; aquaj menth. pip., fiv. ; olei
cajeputi, TTlxii.; syrupi  zingiberis, ?j.  Misce secundum
artem.  Capiat cochlearia ij. larga omni bihorio.
on a poor vegetable diet.  Even in those from
whom the abstraction  of blood is admissible,
the strength, habit of body, the previous health
of the patient, as well as the state and progress
of the disease, should be duly considered, the
effects  of the  loss  carefully observed,  and
the quantity  cautiously regulated  accordingly.
Blood-letting  ought  never to  be attempted
where there appears evidence of the  loss of a
large portion of the serum of the blood from
the alimentary canal, or when the pulse at the
wrist is small and weak.   At the  time of its
being instituted, as well as afterward, and in
those cases where it should not be practiced,
internal medicines should  be  administered, in
addition to the external means already noticed,
in order to rouse the energies of  the nervous
and vascular  systems ;  and thereby, while the
second and third intentions of cure are being
fulfilled, congestion will also be removed.   Of
the various internal stimuli which have been
recommended—and almost  every one in both
the mineral and vegetable kingdoms of nature
has been  tried—the  most  eligible, and,  I  be-
lieve, the most successful, are camphor in large
doses, opium, ether, the preparations of ammo-
nia,  the aromatic  and essential oils, particu-
larly  the  oils of peppermint, cloves,  cajeput;
the spirits of mint, lavender, cardamoms, &c.;
solutions  of  phosphorus in ether, or in oil. ;*
the  magistery of bismuth ;  large  doses  of
musk ; the hot spices, and numerous warm and
aromatic plants, in various forms  of  combina-
tion,  &c.   Most  of those may be conjoined
with  the   astringents  already  recommended^
(y 177), and taken either in the form of pill or.
mixture.  In many cases it will be advisable to
give also stimulating beverages, especially those
to which the  patient has been most habituated,
as any of  the several spirituous liquors diluted
with  warm water,  sugar, &c. ;  hock, Cham-
pagne, sherry, or Madeira wine in Seltzer, soda,
or potash  water.  In this state of the disease,
particularly when  the  depression of the  vital
energies is extremely  great, the assiduous ap-
plication of the  turpentine fomentation to the
abdomen, as  well as of the hot liniments to the
insides of the thighs (y 179, 180), and the ad-
ministration  of  injections, as stated above (§
186), in conjunction with the internal exhibi-
tion of the stimulants now mentioned, will also
be requisite, and, when appropriately prescribed,
will often  prove highly beneficial.
  196. It is unnecessary in enter farther into de-
tail as to  the treatment  of the early stage of
the severer grades of the pestilence.   It may,
however,  be remarked, that in addition to the
medicines already noticed, others have been
employed. Among these the most deserving of
mention are, musk in large doses, with camphor
or ammonia ;  infusion of valerian with camphor
or asafcetida,  particularly as an enema ; the de-
coction of guaiacum, in a similar  combination
and  mode of exhibition ; warm  infusions of
rosemary, mint, and lavender, with spirit of ni-
tric ether ; and  various  other vegetable infu-
sions and  essential oils.  They may be exhibi-
ted either by  the mouth or in enemata. 
146                     PESTILENCE, CHOLERIC—Treatment.
  197. (b) When imperfect  reaction  occurs—
for reaction is seldom or ever freely and openly
developed—it presents the  same manifesta-
tions,  in  respect  of vital organs, that  have
been already described (y  184,- et seq.); and the
treatment, which  has been  recommended  as
appropriate to each of the states in which this
stage  of imperfect  reaction  shows  itself, is
equally applicable here, and is directed to the
accomplishment of the same intentions as in
the first or slightest grade of the malady.  The
typhoid state of fever, which frequently pre-
sents itself,  requires  the remedies  described
above  ($  186, 187);  and the  congestive and
sub-inflammatory states of the liver (y  189),
stomach, bowels (v 188), and lungs (§  191) gen-
erally demand the means which are applicable
to them respectively.  In this state of the mal-
ady  the  secretion  of urine is very  generally
suspended, or at least is very scanty, especially
when  the discharge  of serous fluid  from the
bowels has been abundant, the blood being  in-
capable of furnishing the  fluid material of urin-
ary discharge.  The chief object of treatment
is, therefore, to change  the morbid  condition
of the circulation  by means  of the  secreting
viscera, and  by furnishing the stomach with a
sufficient quantity of medicated or simple dilu-
ents, whence the inordinate loss of the serum
of the blood may be replaced, and the functions
of secretion  supplied and promoted. At the
same time that these views are being acted
upon, those organs  which suffer congestion and
a sub-inflammatory state of action, arising from
the depressed state of the vital powers and the
morbid condition of the blood accumulated in
or circulating through them, must be, as far as
possible, preserved from disorganization.  This
latter  object is best attained  by cautious local
depletions, by rousing, and, at the same  time,
controlling   the  functions  of  the  different
emunctories, by expelling morbid matters from
the prima via, and  transferring  irritation to
parts which  cannot be materially injured  by it,
   198. In this, and, indeed, in all stages of the
disease, as long as  the  sensations  of heat at
the epigastrium and thirst are complained of, the
patient should be allowed such fluids or bever-
ages as may prove most  grateful to  him ; and
these may be made the vehicle of the  medicines
already  advised, and taken at a temperature
which is most agreeable to him—generally in
small quantity at a time, and frequently.  I have
often  allowed fluids to be taken, either cold or
slightly warm, with small quantities of the ni-
tric and  hydrochloric acids, when the  medicines
given at the time were  not chemically incon-
gruous with them.   The Anglo-Indian practi-
tioners  have lauded  these  beverages; but  I
have  experienced  but little benefit from them
unless during convalescence, when they tended
to  restore  the torpid functions  of  the  liver.
During the  period of imperfect reaction I have
 found more  benefit result from a liberal use of
diluents containing liquor potassae, or the alka-
line carbonates, or the biborate of soda ;  these
 appearing to favour the passage of fluids into
the circulation, to correct the state of the blood,
 and to excite the action of the kidneys.
   199. During the  consecutive fever,  as well
 as at an early period  of  convalescence,  the
 bowels  may become torpid, and require  warm
 stomachic  aperients, such as  the  decoctum
aloes compositum with a little  cinnamon wa-
ter ;  equal parts of the compound infusions of
gentian and of senna,  or the mistura gentianae
composita; and  any of the  preparations of
mercury which the state  of  the  patient  may
suggest.  The " droque amere,"* a tonic aperi-
ent tincture long used  among the Jesuit  mis-
sionaries  in the  East, obtained much  reputa-
tion  in this period and grade of the pestilence,
as well, indeed, as  in all its grades and stages,
where a stimulating aperient was indicated, and
was much  employed  by Anglo-Indian practi-
tioners : it was  generally  given  in  doses of
half an ounce  to an ounce, in camphor water,
or in any suitable vehicle.
   200. C.  Treatment of the Third, or most intense
Grade  of the Malady.—In this grade the depres-
sion of the energies of the frame is  as  pro-
found  as is consistent with the continuance of
life.   The means of cure, therefore, ought to
be most promptly administered, and energetical-
ly devised. The objects proposed to accom-
plish them are in  every respect  the  same as
were stated when treating of the stage of de-
pression  in the  slighter grade  of the  disease
(y 177); but still more energetic agents are re-
quisite to attain  them than have yet been rec-
ommended, and most frequently even the most
active we can devise are  entirely unequal to
the  accomplishment of the ends  we wish to
attain.  Indeed, the vitality of the several or-
gans is so extremely depressed as to be inca-
pable  of  being  influenced by any  moderate
agent; the structures are far advanced to the
state  presented by them immediately  after
death  ; and the blood is no longer capable of
being  circulated.   Treatment is, therefore, en-
tered  upon with feelings  of  despair ;  still, as
recovery  from this state  does occur  in  rare
instances, it  is our duty to  employ  rational
means to attain this end as long as life contin-
ues.
   201. In this grade of the malady the stimu-
lating emetics already recommended (v  177),
with the view of exciting full vomiting, which
the powers of the constitution are of themselves
incapable of effecting, should be employed early,
if at all, with the intention of producing reac-
tion ;  using at the same time stimulating  fric-
tions, the turpentine fomentation to the whole
abdomen, as hot as it can be made ; the hot-air
bath, and the internal stimulants  already pre-
scribed (y 195), or some of those  about to be
noticed (y 203).
   202  Blood-letting is advised by some writers
as early as possible in this grade of the malady,
and denounced by others.   My own experience
and that  of many  practitioners in this country
are  decidedly against its adoption.
   [Emetics and blood-letting invariably proved
injurious in the treatment of cholera, so far as
we  have observed.  If bleeding is practiced at
all,  it  should  be at a very early stage of the dis-
ease ; but at  that period we  have other reme-
dies equally successful, and on all accounts less
  * No. 313.  R Aloe's socot., Jiv. vel fv.; giim. myrrhs,
gum.  mastiches, benzoini, 55, Jij. ; rad. calumbe concis.,
rad gentians, aa, Jij. ; croci stigmat., fj. ; spirit, vim Gal.,
Ibix. ; spirit, viui Hollandias, tbiij.  Macera per menspm,
exprime et cola. This excellent tincture furnishes anil-
lustration of the principle, first clearly explained and in-
culcated by Hoffmann, that purgatives, particularly aloes,
have their purgative actiou greatly increased by being com-
bined with bitters and tonics. 
PESTILENCE, CHO
objectionable.   The vital forces are not to be
reduced, by loss of blood or any other debilita-
ting evacuation, if it can be avoided.  The va-
pour bath is a remedy of decided efficacy in the
early stages of this  disease, and may  be de-
pended  on  with more confidence than  almost
any  other  remedy.  We  have  treated many
cases successfully with  no other means what-
ever, allowing the patient to keep warm in bed,
and take rice or barley gruel, or chicken water.
Cathartics  are unsafe, unless those of the mild-
est description ; antimony in any shape is poi-
sonous.  The  same  remark will apply  to the
more irritating  articles of the cathartic class.]
  203. When  the means already noticed fail,
or seem inadequate to arrest the violence of at-
tack, others which have sometimes succeeded
in similar states of morbid action,  particularly
when -they  cannot prove detrimental, should be
prescribed.  I would, therefore, recommend a
bolus, consisting of from ten to fifteen grains of
camphor, an equal number of grains of calomel,
two grains  of Cayenne, one grain of opium, and
ten drops of any essential oil, as of mint, caje-
put, &c, to be  given with a sufficient quantity
of conserve of roses.  This may be administer-
ed after full vomiting, if it  can  be quickly pro-
cured, but  without any  regard  to its continu-
ance.  If this  bolus be  retained, another  may
be given, and repeated in from one to two, three,
or four hours, according to the urgency of the
attack; but if rejected, it should be immediately
repeated, until  it at  last remains.   Not more
than three or four of those boluses ought to be
given, and  frequently two will be sufficient.
  204. Simultaneously with the administration
of the above, thirst should be  quenched by a
frequent recourse to whey, to Seltzer water or
soda  water with milk,  by  spruce-beer, or by
other diluents ;  and dry  heat may be employed,
and the turpentine fomentation applied, as hot
as  possible, to  the abdomen and  chest; and
friction of the spine and thighs with any of the
liniments prescribed above  (y 187), made warm
by plunging the vessel containing it in hot wa-
ter, resorted to.   From one to three hours after
the exhibition of the bolus, a draught, consist-
ing of from two drachms to half an ounce each
of spirits of turpentine and castor-oil, or of
olive-oil, with a few drops  of the above essen-
tial oils, and forty grains  of magnesia, should
be taken in mint water; and if it be rejected,
another should  be given, and repeated;  if again
rejected, in half an hour afterward ;  if retained,
not until from six to twelve hours, when anoth-
er may be taken.  I have seen cases where the
most urgent vomiting existed, and yet the above
remedies (although  both  the  bolus  and the
draught were taken at the same time) allayed,
instead of aggravating, this  symptom.  Be-
sides, it is  our object to obtain full vomiting at
first; therefore this cannot be viewed as an un-
favourable  operation of the medicine, if it should
follow the exhibition of the  first doses of it.  In
order to promote the influence of these means,
a lavement, consisting of ten to twenty grains
of camphor, or  a drachm of asafcetida, half an
ounce to an ounce and a half of the spirits of
turpentine, and  an equal quantity  of olive-oil,
in a suitable vehicle, should be administered,
and repeated according to the circumstances of
the case.  Much will depend upon the succes-
sion in which these remedies are given, the pe-
iLERIC—Treatment.                     147

 riods which are allowed to elapse between their
 exhibition, and on the doses and the decision
 with which they are prescribed.  The hot tur-
 pentine  fomentation, assisted  by hot air and
 frictions with stimulating substances, is  the
 most powerful means I am acquainted with of
 procuring  reaction,  restoring  the heat of  the
 body, and relieving the viscera from congestion.
   205. The internal remedies now recommend-
 ed, as well as the external means so frequently
 insisted  upon, have been employed  by me in
 many hundred instances of malignant and  ex-
 tremely dangerous diseases, and I have found
 them the most efficient of all others with which
 I  am acquainted, when  judiciously  combined
 and administered, in rousing  the  energies of
 life, restoring the secretions, removing the con-
 gestion of internal organs, and in subduing that
 unhealthy  sub-inflammatory state  of action
 which often  occurs in fevers, and in diseases
 proceeding from infection and  animal poisons,
 and which  generally advances  rapidly to fatal
 disorganization.   In  aid of the above remedies,
 and particularly when the energies of the con-
 stitution seem to react, although most imper-
 fectly, effervescent draughts with the sesqui-
 carbonate  of ammonia,  and the  pyroligneous
 acetous acid in mint or cinnamon water, or in
 an infusion of cloves, the ammonia being in  ex-
 cess, may be given  from time  to time, and a
 large blister applied over the epigastrium upon
 the removal of the turpentine epithems.
   206. I would also recommend, both in this
 most severe grade of the malady, and that next
 it in degree, the administration of  medicinal
 substances in the state of vapour, and medica-
 ted gases through the channel of the respiratory
 organs.  It has already been shown that it is
 through these organs that the specific cause of
 the  disease invades  the frame, and  that they
 suffer in a most remarkable manner from its
 impression, having  their functions  altogether
 paralyzed, and their substance  remarkably con-
 gested at a more advanced stage.   If this view
 be entertained, the means of individual preven-
 tion which are hereafter recommended will
 appear the more deserving of adoption, and  the
 directing of medicinal agents   to this quarter
 will, at least, not be considered unreasonable
 or undeserving a fair trial.   Perhaps the inha-
 lation of the  nitrous  oxide gas, or common air
 with a slight addition  of oxygen, will  be the
 most energetic remedies that can be employed
 in  this way.  Other means, also, which will
 readily suggest themselves to the well-inform-
 ed physician, may be used ;  and among others,
 the vapour arising from gently heating a strong
 solution  of camphor in aromatic vinegar, or the
 vapor of the aromatic preparations of ammonia,
 may  be  mentioned ; and shocks of  galvanic
 electricity may be passed through the chest.
   207. Besides the use  of frictions with hot
 cloths, or dry substances, or  with liniments,
 which will  not occasion cold by their evapora-
 tion—means which  have already been  advised
 —the application of hot air, or of hot salt or
 bran, or hot oats, around the body, have all been
 recommended.  In cases where the hot turpen-
 tine fomentation, or common  sinapisms, have
 no effect, or  in this most intense grade of the
 malady, without waiting for the effects of less
 active means, the subjoined cataplasm* may
  * No. 314.  R Pulv. siuapeos, lt>ss.; pulv. capsici annui, 
148                      PESTILENCE, CHOLERIC—Treatment.
be applied over the abdomen.   A trial may also
be given to medicated vapour baths ;  to baths,
with the fumes of some of the volatile essential
oils extricated by heat; and  to dry-cupping in
the course  of the spine, with the view of re-
moving congestion within the spinal canal,  as
well as  of the kidneys  and other  parts.  It
may be remarked, that in the most severe at-
tacks,  or when far advanced before medical aid
is procured, scarcely any means, however well
and energetically devised and  practiced, will
prevent a fatal result;  while the less severe
visitations will  generally be  removed by any
of the remedies enumerated,  when judiciously
combined and employed.  There is  reason  to
suppose that the slightest grade of the malady
will even, by means of the vomiting and tumult
excited in the frame, operate its own cure ; and
hence the reputation acquired by various mild
or inefficient medicines  and  methods of treat-
ment.  There are few diseases, perhaps, which,
while they preserve a perfect identity of char-
acter, present a  greater range in grade than
this ;  excepting,  indeed, those maladies which
propagate themselves in a similar manner to it.
Indeed, it is chiefly to the mildness of the at-
tack that we are  to attribute  the imputed suc-
cess of such remedies as successive draughts
of warm milk, olive-oil, the Glauber salts, com-
mon salt, and various other mild preparations.
In the  more intense visitations, where the de-
pression  of the vital energies of the frame and
the vitiation of the blood are extreme, remedial
agents should possess a co-ordinate degree  of
activity,  in order  to produce  any effect what-
ever on the  system.
  208. If the above energetic means be judi-
ciously put in practice,  and brought  to act si-
multaneously on  different parts of the body,  or
prescribed in due succession and states of com-
bination, as the scientific, zealous, and experi-
enced practitioner may consider appropriate  to
the grade and stage of the malady, signs of re-
action  will  sometimes  manifest  themselves;
and then—particularly if it have not previous-
ly been employed, or when the state and cir-
cumstances of the patient  furnish  no reason
against it—a small blood-letting, either general
or local, may be cautiously resorted to.  If the
stage of reaction be brought about, however
imperfectly, the same intentions  of cure, and
the same measures to fulfil them, which I have
already described when treating of the various
manifestations of this stage in the less intense
grades of the malady, should be appropriately
employed against each of them respectively, as
they may supervene in  this most severe form
of the pestilence, although success  from the
most active and judicious measures can seldom
be expected in this stage of the malady, more
especially if the urine still continue suppressed,
or means to supply the lost serum of the blood
be still unavailing.*
pulv. zingiberis, 55, 3j. ; ncidi acetici pyroliguei q. s. ut fiat
cataplasma, dein adde olei terebinthins, 51J.  Misce.
  The following compound tincture of camphor and opium
seems well suited  to the worst grades of this malady, in
doses of one or two drachms, given in any suitable vehicle.
  No. 315. R Opii pulveriz., 3iij.; camphone, 3vj. ; cor-
ticis canelUecontusi; croci stigmat., 31J. ; caryophyllorum ;
pulv. capsici,  3jss. ;  potasss sub-carbon,  3jj.; olei anisi,
?j. ; spirit, vini tenuior. (vel sp. vin. Gallics, vel sp. vin.
Hollandise), Oij. Macera leni cum calore, per dies viij. ad
zn.; dein exprime ct cola.
  [* It is questionable if the vitiation of the blood, after it
   209.  As the  exhaustion of  strength  is  ex-
 treme, and as every muscular  effort increases
 it, and as fatal syncope may soon occur in  the
 most severe grades, from  being raised to  the
 erect, or even sitting posture, means ought to
 be adopted to preclude the  necessity of the  pa-
 tient's removal from the recumbent position  for
 the  purposes of evacuation.   The  discharges
 should  be received in a bed-pan ;  and  when
 medicines are exhibited, his head and shoulders
 should be raised no higher  than is requisite to
 the accomplishment of the object.  Mr. Skarle
 very justly remarks, that attention  to this  in-
junction cannot  be too strictly enforced, and
 states that two  patients under  his own obser-
 vation lost their lives from neglecting it.*
  210. It  not unfrequently happens that the
 active stimulants which we prescribed in the
 stage of depression, particularly in the more
 intense grades of the malady, together with the
 natural  tendency of the disease, occasion  in-
 flammation, or a sub-inflammatory state of the
stomach and bowels.   When this occurs, the
epigastrium  and abdomen  become  extremely
 tender,  and even tumid.  Great irritability  of
the stomach is also present, and is increased
 after the  ingestion  of stimulating substances.
 In cases of this  kind, venesection, the applica-
 tion  of  leeches, followed by the hot fomenta-
 tion  or the cataplasm prescribed above ($ 179,
 207), and, upon  their removal, by a  large blis-
 ter ;  the exhibition  of calomel  combined with
small doses of camphor and opium ; purgative
or aperient injections, often repealed, and sin-
apisms  or stimulating liniments to  the lower
extremities, are among the chief remedies.
  211. In the treatment of this as  well as  of
the following stage, all means will  prove inef-
ficacious as long as the urine is  either suppres-
sed  or secreted in very small  quantity.  The
defect of  this excretion proceeds rather from
 the want  of serum  in  the  blood, than from a
paralyzed or congested state of the kidneys;
therefore the beverages already advised (Y 195,
 198) should be freely administered, and be made
the vehicle of medicines in  order to supply the
loss, and  dry-cupping followed  by stimulating
embrocations applied to the loins.
  212. D. Treatment in the Last Stage, or that
of Exhaustion and Collapse.—In  those cases  in
which efforts at reaction, or consecutive excite-
ment, are manifested, exhaustion often rapidly
supervenes, owing to the depressed  and weak
powers of life, to the morbid state of the circula-
ting  fluid, and the deficiency of serum.  Hence
the necessity, during the imperfect manifesta-
tion  of excitement or reaction,  to support the
powers  of life, even while we  have recourse
to small general  or local depletions, to allow a
free  use of whey, or other  diluents containing
saline substances, as Seltzer  and soda water,
 and  to  act upon the  secretions by  means of
has separated or disunited the crassamentum or serum to a
certain degree, can ever again be so repaired as to render it
possible for the vital fluid to reabsorb any substance what-
ever that may be introduced into the alimentary tube, or
otherwise to supply the lost serum.—T.]
  [* In connexion with this subject, it may  be remarked,
both in this disease and in yellow and other infectiuui
fevers, that a great number of cases are made to have a fatal
issue by neglect of such injunctions, and by  removing pa-
tients when in this extreme state from one locality to anoth-
er, as often happens in transporting them from the  place
where they are seized to the quarantine or lazaretto, &c.
-T.] 
PESTILENCE, CHOI
purgatives given by the mouth, and in the form
of injections ;  hence the propriety of removing
the local determinations and congestions with
which the attempts at reaction are more or less
accompanied, by means of external derivatives
and  counter-irritants,  employing tonics at the
same time  that we endeavour  to  restore the
suspended secretion, and  thereby to purify the
blood, and to derive it from the seats of conges-
tion.   It  is obvious, however, that these  ends
cannot be attained while the physical condition
of the blood is such as not to admit of secretion
or even  of due  circulation, while the  blood  is
deprived  of one half of  its due  quantity of se-
rum.   Therefore,  due care should  be taken to
administer, by the mouth, and by  injections,
suitable  diluents, and  to  persist in the exhibi-
tion  of them, especially of those already men-
tioned (y 195, 198), in hopes that a portion  of
them will be carried  into the circulation, and
supply the deficiency of the watery portion  of
the blood.
   213. As all attempts at reaction must neces-
sarily soon lapse  into  profound exhaustion,
when made during inordinate depression of the
powers of life and a morbid state of the blood,
characterized, not merely by loss of the serum,
but also  by an accumulation  of urea, carbon,
and  other effaete  materials  requiring removal
by the several emunctories,  so the objects en-
tertained should be to supply a due quantity of
fluid  to  the circulating  mass, and to  conjoin
with, or dissolve in, that fluid, such substances
as will most  powerfully and readily excite the
action of the excreting viscera, particularly the
kidneys  and liver, and thereby remove the im-
purities accumulated in the blood.  We ought,
therefore, to resort to these means as  early as
possible,  and  in such  modes  and combinations
as are best calculated to attain  these  objects.
If, however, exhaustion proceeds rapidly, stim-
ulants and  permanent tonics, given internally ;
antispasmodic and tonic injections ; hot air, hot
cataplasms and fomentations ;  and  the other
internal  (y 195, 207) and  external stimulants,
described when treating of extreme depression,
occurring early in the disease (y 201-203), may
be resorted to.  Yet the vital  depression will
never be removed while the urine is suppress-
ed or scanty, without administering diluents as
advised above (y 204), and saline purgatives and
aperient  enemata.  It is in this state of the
disease that the warm tonic and purgative med-
icines prescribed above (y 199) prove most ser-
viceable, and  that the patient requires to have
his energies  kept  up by light nourishment, by
grateful diluents and beverages, with  a moder-
ate quantity of wine, which latter may also be
administered occasionally with  injections.
   214.  In the more extreme cases of this stage
of the disease, oil of cloves, or  of  mace, or of
rosemary, or of British juniper, or of rue, or
lavender, to be applied  warm,  over the abdo-
men  or epigastric region, and  allowed to  re-
main there, or  to be renewed, according to the
effect produced.   In the more  urgent cases, a
cloth moistened  with  the warm  oil  may  be
placed  in this  situation,  and  kept closely ap-
plied by means of a compress, which will tend
to prevent its rapid dissipation.   In milder ca-
ses the oil may be combined with camphor and
some one of the plasters  in common use, as the
galbanum, the pitch, or ammoniacal plaster, and
LERIC—Treatment.                       149


 these applied and renewed from time to time.
 I have seen, in cases of extreme vital exhaus-
 tion, with  depression  of the animal warmth,
 from other causes, the skin of a recently-killed
 animal, particularly that of  a sheep, wrapped
 round the  body of the patient,  the wool out-
 ward, and advantage derived from the applica-
 tion.  Even this or similar means may be tried
 as  a last resort.*
   215. D.  During convalescence from this dis-
 ease, care should be taken to prevent relapses.
 It is very frequently observed that at the com-
 mencement of"convalescence, the patient is tor-
 mented with an uncommon craving for  food.
 This should be restrained, and but little, or at
 most a moderate quantity only,  and of a light,
 digestible kind, allowed to be taken.  The se-
  * I have adverted, in another part of this work, to the
 influence of the animal warmth of young healthy persons on
 those who are debilitated, or are labouring under extreme
 exhaustion.  Since that was written, I chanced to find this
 mode of treatment  strongly insisted upon by Sydenham
 (Observat. Med., i., 4, y 40), and as follows, in the " Medi-
 cal Notes and Observations" of Sydenham, just now pub-
 lished for the first time by Dr. Greenhill, of Oxford, the
 learned editor of his works:
  " De Methodo medendi Morbos per Accubitum Iunioris.
 Cap. 16. May ye 19th 1662 I was called in ye  night to
 Mrs Change, whom I found very ill of a Cholera Morbus ;
 she had many ugly Symptoms,  as coldness of the Extreme
 parts, talking a little idly, intollerable Sickness, <fc felt a
 tingling in her Fingers <fc flesh outwardly.  I judge it dan-
 gerous to use Dilutients especially by Clysters in a Women
 {sic] soe green (she having not lain in a Month) & ye Dis-
 ease pressing soe hard upon my heels ; Soe I orderd her to
 take a warm Cordial, & that a good draught of it, <fc her
 Husband to lie close to her Back naked, and her sonn of 12
 years close to her Belly, & to lay on  more. Cloths & to
 warm her Leggs & Hands with hot Cloths: She immedi-
 ately fell into a moderate Breathing, & all Sympt. ceased :
 & after enjoyning her to keep her bed ye next day, & to
 eat  & drink nothing save a small Quantity of Barly-broth
 a day for 2 days she perfectly recoverd.
  " February 1661 I was called to Mrs Hulston, who after
 a very Chronical fever was fall'n into a very fatallike Diar-
 rhea ; I saw it was to noe purpose to give astringents see-
 ing ye Disease proceeded from a Decay of natural heat,
 therefore I took this Course, viz. I caused her Sonn a plump
 hot Lad of 13 years of age, & her Nurses sonn of 6 or 7
 years to goe to bed to her naked, <fc to lie ye one close to
 her Belly, ye other close to her Back, wch they did, & as
 long as they continued wth her she had  noe stools :  but ye
 Buys rising at any time ye  Looseness would immediately
 return.  1 commanded that she should persist in ye Course
 till  her cure should be compleat, (the Boys relieving one
 another by turns in ye daytime) &  soe  she fully recoverd
 not only of her Looseness but allso of her Sickness in gen-
 erall.
  " The very same course I took with one Mr Little, who
 had a fever abt 7 weeks, <fc  at yt time  Aug. 1662, soe far
 spent yt his Drs judged him a Dead-Man : He was ancient
 & having  been much purged wlh violent  Medicaments,
 he was as weak as ever I saw  any yt recoverd ; I (having
 to noe purpose made attempts to lay his fever by inward
 Medicines & to raise his strength by Cordials) told his wife
 that nothing could preserve his life but ye putting a Boy to
 bed to him: soe she procured a Link boy to lie very closo
 to him all night, & ye next  morning 1 found his fever all-
 most off,  & his Eye  <fc Countenance  more lively,  upon
 wch I pronounced all danger to be over, y'ett afterwards
 upon my giving him a Clyster <fc upon ye recess of ye Boy
 he began to relapse; but ye  Boy being gott again  & I giv-
 ing noe more  Clysters he perfectly recoverd.
  " The very  same way had  I cured before Bp. Monk's
 Lady, who was an aged Woman of a very feeble  & thin
 habit of Body, & had an Ague wch (tho' gone) had soe
 weakend her yt her Physician Dr. Ridgley looked  upon
 her as dead ;  when I was sent for she had allso spitten some
 purulent matter &  blood wch they shewed me (in abun-
 dance) upon ye Napkin.  I told ye Dr yt I apprehended yt
 nothing could save her life, but a speedy transplantation of
 some young Spirits upon her, to wch he readily agreed, &
 a Girl of 13 years was put in close to her Breast, upon thin
 she recoverd  very speedily both of her Unspiritedness <fc
 her  Cpughing: But ye Girl fell sick, wch was attributed
 to her lying wth ye Lady, tho' I was confident to ye Con-
 trary, having never known any Mischief yt way ; however
 she had first  coming out upon her Petechia, & afterwards
 large Ulcers upon her Breech; But Dr Ridgley & I recov-
 erd her." 
150                     PESTILENCE, CHOLERIC—Treatment.
vere nature of the attack, the derangement of
the digestive mucous surface, and the disturb-
ance  accompanying it of all the digestive or-
gans, must  necessarily leave them for a time
incapable of discharging  their functions in a
regular or active manner.   They should, there-
fore, have  no more imposed upon them than
they seem capable of performing.
  216. It frequently happens that, owing to
neglect of this precaution, and occasionally to
too early exposure  to the vicissitudes of sea-
son or of weather, or to cold, chills, or wet,
after  an  attack of this malady, a relapse oc-
curs and carries off the patient.   Care, there-
fore, should be taken to protect the surface of
the body, and particularly the extremities, from
cold during convalescence, to regulate the diet
and regimen of the patient, and to promote the
return of the healthy action of the  stomach,
bowels, kidneys,  and other secreting viscera.
In order to accomplish  this last object, gentle
tonics will be necessary ;  and as the  functions
of the bowels generally require aid, this should
be afforded by  combining aperients with ton-
ics, and  by gradually increasing the  quantity
and nutritious quality of the food.
  No. 316.  R Pilulrehydrarg., 3j. ; Pilulaealogs cum myr-
rha, 3ss.; Sapoms Castil., gr. x.  Fiant pilulse, xii., qua-
ruin capiat binas ahernis noctibus.
  No. 317.   R Quininae sulph., 3j.; Pilulie aloe's cum myr-
rha ; Extr. gentianse, 5a, 3ss. ; Pulv. capsici, 3j.; Olei
caryoph., q. s.  Fiat massa jequalis et divide in pilulas
xxx., qnarum capiat binas omni meridie ; vel
  No. 318.   R Infusi gentianae  co. ; infusi senntB comp.,
a5, ^iij.; potass* sub-carb.,  3j. ; tinct. cardain. co., fss.
M.  Fiat mist, cujus capiat cochleana, iij. vel iv., ampla,
hora somni vel primo mane.
  217. After the frame has been fortified to a
certain extent  by these means, and  the  func-
tions  of the bowels and  the secretions are
brought to a healthy state, the shower bath or
the salt-water  bath may  be  employed,  in or-
der to bring about a complete restoration of the
energies  of the constitution.  Whichever  of
the two  kinds  of bathing be adopted,  aetive
friction of the surface of the body should fol-
low upon coming out of the bath, and moderate
exercise  be  taken  in the  open air,  either on
foot or on horseback.
  [In the United States the treatment of chol-
era has been equally various  and unsuccessful
as on the other side of the Atlantic.   For ex-
ample, the treatment pursued in the four chol-
era hospitals in this city, in 1832, was very
different, corresponding with the pathological
views of the physicians attached to them, and
yet the lowest  mortality was, perhaps, equally
great as that generally observed in Europe.
Hospitals.	Canes.	Cured.	Died.
Greenwich Hospital . . .	350	204	146
Park Hospital .....	5U0	312	278
Rivington-st. Hospital . . .	410	231	179
Corlear's Hook Hospital. . .	281	93	184
Bellevue Hospital ....	447	232	315
  Thus the mortality at the Greenwich Hospi-
tal, of all received, was 41 10 per cent.;  of the
Park  Hospital, 48-60; Rivington-street Hospi-
tal, 43 60 ;  Corlear's  Hook Hospital,  6540 ;
Bellevue Hospital, 57 50.
  There were local  causes, however,  which
might account for the increased  mortality at
Corlear's Hook and the Bellevue Hospital, apart
from  any differences in the mode of treatment.
  Among the various remedies employed were
bleeding, opium, mercury, purgatives, emetics,
ice, brandy, camphor, ammonia, ether, tobacco,
external heat and  friction, infusion of saline
substances, non-purgative salts, sinapisms and
blisters, asafcetida, enemata, &c.   At one time
in the Greenwich Hospital, frictions with strong
mercurial ointment, incorporated with camphor
and capsicum, were thought to prove more suc-
cessful  in  certain cases of collapse than  any
other; but  this was  eventually found equally
unsuccessful as the other methods previously
employed.  Indeed, the exposure, with the alarm
and agitation caused by powerful friction, long
continued, together with the dangers arising
from  over-mercurialization,  counterbalanced
any beneficial effects arising from the practice.
We  know of no one remedy adopted in the
treatment of the disease in this city which de-
serves, from the results, to be ranked above all
others.
  Uncommon success in the management of
this  disease has been  claimed for Dr. Cart-
wright, of Natchez, who states that he treated
more than  three hundred patients without a
single death, by giving freely calomel, capsicum,
and  camphor.   Dr.  Dickson also speaks  very
favourably of these articles, especially of cap-
sicum, which, he says, was the most relied on in
the southern and southwestern  parts of  our
country, often combined  with morphine, qui-
nine, ether, &c.  The  quantities  of camphor,
calomel, capsicum, and  morphine  were care-
fully adapted to the age of the patient and the
apparent urgency of the case.  We consider
the evidence in favour  of these remedies am-
ply sufficient to entitle them to the first rank in
the treatment of this  fatal malady.
  The indications are sufficiently obvious, viz.:
to arrest the alvine evacuations ; to relieve ir-
ritation of the gastro-intestinal membrane; to
restore  the suspended secretions ;  to  equalize
the circulation ; to relieve the nervous disturb-
ance  ; and to support  the  general strength.
The most important indication, undoubtedly, is
to check the escape of the serous portion of
the blood into the intestinal canal, which is to
be done by inviting the  fluids  to the  external
surface  of" the body by  powerful  sinapisms,
and by internal astringents, of which capsicum,
rhatany, tannin, acetate of lead, and opium are
the most important.  To meet the  first indica-
tion, we think galvanism or electricity worthy
of trial.  A combination of calomel, capsicum,
and  morphine tends  to check exhalation into
the bowels, determines  to the surface, relieves
pain  and irritation, and sustains  a moderate,
general, diffusive excitement.  Calomel allays
gastric  irritation,  especially  when accompa-
nied with the exhibition of ice, while it, at the
same time, promotes the biliary secretion.   We
have oftener succeeded in checking gastric dis-
tress and vomiting  by administering small  pie-
ces of ice, than by any other remedy. It should,
however, be aided by a sinapism over the stom-
ach, and by immersing the feet and legs in a
strong,  hot mustard  bath.  We have also de-
rived very  great benefit in these  cases from
small quantities  of cold carbonic  acid water,
and   the  effervescing  draught.   Hot drinks
should  never  be allowed.   In the diarrhoea
which ushers in a choleric  attack,  we found it
sufficient to direct the patient to keep his bed,
using the stimulating foot-bath, mustard to  the
bowels, and warm diaphoretic drinks, with, per- 
PESTILENCE,  CHOLERIC—]
■Bibliography  and  References.             151
haps, a little chalk mixture, or  an occasional
pill of calomel and opium.   We  treated about
eighty cases of cholera, in the incipient stage,
in this  manner,  in the  orphan asylum  of this
city, without losing a  patient.   The diarrhoea
was  invariably checked by determining to the
surface in the manner above mentioned.   Two
cases attacked in precisely the same  way, pre-
vious to our attendance, speedily ran  into col-
lapse, and terminated fatally.   In our own case
we  several  times resorted  to the same simple
means, with the  same results.  Hence we can-
not but regard the cholera as one pf the  most
generally manageable diseases which we have
to  treat,  provided it be taken early  in hand.
Thestage of collapse, in which  about half of
our cholera  patients  were  received  into the
hospital, is really the  dying  stage.   Occasion-
ally, however, when the epidemic influence is at
its height, cases will occur which baffle all the
resources of art.  We  have seen such march
on to a fatal termination in the course of three
or four hours,  without being affected  in the
slightest  degree  by the most  powerful  reme-
dies.   Of several such cases, treated in con-
junction with Prof.  Paine, see Med. and Phys.
Commentaries, vol. iii.    For  a very full and sat-
isfactory account of the disease  as  it prevailed
in this  city, including pathological appearances,
treatment, &c, see  the above  very able work,
passim.   Also, on the treatment, Wood's Prac-
tice of Medicine, vol. ii., p. 664.]
  Biblioo. and Refer.—Reports on the Epidemic Chol-
era which has raged throughout Hindostan and the Penin-
sula of India, since  August, 1817.   Published  by the au-
thority of Government. 8vo.  Bombay, 1819.—J.Jameson,
Report on the Epidemic Cholera Morbus, as it visited the
Territories subject to the Presidency of Bengal, in the years
1817, 1818, and 1819.  Drawn up by order of the govern-
ment,  under the superintendence  of the Medical Board,
8vo.  Calcutta, 1820.—H'. Scott, Report on the Epidemic
Cholera, as it has appeared in the Territories subject to the
Presidency of Fort St. George. Drawn  up by order of the
government,  under  the  superintendence of the Medical
Board, folio.   Madras, 1824.—Corbyn, Medico-Chirurgical
Transactions, vol. xi., part i., 1820.—R. Orton, An Essay
on  the Epidemic Cholera  of India, 8vo.  Madras, 1820.
Second Edition, with a Supplement.  London, 1831.—J.J.
Deville,  Mem. et  Observat. sur l'Epidemie  de Cholera
Morbus qui a Tegne  au Bengale pendant  l'ete de 1818, 8vo.
Logd. Bat., 1819.—J. Boyle, A Treatise on the Epidemic
Cholera of India, 8vo. Lond., 1821.—A. Moreaude Jonnes,
 Notice sur la Maladie Pestilentielle importee aux lies de
France et de Bourbon, et designee sous le nom de Cholera
Morbus de l'Inde, 8vo.  Paris, 1821.—T. Brown, On Chol-
era, more especially as it has appeared during late years in
Eritish India, 8vo.   Edin.,  1824.—W. Ainslie, Observat. on
the Choi. Morb. of India, 8vo.  Lond., 1825.—J. Annesley,
Sketches of the most prevalent Diseases of India, compri-
sing a'Treatise on the Epidemic Cholera of the East, &c,
8vo.  Lond.,  1826;  sec. ed.,  Lond., 1831.—R.  H.Kennedy,
Notes on the Epidemic Cholera, 8vo.  Calcutta, 1827.—A.
T. Christie, Observations on the Nature and Treatment of
Cholera, 8vo.  Edinb., 1828.—L. J. M. Robert,  Guide San-
itaire  des  Gouvernemens  Europeens, on Nouvelles Re-
cherches sur la Fievre Jaune et le Cholera Morbus, &c,
6vo.  Paris, 1826.—B. Hawkins, History of the Epidemic
Spasmodic Cholera of Russia, &c, 8vo.   Lond., 1831.— L.
Bodin. Precis sur le Cholera Morbus, et sur la Contagion,
&c, 8vo.  Paris, 1831.— H. Ranque, Memoire sur un Nou-
veau  Traitement du Cholera Morbus, et  des Affections Ty-
phoides, <fcc, 8vo.  Paris,  1831.—C. Searle,  Cholera,  its
Nature, Cause, and Treatment, clearly  and concisely ex-
plained.  Second edition, 8vo.  Lond., 1831.—G. H. Bell.
A Treatise on Cholera Asphyxia, or Epidemic  Cholera, as
it appeared in Asia and in Europe, 8vo.  Edinb., 1831 ; and
Letter to Sir Henry Halford, Bart., &c, on the Tendency
of the proposed Regulations for Cholera, on the Nature of
the Disease, <fee.  Edinb.,  1831.—H. Young,  Remarks on
the Cholera Morbus, its Symptoms. Causes, and Treatment,
<fec,  8vo.  Lond.,  1831.—/. R. Lichtcnstadt,  Die Asfcti-
sche  Cholera in Rnssland in den  Jahren 1830 und 1831,
&c, 8vo.  Berlin, lb3l.—/.  Goss,  Practical Remarks  on
the Disease called Cholera, now existing on the Continent
of Europe, 8vd.  Lond., 1831.—G. W. Lefevre,  Observa-
tions on the Nature and Treatment of the Cholera Morbus,
now prevailing epidemically in St. Petersburgh, 8vo.  Lond.,
1831.—T. J. Pettigrew, Observations on Cholera, compri-
sing a Description of the  Epidemic Cholera of India, the
Mode  of Treatment, and  the Meaus of Prevention, 8vo.
Lond., 1831.—Briere de Boismont, Relation Historique et
Medicale du  Cholera Morbus  de Pologne,  comprenant
l'Apparition de la Maladie, ses  Progres, ses  Symptdmes,
son Mode de Traitement  et les  Moyens Preservatifs, 8vo.
Paris, 1831 ; Observations sur le Cholera Morbus, recueil-
lies et publiees par l'Ambassade  de France en Russie, 8vo.
Paris, 1831.—F. G. Boisseau, Traite de Cholera Morbus,
considere sous le Rapport Medical et Administratis ou Re-
cherches sur les  Symptdmes, la Nature, et le Traitement
de cette Maladie, etsur les Moyens de l'eviter, 8vo.  Paris,
1831.—F. E. Foderi, Recherches Historiques  et Critiques
sur la Nature, les Causes, et ie Traitement du Cholera
Morbus d'Europe, de l'Inde, de  Russie, de Pologne, &c,
specialement appliquees a J'Hygiene Publique,8vo. Paris,
1831.—A. Moreau de Jonnes, Rapport au Conseil Supe-
rieur de Sante sur le  Cholera Morbus, les Caracteres et
Phenomenes pathologiques de cette  Maladie, les  Moyens
curatifs et hygieniques qu'on lui  oppose, son Mode de Prop-
agation, <&c, 8vo.  Paris, 1831.—Af. Bunavi, Trattato delle
varie Specie di Cholera Morbus,  8vo.  Turin, 1831.—P. F.
Kerauden, Memoire sur le Cholera Morbus de l'Inde, 8vo.
Paris, 1831.—C. Horn et  G. Wagner,  Instructions sur le
Cholera  Morbus, contenant les Moyens de s'en preserver,
d'en guerir, et d'empecher sa propagation.  Traduite par
M. L. Paris, 8vo.  Pans, 1831.—Desruelles, Precis Physi-
ologique du Cholera Morbus, <fcc, &c, 8vo.  Paris, 1831.—
Larrey, Memoire sur le Cholera Morbus, 8vo.  Paris, 1831.
—B. Zoubroff, Observations faites sur le Cholera Morbus
a Moscou, 8vo.  Moscow, 1831.—G. F. von Wedekind, Ue-
ber die Cholera im Allgemeinem und die Asiatische Chol-
era insbesondere, 12mo.  Frankfurt am Main,  1831.—C. F.
Harless, Die Indische Cholera uach alien ihren Beziehun-
gen, geschichtlich, pathologisch-diagnostisch, therapeutisch
und als Gegenstand der Staats und SanitatsPolizei darge-
stellt, 8vo.  Braunschweig, 1831.—Af. G. Weyland, Traite
sur le Cholera Asiatique, <fcc,  8vo.  Paris, 1831.—Edin-
burgh Medical and Surgical Journal for April, July, and
October, 1831.— W. Macmichael, Is the Cholera Spasmodi-
ca of India a contagious Disease ? 8vo.   London, 1831.—/.
S. Borchardt, Kurze  Darstellung der Cholera, 8vo.  Ber.,
1831.—/. Lizars, Substance of the Investigations regarding
Cholera Asphyxia, 8vo.  Edinburgh, 1832.— J. Copland, Of
Pestilential Cholera, its Nature, Prevention,  and Curative
Treatment,  &c,  12mo.  Lond., 1832 ; and Foreign Quar-
terly Review, art. Pestilential Cholera, Oct.,  1831.—D. M.
Moir, Practical Observat.  on Malignant  Cholera, as  that
Disease is now exhibiting itself in Scotlond, 2d ed., 8vo.
Edinburgh,  1832.—T. Molison, Remarks on the Epidemic
Disease called Cholera, as it occurred in Newcastle, 8vo.
Edinburgh, 1832.— T.  Thackrah,  Cholera, its  Character
and Treatment, with reference to the Disease as now ex-
istent at  Newcastle,  8vo.  Leeds, 1832.— W. Haslewood
and W. Moody, History and Medical Treatment of Cholera,
as it appeared at Sunderland. 1831, with Cases and Dissec-
tions, 8vo.   Lond., 1832.— W. B. O'Shaughnessy,  Report
on the Chemical Pathology of the Malignant Cholera, con-
taining Analyses of the Blood, Dejections, &c, of Patients
labouring under  that Disease, 8vo.  Lond., 1832.—F. W.
Becker, Letters on the Cholera  in Prussia, 8vo.  London,
1832.— T. M. Greenhow, Cholera,  as  it appeared  in the
Towns of Newcastle  and  Gateshead, with Cases illustra-
tive of its Pathology, &c, 8vo.  Lond., 1632.— W. Ains-
worth. Observations on the Pestilential  Cholera, as it ap-
peared at Sunderland in 1831, and the measures taken for
its Prevention and Cure, 6vo.  Lond., 1832.—W. R. Clan-
ny, Hyperanthraxis,  or the Cholera of Sunderland,  8vo.
Lond., 1832.—F.  Cobb, Report, <fec, on the Subject of the
Epidemic Cholera now prevailing at  Newcastle  and its
Neighbourhood, 8vo.   Lond., 1832.—W. Fergusson, Letters
upon Cholera Morbus, with Observat. on Contagion, Quar-
antine, <fec, 8vo.  Lond., 1832.— W. H. C. Gray, Dysen-
teria Serosa, or Convulsive Nervous Cholera of Hindostan:
its Progress from  Asia, 1817, to England in  1831, and its
Remedy, 8vo.  London, 1832.—J. Webster, On Epidemic
Cholera, its contagious Character, Treatment, <fec, 12mo.
Lond., 1832.— W. Russell and  D. Barry, Official  Reports
made to  Government on the  Disease called Cholera Spas-
modica, as observed by them in their Missionto Russia in
1831, &c, 8vo.   Lond., 1832.—Tacheron, De  la Mortalite
du Cholera Morbus  dans  le xi  Arrondissement de Paris,
&c„ 8vo.  Paris, 1833.—P. Voisin, Mem. sur le Cholera
Morbus a l'Hdpital St. Louis, Svo.  Paris, 1833.—Briere de
Boismont, Des Premiers Secours a donner aux  Personnes
atteintes du Cholera, 8vo.  Paris, 1832 ; et Relat. Histo-
rique et M*dicale du  Cholera Morbus de Pologne,  8vo.
Paris, 1832.—J.  Bouillaud, Traite  Pratique, Theorique et
Statisque du Cholera Morbus de Paris, 8vo.   Paris, 1832.
— L. C. Roche, Mem. sur  le  Cholera Morbus epidemique
observe a Paris, 8vo.   Paris, 1832.—A. V. Gendrin, Monog.
du Cholera Morbus Epidemique de Paris. 8vo.  Paris, 1832.
—J. Delpech, Etudes de Cholera Morbus en Angleterre et
en Ecosse, 8vo.   Paris, 1832.—Martyn  Paine, Letters on 
152                     PESTILENCE, HJEMAGASTRIC—Characters.
the Cholera Asphyxia in New-York, 8vo.  New-York, 1833.
— A. Smith, The Cholera Spasmodica as observed in Paris,
1832, 8vo.  New-York, 1833.— Beaumont, Mem. sur la For-
mation et la Contagion apparente  des Atmospheres Chol-
eriques,  bvo.   Paris,  1633— W. Leigh,  Narrative of the
Cholera at Bilston, 8vo.  Wolverhamp., lr>33.—D. B. Bui-
len,  Pract. Observat. on the Epidemic Cholera  at Cork,
Svo.  Lond., 1832.—Brown, in Cyclop, of Practical Medi-
cine,  vol. i., 1832.—F. Corbyn, Treatise on  the Epidemic
Cholera  in India, 8vo.  Calcutta,  1832.—T. W.  Francis,
Letter on the Cholera Asphyxia of  New-York, 8vo.  New-
York, 1832.—/. Hamet, Official Reports on the Cholera at
Dantzich, 8vo.  Lond., 1832.—/. Keir, A  Treatise on the
Cholera of Moscow, in 1830, 1831,  8vo.  Edinburgh,  1832.
—T. M.  S. Kennedy, A  Lecture on the Cholera at  Ash-
by-de-la-Zouch, 8vo.   Ashby, 1832.—H.  M'Cormac,  Ob-
servations on  the  Spasmodic Cholera, <fcc, 8vo.  Belfast,
183?.—D. M. Moir, Proofs  of the  Contagious Nature of
Malignant Cholera, 8vo.  Edinburgh, 1832.—H. Gaulter,
The Origin and Progress of the Cholera at Manchester,
8vo.  London,  1833.—/. P. Needham, Facts and Observa-
tions  on  tne Cholera  in York, 8vo. London, 1833.— W.
Twining, A Practical  Account of Epidemic Cholera, 8vo.
Lond., 1833.—R. Cranfield, Pract. Observations on Cholera,
and on the Treatment of the Disease, 8vo.  Dublin, 1834.
—/. B. Kelt, On the Appearance of the Cholera at  Sun-
derland in 1831, with  some Account of that Disease, 8vo.
Edinburgh, 1834.—/.  Parkin, Mem. sur le Traitement Cu-
ratif de  Cholera Epidemique, 8vo.   Mont., 1835 ; Rapport
sur le Cholera dans Paris et le Departement de la Seine,
in 1832,  4to.   Paris,  1834.—C. Y. Haines,  Practical  Re-
marks on the Treatment of Malignant Cholera, 8vo.  Cork,
1838.—Griffin,  in Med. Gazette, April 14, 1838, p. 113 —
Bellingeri, in Brit, and Foreign Med. Review, Jan., 1838,
p. 234 ;  Med. and  Chirurg. Review, Jan., 1838, p. 164.—
G. Budd, In Library of Pract. Med., vol. iv., p. 103.— W.
Merriman, in  Trans,  of Med. and Chirurg. Society, vol.
xxvii., p. 405.
  [Am. Bib. and Refer.—Essays on Pathology and Thera-
peutics, being the Substance of the Course of Lectures de-
livered by Saml. Henry Dickson, M.D., Prof,  of the  Inst.
and Pract. of Med. in the Medical  College of  the State of
South Carolina, 2 vols., 8vo, p. 588-651.  Charleston, 1845.
—A Treatise on the Practice of Medicine, by George B.
Wood, M.D., Prof, of Mat. Med. and Pharmacy in  the Uni-
versity of Pennsylvania, 2 vols., Svo.  Philadelphia, 1847.—
Moore Hait, in  Bost. Med. and Surg. Journ., vol. vi., p. 59.—
Joseph Comstock, Ibid., p. 269, and  vol. vii., p. 149.—N. P.
Willis, Account of Cholera in Paris, Ibid., p. 279, 302.—
Mass. Report on Cholera, by Drs. Warren, Shurtleff, Shot-
tuck,  Hayward, and Randall, Ibid., p. 320.—Cholera in
Canada, Ibid.,  p. 340.—Report of Urs. Bigelow, Ware, and
Flint, a Boston Committee to visit New-York,  and investi-
gate the Nature and Treatment of Cholera, Ibid., p. 353.—
/. A.  Allen, in Ibid., p.  367, and  vol. vii.,  p. 165, 213.—
Thomas  Miner, On Cholera, in Ibid., p. 395,  and 375, et
vol. vii., p. 21,  44, 63.—Henry Branson, in Ibid., Account
of Cholera at  Albany, p. 379.—John  Ware, Account  of
Cholera  in New-York, in Ibid., p.411.—History and Prog-
ress of Cholera m New-York City,  Ibid., p.  353, 369, 386,
402, et vol. vii.—James Morgan, in  Boston Med. and Surg.
Jour., vol. vii.,  p. 14.— Charles A. Lee, in Ibid., p. 17.— W.
Turner,   Account  of Cholera at Newport, Ibid., p. 26.—
Martyn Paine,  in Ibid., p. 35, 74, 95, 196, and Letters  to /.
0. Warrin, on  Cholera Asphyxia,  as it  nppeared in  the
City of New-York, Svo, p. 160. New-York, 1832.—Au Ac-
count of the Progress of Cholera in  the United States.  See
Bost. Med. and  Surg. J., vols, vi., vii., viii., ix., x., xi., xii.,
xiii.—C. Jewilt, in  Ibid., vol. vii., p. 64.—E. G. Davis, On
Saline Injections in Cholera, Ibid., p. 222.—E. M. H. Ellis,
On  Cholera, in Ibid., p.  349.—f. C. Howard,  in  Ibid , p.
282, 351.— B.  James,  in Ibid., p. 160 — L.  W. Sherman,
Ibid., p. 331.—/. E. Stevenson, Ibid., p. 181.—A. F. Holmes,
History of Cholera in Montreal, Ibid., vol. viii., p. 53.—C.
Hooker, in Ibid., p. 378.—B. F. Rose, Ibid., p.  119.—T. S.
Savage, Ibid., p. 202.—Facts and Observations upon Spas-
modic Cholera, addressed by the Board of Health to the In-
habitants of the City of Quebec, &c.  Quebec, 1832.—In-
formation for the People on Cholera, including a Sketch of
its History, Symptoms, Preventives, and Treatment.  Phil-
adelphia, 1632.—C. R. Gilman, Hints to the People on the
Prevention and Early  Treatment of Spasmodic Cholera.
New-York, 1632.—Remarks  on  the  Cholera,  embracing
Facts and Observations collected at  New-York during a
visit to the city expressly for that  purpose.   Providence,
1832.—Report of the Committee of  the Kappa Lambda So-
ciety, appointed for the purpose of preparing an account of
the  mode of Treatment  of Epidemic Cholera, June, to-
gether with an  additional Report, presented Aug. 15, 1832.
New-York, 1832.—Ashbel Smith, The Cholera Spasmodica,
as observed in Paris in 1832, comprising its Symptoms, Pa-
thology,  and Treatment, illustrated  by Ca6es.  New-York,
1632.—Edward W'arrj'n, Sketch of the Progress of the Ma-
lignant or Epidemic Cholera, from  its arrival in America,
with Tables illustrative  of  its Progress  in  the principal
Cities it  has visited.  Boston, 1832.—A. Brigham, M.D., A
 Treatise on Epidemic Cholera, including a Historical Ac-
 count of its Origin and  Progress to the present  Period.
 Compiled from the most authentic Sources.   Hartford,
 Conn., p. 368,  1832.—Elisha North, On Cholera, in Boston
 Med. and Surg. Jour., vol. vii.,  p. 197.—Daniel Eastman,
 in Ibid., Reports of Hospital Physicians, and other Docu-
 ments in relation to the Epidemic Cholera of 1632.  Edited
 by Dudley Atkens, M.D.   New-York, 1832, 8vof p. 200.—
 G. R. B. Horner,  Account of the Cholera which occurred
 on board the U. S. Ship  John  Adams (Am. Journ. Med.
 Sci., vol. x., p. 257).—Joseph M. Smith, A Discourse on
 the  Epidemic  Cholera Morbus  of Europe and  Asia, &c,
 1831.—C. W.  Pennock and W.  W. Gerhard,  Observations
 on the Cholera of Paris, Am. Jour. Med. Sci., vol. x., p. 319,
 521.—Paul M. Eve. in Ibid., p. 524.-/. P.  Hopkinson, in
 Ibid., 533.—C. A. Lee, On Cholera, in Ibid., 544, and vol.
 xv.,  p. 256.—James Jackson, Jr., Cases of Cholera, col-
 lected at Paris, at the Hospital la Pitie.  Boston, 1832, Hvo,
 p. 212.—L  Munsell, in Am. Jour. Med. Sci.,  vnl.ii.,p. 251.
 —/. C.  Skinner, in Ibid., p. 252.— W. Channing, On the
 Camphor Treatment of Cholera, in  Ibid., p. 254 — H. W.
 Baxley, in Ibid.,  p. 257.—James MlNaughton,  Letter oi
 Epidemic Cholera of Albany, addressed to Thomas Spen-
 cer,  M.D., in Ibid., p. 260.—Chas. T. Jackson, in Ibid., p.
 266.—Samuel Jackson, in Ibid., vol. xi., p. 275; vol. xii.,
 p. 76.—/. B. Zabriskie,  On Cholera, in Ibid., p. 355.—
 Henry Branson, Observations on the  Chlorides and  Chlor-
 ine,  as ■' Disinfecting Agents," and as preventives of Chol-
 era.  Boston,  1832, p. 12, 8vo.—H. Chapman, Lecture on
 Cholera Morbus, in Am. Jour. Med. Sci., vol. xii., p. 281.—
 Hunting Sherrill, On Epidemic Cholera, as it prevailed la
 Dutchess County, New-York, 8vo,  1832, p. 38.—Hugh L.
 Hodge, On Cholera, in Ibid., p. 386.—James Cauper, in
 Ibid., p. 261 —John S. Brown, Observations on the Origin-
 al Causes of Malignant Cholera, C. S. Francis, New-York,
 1835, p. 41.— W. E. Horner,  On  the Anatomical Charac-
 ters  of  Asiatic Cholera,  with Remarks on the  Structure
 of the Mucous Coat of the  Alimentary Canal, in Am. Journ
 Med. Sci., vol. xvi., p. 58, 277.—Roble.y Dunglison, The
 Practice of Medicine, A Treatise on Special Pathology and
 Therapeutics,  &c, 2 vols., Svo.  Philadelphia, 1844.—
 Thomas Spencer, An Address on Diarrha'a Serosa (Chol-
 era), before  the New-York State Med. Society.]
 PESTILENCE,  HJEMAGASTRIC —Synov.
   Pestilentia hamagaslrica (from aiua, blood, and
   yaoTTip, the belly), Author.   Typhus icterodes,
   Sauvages, Cullen.    Fcbris flava, Auct.  Var.
   Sy?wchus icterodes,  Young.   Causus, Moseley.
   Febris flava Americanorum, I. Frank.   Epane-
   tus  malignus  flavus,  Good.   Fievre Jaune,
   Typhus Jaune, Fievre Matelotte,  Mai de Si-
   am,  Fr.   Gelbes Fieber,  Schwartes erbrechen,
   Westindisches fieber.  Germ.   Fiebre gialla,
   Ital.   Fu.bre  Amarilla,   Vomito negro, Vomito
   prieto,  Span.  Hamagastric Fever, or Pesti-
   lence,  Author.   Yellow  Fever,  Black Vomit,
   Malignant Yellow Fever, Pestilential or Bulam
   Fever,  Epidemic  Yellow  Fever.
   1. Defin.—After chills [or rigours], shivering,
 and languor, severe pain in  the  orbits and fore-
 head, also  in the [back], loins,  and limbs; rapid
pulse, flushed face ; glassy, suffused eyes ; pecu-
liar burning heat  of skin, and frequently delirium;
nausea  and  vomiting, with epigastric  pain, cos-
tiveness, great anxiety, restlessness, and watchful-
ness :  subsequently hiccough, black vomiting, scan-
ty or suppressed urine, hamorrhage.s from the mu-
cous canals,  lemon or muddy yellowness  of  skin,
generally  terminating  in  death in its most severe
 form.
   2. Pathological  Characters.—An  infec-
tious miasm or animal poison, specifically affecting
the organic nervous and vascular systems and the
vitality of the structures;  impairing the crusis and
constitution of the blood and the vital cohesion of
the  tissues;  and more especially implicating the
stomach and  digestive mucous surface, and leaving
the frame protected from a second attack,  if recov-
ery take place.
   a. The origin, nature, and treatment of this
pestilence have attracted  the  attention of the
medical  profession, and even  of governments,
m a remarkable manner for many years.  The 
PESTILENCE, H.EMAG
ravages of it, during  1793  and  1794, in the
West Indies and the United States, and the sub-
sequent recurrences of these ravages  both  in
America and in Spain, have furnished most im-
portant subjects  for investigation, and have en-
gaged the abilities of several eminent physicians,
both in this and in foreign countries.  Notwith-
standing the volumes  of descriptions  and of
controversy which have resulted, opinions are
still unsettled respecting the source and true
nature of the disease.  It may be reasonably
inquired, what are the  causes which have so
long retarded our knowledge of so important a
subject ?  These, it may be  presumed, are  in
many respects the same as those which usually
stand in the way of our advancement in  every
other department of human science.  The sub-
ject presents also difficulties which  are  pecu-
liar to  itself; and not  a few sources of error
are  attributable to  many of the writers who
have attempted to furnish information respect-
ing  it,  or  to enter the  lists of controversy.
There  are, perhaps, but  few of the  numerous
disputants  on either side of the question who
can at the present day be quoted as authorities,
deserving in every respect implicit confidence.
The majority of them entered upon the inquiry
—if, indeed, due inquiry or research were ever
attempted—with judgments  previously biased.
Others possessed neither that amount of scien-
tific education, nor that tutored state of intel-
lect, which are requisite to medical observation
in all circumstances, and particularly in  those
connected with investigations into pestilential
visitations.  Where it was most necessary that
the relations subsisting between  the geological
formations, the  soil, the locality, the climate,
and the meteorological vicissitudes of a country,
and the states of the brute,  as well as the hu-
man inhabitants, should be comprehensively yet
accurately observed, in respect of their healthy
condition, of prevailing diseases, and of epidem-
ic visitations, many of the  elements requisite
to  the formation of sound  views have  either
been overlooked, or purposely exaggerated, or
even misrepresented: some have drawn sweep-
ing conclusions  from narrow fields of observa-
tion ;  and  many have erred, more or less, in
considering this pestilence in too close connex-
ion with those  maladies which  have  existed
previously or appeared subsequently to its prev-
alence.  The importance of ascertaining  differ-
ences, as well as of marking points of similar-
ity, upon which specific differences, or identity
of nature, may be based, has been overlooked ;
and much too frequently a few features of sim-
ilarity have been seized, and identity of char-
acter has been  thence assumed, without duly
estimating the numerous differences associa-
ting themselves with  each  of  these features.
It must not, however, be forgotten that occa-
sionally there appeared in the arena individu-
als whose opinions will always obtain  respect,
and who added  to their scientific and  medical
reputation  by the discussion, and who evinced,
by  an honourable spirit and temperate  zeal,
that truth was the sole object of their inquiries.
  4. In thus regretting that the visitations of
this pestilential  fever—which I  have  above
denominated, from its prominent pathological
characters, Haemagastric Pestilence or  Fever
—have not always been observed, during their
rise, progress, and decline, by persons altogeth-
rASTRIC—Characters.                 153

er qualified  for the undertaking;  and that the
subject has been viewed  as  seldom from the
" elevated  table-land of human  science," as
with  minds entirely divested of prejudice or
preconceived opinions ;  it must also be admit-
ted that the amount of scientific acquirement
actually brought  to  the task  of  investigation
has often tended more to entangle than to elicit
the truth.  The little that is  known, or rather
our want of knowledge, of the nature of malaria,
of the constituents of emanations from the soil,
and of other imputed sources of pestilential dis-
eases—the mist of ignorance  and of prejudice
involving these agents and exaggerating their
influence — their inferred  operation, without
further proof of their existence than certain ef-
fects which have been imputed to them, either
upon  insufficient  data, or even  without the
smallest evidence—combined  to mislead those
who generally repose on the authority of others,
and to prevent those salutary  measures of pre-
vention being undertaken which can  be based
only upon sound views of the source and nature
of pestilence.  The undue weight of insufficient
or false authority, the array of imperfectly ob-
served  phenomena and  "false facts," and the
prevalence of hastily preconceived opinions, of
false theory, and of  premature generalization,
have swayed the minds of many from obvious
truths and natural conclusions into errors of
the most deplorable kind, and plunged not mere-
ly towns and districts, but populous cities and
kingdoms,  into the  deepest abyss  of misery.
Concentrated marsh or  terrestrial exhalations,
according to many of those who  most plumed
themselves  on their science  and philosophy,
produced plague in Egypt and other parts of the
Mediterranean coasts, gave  origin to  yellow
fever in the West Indies, the United States,
and in Spain, and was the only cause of pesti-
lential cholera over  the globe. The influence
of this cause, and its power to produce all these
and many other effects, were as firmly believed
in by them, and with less, certainly with no
greater reason,  than Tertuli.ian believed in
the power  of the devil to produce similar dis-
tempers : " Inducere potest morbos et sanitates.
Viscerum actiones potest inhibere latenter, et
venenis nobis ignotis  corpus inficere."  And
what have been the results 1   The history of
pestilential  yellow fever on  both sides of the
Atlantic during little more than half a century
is the reply—a history the more humiliating to
medical science, and  to human  nature, the
more intimately it is investigated.   Whether a
belief in the influence of terrestrial exhalations,
as presumed  by  the pseudo-lights  of medical
knowledge, or confidence in the power so dread-
ed by Tertullian and some other fathers of
the Church, actuated those whom circumstan-
ces unworthily and most unhappily clothed  with
authority on many important occasions, is not
material as respects the results ;  for,  as either
belief must  necessarily have led to similar con-
sequences, and as neither agency could be con-
trolled  by  available means  of prevention or
counteraction, so they were  left to their  own
course, and thus gave  ri%e  to effects  of the
most  deplorable kind.  If the simple truth had
been seen, and the dictates of common sense
been followed, measures calculated to prevent
the extension of pestilence at its earliest ap-
pearance would have been taken, and success- 
154
PESTILENCE,  HJEMAGASTRIC—Description.
fully carried out on many occasions; but, un-
happily, truth and common sense are as seldom
the basis of theory, as they are the incentives
of human actions.  The simple fact that cer-
tain distempers were communicated from one
person to several, from a few to  many, might
have  been viewed as  sufficiently intelligible,
and considered as  sufficient grounds for a dis-
regard of all opposing views which had no other
basis  than vague  hypothesis,  certainly  none
stronger than that confided in by Tertullian,
and have led to attempts at isolating the affect-
ed, and thereby  protecting the healthy.  But,
before proceeding to the discussion of the topics
to which this train of ideas would lead, and
which will more appropriately be considered in
the sequel, I must first describe the pestilence
now under consideration.
  5. I. Description.—Hamagastric or continued
yellow fever resembles scarlet  fever in some re-
spects, and more especially in the several  de-
grees  of malignity and the modifications it pre-
sents, in different individuals, during the same
epidemic.  Generally, the higher the grade of
atmospheric temperature in  which it  occurs,
the more stagnant the air, the closer the situa-
tions  and the apartments, the greater has been
the prevalence and the  mortality  of the pesti-
lence. It manifests, also, a greater perdilection
for some constitutions  than for others, attack-
ing some in a very mild, and others in a very
malignant form.   Sir W. Pym stales that this
peculiarity was  very remarkable at Gibraltar
in 1804, where, in  some instances, whole fam-
ilies fell victims  to it, while others, equally  nu-
merous,  under  the same treatment, escaped
with a slight attack.  The same was remarked
at Seville, Cadiz, and other places, and in other
epidemics. The states of constitution and tem-
perament giving  rise to this predilection are  not
so manifest as to permit anything being stated
with precision respecting them.  Owing, how-
ever,  to temperament,  sex, age, and constitu-
tion, in some measure, and to  other predisposing
and concurring causes hereafter to be mention-
ed, this  distemper presents  certain grades or
modifications.
   6. i. The mildest form of haemagastric  pesti-
lence  is  most frequently observed in children,
and,  during some epidemics, in females,  al-
though occasionally females have suffered most
severely.   It generally makes its appearance
with languor and slight chills, soon followed by
heat of skin ; quick and full pulse ;  uneasiness
in the loins and  limbs ;  severe headache, con-
fined  chiefly to the orbits and forehead ; a pe-
culiar shining or  drunken appearance of  the
eyes ; hot, dry skin ; a loaded but moist tongue,
with  little thirst; sickness  at stomach, with
costiveness, and a feeling of uneasiness,  not
amounting to pain, at the epigastrium, and  a
sense of rawness or soreness in the fauces and
in the course of the oesophagus.   These symp-
toms  may continue from twelve to twenty-four
or thirty-six  hours, when the patient, having
taken only some purgative and febrifuge medi-
cines, or an emetic,  falls  into  a refreshing
sleep, from which he  awakes in a gentle per-
spiration, free from pain and fever, and com-
plaining of debility, from which he rapidly re-
covers.
   7.  ii. The more severe and more frequent form
appears more suddenly, and the symptoms  are
much more violent.  The attack is ushered in
by shivering and rigours.  The pain in the or-
bits and forehead is excruciating; severe pain
is also complained of in the loins and calves of
the legs ;  the face is flushed;  the eyes  are
glassy, suffused,  or  apparently  inflamed ; the
pulse is rapid ; the skin burning hot and dry;
and the tongue is loaded, but moist, with little
thirst.  A few hours  afterward uneasiness o4
stomach,  with nausea  and  vomiting,  super
venes ;  followed by severe pain and tenderness,
at the epigastrium, with a sense  of rawness,
heat, or inflammation in the  fauces and down
the  oesophagus ;  great  anxiety,  restlessness,
and  watching,  with  a desire  of  sleep.   The
bowels are constipated, the evacuations scanty
and deficient in bile ; the  urine dark-coloured,
and small  in quantity.
  8.  If the disease be judiciously treated, these
symptoms  often  become  ameliorated  on the
second or third  day, the  patient  falling into a
sleep, from which he awakes refreshed, with a
perspiring or moist skin, and nearly free from
all the symptoms.  Debility only remains, the
recovery  from which is  generally rapid.  In
many cases, however, either a partial ameliora-
tion  only occurs, or the more complete subsi-
dence of the symptoms  is of short duration,
the  patient in  a few hours beginning to be
troubled with flatus in the stomach, and dis-
tressing hiccough.   Not unfrequently the pa-
tient is suddenly and unexpectedly seized with
faintness,  sickness, and painful retchings, fol-
lowed by  vomiting, at  first  of whatever had
been taken into the stomach, but soon after-
ward of a brownish fluid,  resembling dirty wa-
ter, mixed with  a dark-coloured, flaky matter,
which floats upon its surface; and at last by a
matter resembling coffee grounds or thin pitch.
At this time, also, a great change takes  place
in the countenance, which assumes a putrid,
dingy, and bloated appearance, which is most
remarkable in those of a florid  or sanguine
complexion.  A  light yellow or  lemon  tinge
appears under the  eyes  and ears, and soon
spreads down the neck to the chest, and over
the whole body.   The vessels of the conjunc-
tiva appear relaxed, and distended with blood.
The vomitings continue,  and the quantity of
fluid ejected much exceeds that which has been
drunk.  They often return without being exci-
ted byingesta ; or even suddenly or unexpect-
edly, and  when  the  patient has  just  before
considered himself relieved from them.   In the
latter hours of the disease, they are attended
by a peculiar loud and  hollow noise, which is
heard at a considerable  distance.  During this
state the  patient is generally sensible to sur-
rounding objects, and aware of his fate.   He
is restless, continually tossing about in his bed,
with an expression of despondency in his coun-
tenance.  He looks anxiously  and inquiringly
around for relief, but unable  to express all his
misery and his wants.  At last, worn out with
restlessness  and fatigue, he sinks  without a
struggle.
   9. iii. The  third form of attack also  com-
mences with shivering or rigours, and is an ag-
gravation of the symptoms of the  second from
the  beginning.   In  this form the  face is more
flushed, and the burning heat of skin is greater
than in the preceding. The sickness at  stom-
ach, hiccough, and black vomiting appear much 
PESTILENCE, H^MAG
earlier.   The bowels are obstinately constipa-
ted, and resist strong purgatives ; the motions
being watery, of a dirty colour, and rarely fec-
ulent or bilious.   Violent delirium often occurs
early in the attack, and haemorrhages frequent-
ly take place at an early period from the nose,
mouth, eyes, ears, and  even from  all the out-
lets  of mucous canals.  The  tongue is  often
clean, moist, livid, or red, and raw-like, or cov-
ered with dissolved blood.   The action of the
kidneys is suppressed,  either little  or no urine
being secreted.  The  countenance changes to
a livid and yellowish hue, with yellowness of
the skin.  In the  most  severe of these attacks
the patients may be carried off on  the second,
but generally on  the third day, sometimes in
convulsions.
  10. In plethoric persons and in the sanguine
temperament the  attack is often  most violent;
and  in  addition  to the symptoms just  men-
tioned, the  countenance appears bloated and
heavy, with an unnatural expression, or wild
and  agitated.  The  heat of the surface, which
was at first  great and pungent, falls first in the
extremities, and afterward over the whole body,
especially after the  occurrence of black vomit-
ing ; and ultimately it  sinks below the natural
standard.  The skin becomes compacted, los-
ing its vascularity, and is insensible to the irri-
tation of blisters.   It is rarely dotted with pe-
techia?, but much oftener streaked with yellow-
ish lines, particularly  in the course of large
blood-vessels, or is covered by patches of a blu-
ish or leaden colour, especially in flaccid parts.
The sense of internal distress increases as the
febrile action subsides.   Distention of the hyp-
ochondria, and explosions  of flatus from the
stomach, are frequent,  with occasional obscure
hiccoughings.   Sometimes the vomitings are
hardly complained  of until the more  febrile
symptoms  begin  to abate, when they become
unrestrainable: the matters ejected  are then
muddy or turbid,  like unstrained coffee ;  occa-
sionally  they are of inky blackness, like the
juice of the cuttle-fish,  The evacuations by
stool sometimes also  present a black appear-
ance at this stage.  In the more severe states
the disease frequently terminates fatally within
the fifth day.  In the  less severe cases signs
of an imperfect crisis sometimes appear about
the seventh day,  and improve to favourable in-
dications, but occasionally they are arrested in
their course, and superseded by an unfavoura-
ble train of symptoms, as haemorrhages from
the throat, gums, mouth, and sometimes from
other outlets of mucous canals.   The blood is
dissolved, dark,  incoagulable or grumous, par-
ticularly at a  far-advanced  period  of the dis-
ease.
  11. iv. The fourth  form  of the pestilence
seems a modification of the symptoms by tem-
perament and habit of body, although the pre-
cise conditions of these cannot  always be as-
signed, the  phlegmatic, apparently,  most fre-
quently exhibiting  it.  In  this  the symptoms
are not so violent as in the third form, but they
are equally  fatal.   It  often  commences  insid-
iously, the  patient  complaining for hours, or
even longer, of nothing but languor or fatigue,
which is followed by chilliness or rigour, with
pains in  the loins and calves of the legs.   The
headache is not  very severe.  The pulse  is
quick and small.  The heat of skin is very lit-
JASTRIC—Description.                 155

tie increased ; but there are great anxiety and
oppression at the praecordia, and an indiffer-
ence to surrounding objects.   The bowels are
obstinately confined, and the secretion of urine
is arrested.  The tongue is  often unnaturally
clean, and of a clear, shining, vermilion colour.
Haemorrhage  appears  early  from  the  nose,
gums, or mouth, and is  sometimes attended by
petechia?  and vibices.  There is little or no
thirst, but great irritability  of stomach, with
hiccough  and black vomiting, attended some-
times, as the distemper  proceeds,  especially
towards the fatal close, by an involuntary dis-
charge of the  same appearance from the bow-
els.   The peculiar change of countenance, with
yellow skin, takes place as in the other states,
and  is frequently accompanied with a low mut-
tering delirium.   The temperature of the sur-
face generally falls  below the natural standard
as the disease advances.  Distress at stomach
and  intolerance of pressure over this region are
generally present.  The bowels are almost in-
sensible to the action of purgatives,  which
either produce no effect or only watery evacua-
tions—sometimes cold, ropy, and black, as if
mixed with powdered  charcoal.  As the dis-
temper  advances, the pulse sinks in frequency,
becoming weak and small.  In some instances
it sinks below the  natural frequency, and be-
comes irregular or intermittent.  Death in this,
as well  as in the preceding state, may occur as
early as the second day, especially when the
brain is the prominent seat of morbid  action ;
but  it more frequently occurs on the third or
fourth day, or not until  the fifth, sixth, or sev-
enth.  A favourable change is remarked chief-
ly on the third, fifth, or seventh day.
   12. v. The above are the chief states of the
distemper commonly observed, modified, how-
ever, or the one passing into the  other, ac-
cording as constitution, Concentration  of the
cause, and varying  concurring circumstances
aggravate the seizure.  Certain anomalies may,
however, occur  ; but modifications in the type
are not observed.  They are, however,  noticed
by some writers, and  others, as  Dr. Jackson,
have described a form in  which the symptoms
are at first remittent, but  become continued in
the course of the malady.  When treating of
the more severe states  of remittent fevers, es-
pecially as they occur within the tropics, and
beyond  the tropics in localities and seasons fa-
vouring the development  of  the more  intense
or malignant forms  of  remittent  fever, I have
shown,  that the passage  of that  type into the
continued  is  extremely  frequent,   especially
when vital organs become more and more im-
plicated, and  when  the disease  increases in
prevalence, so as to assume an epidemic char-
acter, the fever, with this change of type, gen-
erally also presenting in  the worst  cases the
chief features of the true haemagastric pesti-
lence, particularly yellow  skin, and in rare ca-
ses  even  black  grumous vomiting.  (See art.
Fever,  Remittent, § 233,  el seq.)  These facts
are admitted by the non-infectionists, and are
indisputable.  But it is not proved,  that, with
this  change of type, and with the  supervention
of these features, the  fever, which certainly
was non-infectious as long as it was  remittent,
becomes infectious as soon as it becomes con-
tinued, unless  a number of affected persons are
so circumstanced, especially from crowding and 
.GASTRIC—Description.
 156                  PESTILENCE, HJJMA

imperfect ventilation,  during very warm and
humid states of the air, as to contaminate the
surrounding atmosphere ;  and thereby either to
superadd the additional cause of a morbid ef-
fluvium exhaled from the sick to existing marsh
miasmata,  or to  generate a  morbid poison or
vapour, which  is of itself capable, independ-
ently of marshy or other  miasmata, of infect-
ing the healthy, and of disseminating the dis-
temper.  It is  almost  impossible on some oc-
casions, and  certainly difficult in all, to ascer-
tain, beyond the reach of controversy, whether
the one contingency or the other obtains ;  still,
the observing physician will generally arrive at
just conclusions on the subject, and act in such
a manner as the  great responsibilities reposed
on him will justify.
  13. That a superadded property, or at least a
change of character, should result from the cir-
cumstances just alluded to,  may be rationally
inferred ; for the aggravation of symptoms and
the development of new features, in these al-
tered circumstances, have frequently been ob-
served, are undoubted, and are the chief sour-
ces of much of the differences of opinion, and
of the discussions which  have appeared since
the end of the last  century  on the subject of
yellow fever ; for, owing to them, and to causes
sufficiently noticed above (§ 12), these aggra-
vated states of remittent fever,  either passing
into, or originally assuming more or less of a
continued form, have been confounded with the
true or infectious yellow fever—with the pesti-
lence now  under consideration.   The circum-
stances, moreover, of the latter being devel-
oped only during those high ranges of temper-
ature, and in those situations which render re-
mittents thus malignant and  prevalent, has in-
creased the difficulty of distinguishing the one
from the other,  and has led several writers, who
have observed  the simultaneous prevalence of
both maladies in the same locality—a circum-
stance by no means infrequent in the West In-
dies and in some other countries—to describe
both as varieties merely of one distemper, and
to ascribe the properties possessed only by the
one to the  other also.   As much ambiguity has
arisen  from this source, I  will notice more par-
ticularly than can be done when treating of the
diagnosis of this  pestilence, certain symptoms
which require attention, as well as others which
are only occasionally remarked.  Such diversi-
ties or modifications of character evidently re-
sult from diversity of the predisposing and con-
curring causes, from the concentration of the
infectious  agent, or the  dose of the animal
poison conveyed in the atmosphere, and from
the idiosyncrasy or constitution of the infected.
  14.  Suddenness of attack is one of the promi-
nent characters of the  malady;  there seldom
appearing any premonitory ailment, at least of
such severity as to attract particular notice.  In
some cases, however, a feeling of fatigue or
lassitude, with  headache and costiveness, are
complained of for a short time previously.   The
pains  felt in  the head, loins, limbs, and often,
also, in the large joints, generally precede or
accompany the  chills, shiverings, or rigours at-
tending the seizure ;  and these are often very
severe, but they appear to change their charac-
ter, without being less distressing, as reaction
takes place.  The seizure usually occurs in the
night or morning, but  there are numerous ex-
ceptions to this period.   The pulse, during the
cold or  incipient stage, varies.   It is small, fre-
quent, and irregular during the incipient state
of chilliness or rigour, during which the temper-
ature of the  skin over the trunk is  generally
increased, although it is much lower in the ex-
tremities.  The pulse becomes more frequent,
sometimes very quick, as reaction is developed,
but  it is also broad, open, soft, or very com-
pressible.  As collapse supervenes, it is soft,
weak, or irregular, ultimately becoming  small,
feeble, or suppressed.  The pulse, however, in
this stage of exhaustion varies  much in  differ-
ent  cases,  owing to the  loss of a considerable
portion of the serum and haematosine of the
blood by vomiting, and according to the amount
of such  loss, as well as to the  impaired  irrita-
bility of the heart.  The tongue varies  in its
character as the disease advances, and  often,
also, at the commencement, as well as at the
close of the distemper, it presents different ap-
pearances in different cases.  It is frequently,
at first, furred or loaded in the middle or root,
but moist and  red, or inflamed, at the point and
edges.  It  is in  some moist, red, purplish, and
clean ;  in others it presents a dry streak in the
middle, and in many, and those the most un-
favourable, it  is of a vermilion red or purplish
red colour, covered in a few instances with an
exudation of fluid blood, either at  an early or
at an advanced stage, according to the violence
and  danger of the attack.  It often has a raw
appearance, and is  more  or less  swollen or
flabby.
  15. The countenance varies in appearance and
expression with the  progress of the distemper,
and  the age, habit of body, and temperament of
the  patient.   At  the  commencement of the
seizure, the face is  usually pale, and the fea-
tures somewhat sunk ; but as soon as the chills
and  rigours cease it becomes full, flushed, anJ
turgid;  the lips tumid and red ; and the eyes
protruded, prominent, bright, and inflamed, with
exquisite pain at  the bottom of the  orbits, and
in the forehead.   As the disease advances, the
countenance assumes a peculiar pale lemon col-
our,  which, in the most  unfavourable  cases,
passes into a livid, muddy, or putrid  appearance,
which has been aptly likened by Sir W. Pym to
that presented by the face  in the childish di-
version of snap-dragon.   In thin,  emaciated,
and  aged persons the features  become sunk,
especially as the disease advances ;  but in oth-
ers,  unless  when the quantity  of  dark fluid
thrown  off the stomach is very great, the  face
continues tumid to the last, particularly when
the  fatal progress of the malady is rapid.  A
sense of constriction is often felt in the chest,
and anxiety at the praecordia ; and towards the
close there  is a  continued  movement of the
hand over the praecordia and chest.   The breath-
ing is often laboured, occasionally deep or sus-
pirous, with a peculiar groaning or moaning;
and the voice is frequently altered.  A burning
heat is usually felt at the epigastrium, and not
infrequently in the course of the oesophagus
Everything is  rejected from the  stomach, and
the  patient  tosses  his head and limbs about.
Stools are always procured with great difficulty
early in the distemper, and while reaction con-
tinues ;  but  after the deceitful calm, about to
be noticed (§ 17), they often become more free,
and  sometimes involuntary.   They  are always 
GASTRIC—Description.                  157
                     PESTILENCE, ILEMA

scanty at first, offensive, watery, and deficient
in  bile ; but they frequently are black and wa-
tery,  sometimes  with small, lighter-coloured
flocculi in the last stage, and when black vomit
has taken place.  The  urine is at first scanty
and high-coloured, and in the worst cases it is
entirely suppressed, none being secreted, ow-
ing either to a paralyzed state  of the kidneys,
or to the quantity of serum lost by the blood,
as in  the  pestilential  cholera, by the frequent
and copious discharges from the stomach.  The
patient generally  feels severe pain in glans pe-
nis and urethra when the urine is suppressed,
or passed only in  a few drops.   The blood is al-
ways  more or less changed—most remarkably
after the calm occurring on the third day.  Even
at the commencement and during reaction, it
does not coagulate, or does so imperfectly and
loosely, and is deficient in fibrin.  It afterward
becomes still more loose  and  defective as to
crasis, and ultimately very dark, partially dis-
solved, and grumous  ; and apparently insuffi-
cient  in quantity, in many cases, to distend the
veins.   The perspiration and the evacuations are
very offensive, and have a peculiar sickly odour,
which thoroughly imbues  woollen and cotton
clothes, and the patient's bedding.
   16.  The  mental manifestations are variously
affected in different persons.  In some, violent
delirium occurs;  in others, low delirium, oc-
casional wanderings  of  the mind,  or waking
dreams, are remarked;  in many, the mind  is
not materially affected throughout, unless inas-
much as the patient may be despondent, taci-
turn,  depressed,  or  apathetic.   An  early con-
viction of a fatal issue, indifference  to the re-
sult, and a calm apathetic resignation to  his
fate, are frequently observed without any far-
ther mental disturbance, the patient's intellects
continuing unimpaired to  the last.  In some,
the violent delirium  present during  an early
period disappears, and the mind afterward re-
mains calm until  death.
   17.   Slight exacerbations are  sometimes re-
marked in the evening, and ameliorations  in
the morning ;  but these are rarely so consider-
able  as to amount  to remissions, the disease
generally pursuing a continued  course until the
third  or early in the fourth day, when a deceit-
ful calm appears.  The pulse then often falls to
nearly its  natural frequency, sometimes even
below it; the  eyes lose their brilliancy.  The
heat  of skin also sinks, especially in the  ex-
tremities, when it often falls below the natural
standard.   This calm usually continues all the
fourth day, and  the patient, feeling  some re-
turning craving  for food, thinks himself con-
valescent ;- but  lemon-yellowish of the skin,
sometimes delirium, mental depression or ap-
athy,  faintness upon  being raised up, or upon
being placed on the night-stool, vomitings, and
hiccough often appear about the following even-
ing or night; sinking  of the pulse and tempera-
ture, especially in the extremities, black vom-
iting,  suppression of urine, and other fatal symp-
toms, supervening more or less rapidly.   In
many cases the heat of  surface sinks remarka-
bly, and the extremities assume a livid appear-
ance, the pulse being  hardly feft in the limbs.
   18.   In the above  description  of this malady
I have followed  my own  observation and rec-
ollection, aided by notes  taken during my at-
tendance  upon cases which came before  me
within the tropics.  Some of these cases oc-
curred in a vessel in which I was a passenger,
and  in circumstances which strongly favoured
a belief in an infectious source, as will hereaf-
ter be alluded to.  The numerous descriptions
of the disease which I have perused vary some-
what, especially in certain subordinate partic-
ulars, most probably owing to the varying fea-
tures of the distemper in several epidemics, and
in different  climates, localities, and constitu-
tions.  The chief difference, however, consists
in the severity  of attack, and the intensity of
affection evinced by the blood and digestive or-
gans.  The most dangerous cases are not those
in which the  symptoms are most violent, in re-
spect of vascular or nervous excitement; but
those in which  the vital powers are most de-
pressed, the blood most changed, and the black
vomit most early, copious, and frequent.   (See
§ 9-11.)  The  differences between these and
the slightest grade (§ 6) are  very great; the
degree of fatality of  the  disease in America,
West Indies, Spain, or Africa, depending upon
circumstances about to be mentioned.
   19. vi. Several of the writers on this distem-
per have divided it into certain stages or periods.
These stages are often well marked; but in
many cases  they are hardly manifest.  In the
most violent  seizures, the patient is suddenly
struck, and   the  distemper proceeds  rapidly
without reaction, or nervous  or  vascular ex-
citement, to  vital and  structural  dissolution,
with every indication  of extreme vital depres-
sion, of vascular contamination, and of impair-
ed or nearly-lost irritability  and cohesion of
the tissues.   When either the powers of the
constitution  are sufficient to resist  the  over-
whelming influence of the pestilential  poison,
or the dose  of this poison is weak relative-
ly to the state of vital resistance, then vascular
reaction takes  place, with or without nervous
excitement, and a division of the progress of
the malady into stages or periods, according to
the successive changes in the states  of morbid
action, may be made with justice.   But writers
are not agreed as to the precise division which
should be adopted.   Some  recognise  merely
two  stages, viz  , that of excitement, and that of
collapse or  exhaustion.  Others  contend, and
with  much justice, that the stage of invasion,
or that period which is characterized by chills,
rigours, or an alternation of chills and heats, and
which, in a  few cases, is  preceded by a sense
of mal aise, fatigue, and headache, for a short-
er or longer period, should be viewed as a dis-
tinct period.  I  am of this opinion, and am con-
firmed in it from having had an opportunity of
almost constantly observing, in several cases,
the phenomena  during this stage, and its fre-
quent passage into the next, or that  of excite-
ment or reaction.  Other authors have consid-
ered  the delusive calm ushering  in the period
of vital exhaustion as a distinct stage ;  but. it
rather indicates the passage of reaction  into
collapse, the  subsequent severity of the  symp-
toms being merely the efforts made by the vi-
tal resistance of the constitution in endeavour-
ing to overcome the morbid changes  which op-
press and ultimately overwhelm it.
  20. It has just been remarked that, when the
infectious  agent is  very powerful relatively to
the constitutional powers of the  patient, the
attack may then be so violent, and its subse- 
.GASTRIC—Description.
 158                  PESTILENCE, H.EM A

quent course  so malignant, as to deprive the
vital energy of all power of reaction.  In  this
case the invasion  is sudden and severe, and is
attended by general tremour, dread, terror, or
despondency ; the vital depression of this pe-
riod passing into vital  and  even structural dis-
solution, with greater  or less rapidity, and ei-
ther with no attempts at reaction, or with weak
and abortive efforts merely ;  the symptoms of
the first period insensibly passing into those of
the third. .  In  those cases,  which are much the
most  numerous, in which  reaction or excite-
ment occurs, and which are generally met with
in the young, robust, plethoric, and in persons
whose health has  been previously good, the
following division  of the periods of the distem-
per, with their chief characters, may be made.
  21.  First Period—or that of invasion:  Char-
act.—Chills, rigours, or shivering, or alternation
of chills and  heats; headache, with  pains in
the loins and limbs; fear and timidity ; univer-
sal trembling ; tremour of the tongue when held
out, and inexpressible terror in the most severe
or fatal attacks.
  22.  Second  Period—or that of vascular reac-
tion and excitement: Charact.—Very  frequent,
full, broad, or  bounding, but soft or very com-
pressible pulse;  a loaded and pasty tongue,
with redness  at the edges and point; caustic
heat of surface ; rending or throbbing headache,
with red, suffused, protruding, and brilliant eyes;
pain at the epigastrium and anxiety at the prae-
cordia ; racking pains in the loins and limbs;
tossings  and  watchfulness;  general redness,
turgidity, and suffusion of the face  ; sometimes
delirium ;  vomitings and thirst, obstinate cos-
tiveness, and scanty, pale stools.
  23.  Third Period—or that of vital exhaustion:
Charact.—Often an amelioration of the above
symptoms  during  the  third or fourth day, fol-
lowed by an increased frequency of vomiting;
a lemon  hue  of the skin,  with dirty, lurid, or
livid patches as this stage advances,  the mat-
ters ejected becoming in some instances black ;
distressing singultus;  low or muttering delir-
ium, or resignation or apathy to the result, or
a  desire of dissolution ; quick, small, feeble
pulse, which is sometimes at last irregular, in-
termitting, or  slow; raw, red, livid, moist, or
dry, and clean  tongue; faintness, especially
on moving; loss of temperature in the surface
and extremities ; irregular, laborious, deep, and
moaning respiration, the expired air being raw
and colder  than natural; scanty or suppressed
secretion of urine;  small, black,  watery,  and
involuntary stools; exudations of blood from
the mouth, nostrils, anus,  vagina, &c.;  a pe-
culiar offensive odour from the body and  evac-
uations ;  the appearance of large  livid or  dis-
coloured  patches,  terminating in  dissolution,
with marked  putridity,  the  body exhaling  a
tainted odour.*
  24.  vii.  The duration of these stages is va-
rious.   The first is seldom longer than a few
hours ; but it may be hardly of an hour's dura-
tion, or so slight as not to attract particular at-
tention.  The second stage varies  from two to
three days—it is seldom longer, and it may be
even shorter than  the time named.  It may be,
as above noticed (§ 20), altogether wanting, or

  * [The peculiar offensive odour and " putridity" of which
Dr. Copland speaks have not been noticed by writers on
the disease in this country.]
imperfectly manifested.   The  duration  of the
third is still more indeterminate. It may be only
a few hours, or it may be two or three days, or
even somewhat longer, it altogether depending
upon the violence of the  attack and the powers
of the constitution.  In slight or favourable ca-
ses, this stage may not be remarked, or mere-
ly a few of the milder symptoms may only be
noticed.  In the most severe  or fatal  cases,
this stage follows closely upon the first,  and is
attended by most of the  malignant  symptoms
just enumerated, as early as the second or third
day; and in some epidemics by others, but oc-
casionally only.  The whole duration of the mal-
ady varies from three to eight or nine days,
but in  rare instances it has been protracted to
ten or twelve  days.
  25. viii.  The sequela ascribed to the distem-
per by some writers deserve notice, only to ob-
serve that I do not  believe in their existence.
The debility consequent  upon  the attack can-
not be justly viewed as belonging to this cate-
gory, more especially as convalescence is gen-
erally rapid and complete.  The visceral con-
gestions, obstructions, and enlargements men-
tioned as sequelae of  yellow fever by several
authors rarely or never occur after the true
haemagastric distemper, although they are  fre-
quent  after severe  forms of  remittent  fever
(see Fever, §  237, et seq.), attended  by yellow-
ness of skin.   They have been mentioned in
connexion with haemagastric pestilence, owing
to the circumstance of it, and  the worst cases
of the  seasoning fever of hot climates, and of
remittent fever, having  been confounded with
each other  by these  writers.   This  circum-
stance also explains much of the imputed  fre-
quency  of relapse in this pestilence ;  for the de-
bility attending convalescence or recovery from
it, renders the patient  predisposed to be affect-
ed  by the miasmata causing remittent fever;
and hence,  when haemagastric fever prevails,
as it usually does, in  situations where remit-
tent fever is endemic, and in seasons when it
is most prevalent and malignant, recovery from
the former malady is extremely likely to be fol-
lowed  by an  attack of the latter ;  and, more
than this, the  one disease is very liable  to be
mistaken for the other.
  [The symptoms of  yellow fever,  as it pre-
vailed in this city in 1822, have been described
with great accuracy and minuteness by Dr. P.
S. Townsend, of New-York,  from his own
careful and repeated observations ; and as they
differ in some  respects  from those detailed with
such particularity by our  author, we present a
brief analysis  of them  in this place.
  The  invasion of the disease was generally
sudden, and at night ;  sometimes in  the morn-
ing, and most  usually  like that of an ordinary
fever, with, or sometimes without, chill: gap-
ing, yawning,  loss of appetite, languor, hurried
respiration, faintness, nausea, and in some in-
stances vomiting of bilious matter, or rejection
of drinks and  food ; most usually acute pain in
the head and back, and  sometimes violent affec-
tion of the nervous system and severe rigours.
First stage.—In this stage there was common-
ly considerable'  excitement, especially in full
habits, and nervous or sanguine temperaments;
severe  pain in the head, especially the fore-
head, back, and loins, often extending down to
the calves of the leg.   The eye was usually in- 
PESTILENCE,  HAEMAGASTRIC—Descriptiqn.
159
flamed, and tinged or swollen, and often at the
same time dull and  suffused with tears, and a
drunken  appearance, the interstices  between
the red vessels of the adnata remaining white,
and  the  cornea natural or  uncommonly brill-
iant.  In some cases the adnata was so crowd-
ed with blood-vessels as to  appear bloodshot;
after a while the eye assumed a deep  greenish
and dirty yellow colour ; but in some instances
it was almost natural in appearance.  In a few
instances the pupils were unusually dilated, and
in others the eye was intolerant of light.
  The tongue  was generally thick  and some-
what swollen,  more frequently  pointed  than
broad ;  most usually, in the beginning, covered
with a dirty white or lead-coloured fur, darker
towards the base. In some instances the tongue
was besmeared with a thin, white, moist slime
or paste, until towards the  termination of the
disease.
   The pulse varied from 90  to 120, and in  chil-
dren 150 ; sometimes it was as low as 80, 60,
and 55 from the beginning of the attack,  in
which cases the  stage of excitement had not
existed  at all; it was  generally full, but not
strong.  Where the pulse was unnaturally slow,
the skin was cool from the beginning.
  The skin was flushed, generally hot, and some-
what dry, in this  stage ; the degree of temper-
ature corresponding with the force of the cir-
culation ; often moist throughout, and  rarely, if
ever, characterized by the biting, stinging heat
and dry surface of typhus.
   Respiration hurried, in proportion to the vio-
lence of the excitement, and almost invariably
attended with deep sighing.
   The bowels were generally constipated in this
 stage, but after they had been opened  the evac-
 uations continued, often natural  in colour and
 quantity, without fetor, but  rarely bilious,  soft,
 or liquid during the  whole  progress of the dis-
 ease.
   The stomach was usually calm, but sometimes
 a constant nausea or sense of oppression at the
 praecordia, accompanied occasionally with  eruc-
 tations  and  cardialgia ; and  sometimes  great
 gastric distress from the beginning of the at-
 tack, producing violent spasms and retraction
 of the abdominal vessels and legs on the slight-
 est pressure.
    Urine variable ;  often natural in every re-
 spect, but in  many cases scanty and high col-
 oured ;  in some few copious and natural.
    Countenance.—Most   usually   natural  and
 flushed ; often a wild stare  and gaze of the
 eye, but often entirely natural to the  last.
   Position and Actions of the Patient.—Invariably
 lies on his back, and has an  inclination to throw
 his arms above his head.
   Intellect generally undisturbed ; occasional
 delirium, attended  with  coma,  if the excite-
 ment was great.
   Second stage.—In some cases the first  stage
 was protracted till the fifth day, but most usual-
 ly it continued from 24 to 48, or even 72 hours,
 at which time there came on a sudden prostra-
 tion of all the animal forces, producing a  state
 of collapse.
   The countenance  is more  or  less  pale and
 shrunk, and  the patient  becomes calm and
 composed, and, though languid and debilitated,
 entirely free from pain.
   The blood retires to the internal organs, and
there is a strong tendency to haemorrhage from
loss of tone in the contractility of the capillary
vessels and the dissolved  state of the  blood.
The  eye loses its red colour, begins to assume
a yellowish hue, first at the outer angles, while
at the same time the yellowness extends down
from the alae of the nose  to  the angle  of the
mouth ; also around the eyes and  borders of
the lips, and between the  lower lip and chin.
The tongue.—The fur often remains moist, and
still  of a dirty  white  or  leaden colour, but it
most usually accumulates and becomes, at the
same time  with or before the adnata, of a
brownish-yellow hue, and  dry and darker  to-
wards the base, surrounded almost invariably
by a moist, clean, red, or livid margin, extend-
ing along the sides  and round  the apex  of the
superior surface ; the papillae on the apex also
frequently inflamed and swollen.  The  lips  at
this period are  most usually dry and cracked,
or somewhat parched ; while the pulse sinks  to
90, 80, or 70, rarely lower, varying a little more
or less, from day to day, becoming at the same
time soft and easily compressed.  It was never
observed to be  intermittent but in a single case
attended by Dr. Francis.   The skin became
comparatively cool, but still retained a  higher
temperature than natural.   The heat and mois-
ture of the surface  were  unequally distributed,
the feet and hands often becoming  cool, while
the body over the epigastrium was preternatu-
rally warm.  In a great majority of cases,  es-
pecially those of a  mild character, the yellow-
ness did not extend farther than over the face,
blending with the  partial flush which still  re-
mained, giving the countenance a yellowish
red or damask hue.  But in the severest cases
it became  of a greenish  hue, and extended
down the sides of the  neck, over the scalp, to
the chest, shoulders, and  arms, gradually grow-
ing deeper, and spreading over the trunk on the
eighth, ninth, and tenth days, but not reaching
the lower extremities until just before or even
after death.  When this colour is perfectly form-
ed, it has, if the complexion  of the patient  be
fair, a pale lemon colour, and  is of  a greenish,
mottled, or bruised appearance ; in some  in-
stances darker, and  resembling a vegetable
stain ; in others the appearance of a dead body
which has begun to putrefy.   Where the deep
yellow tinge spread entirely over the trunk, the
disease proved almost invariably fatal.   Pete-
chiae about the  forehead,  cheeks, and neck,  es-
pecially on the  backs of the hands, and  on the
arms and chest, were often observed, and occa-
sionally a vesicular eruption about the corners
of the mouth.
  The respiration  continued perfectly natural
and easy, except that the  sighs became deep,
long, and frequent.  The stools occasionally be-
came fetid and dark, but  often remained natu-
ral to the last.   At this stage of the disease the
patient began generally to reject his drinks and
medicines, and about the third or fourth  day of
the disease to complain of a  soreness, tender-
ness, slight burning, or irritability at the pit  of
the stomach, pressure over which caused great
distress, as well as  very cold or hot drinks ;  at
the same time,  the heat seems to be concentra-
ted in the region of that organ.  In most cases
this  irritability was unaccompanied with nau-
sea, but sometimes there were distressing flat-
ulence and cardialgia from the beginning of the 
160                  PESTILENCE, HAEMAGASTRIC—Description.
disease.   The urine was  now generally dimin-
ished,  and of a deep yellow colour, where the
yellowness had extended over the  trunk, and
sometimes it was entirely suppressed for a few
days;  mostly a fatal symptom.
  The countenance was usually more or less anx-
ious and melancholic, or marked by an expres-
sion of pensive  sadness ; hardly ever  entirely
deprived of its florid colour, though somewhat
modified or changed to a damask hue, by being
blended  with the yellow.  The  intellect was
often more or less affected ;  sometimes mutter-
ing delirium was present, but never long con-
tinued ; also more or less coma at times ; most
usually constant pervigilium, occasionally inter-
rupted by dozing;   the eye frequently had  a
wild, fixed gaze, and the patient appeared inat-
tentive to what  was passing;  disinclined  to
talk, but always promptly answering questions.
Convulsions occurred in one case only.
  Third stage.—This stage continued from two
to four, five, six, or even to seven or eight days.
The transition from the second to the third
stage is much less perceptible than from the
first to the  second ; the symptoms being all
rather aggravated than changed.  The counte-
nance becomes more anxious, the adnata of the
eye of an unnatural green-yellow of the deepest
hue, and entirely clear of red  vessels, which,
contrasted with the brilliant colour of a blue or
hazel cornda, gives  the look an unnatural and
grotesque appearance.  The wild stare is rarely
seen at this period.
  The aspect of the face does not materially
change, but the yellowness  in fatal cases, and
sometimes in severe cases  that recover, grad-
ually extends down the body and limbs.  Occa-
sionally there is  furious delirium;  and some-
times the skin, circulation, and  other  organs
all appear to assume their natural and healthy
functions.   Exacerbations and remissions,  as
the frequency of the pulse,  heat of skin, &c,
were frequently observed,  giving the  disease
somewhat the character  of a remittent.  The
extremities now begin to loose their heat entire-
ly, and are covered with a cold, clammy moist-
ure, which finally extends  over the forehead,
shoulders, chest, and thighs, the surface at the
praecordia still retaining its heat. The tongue
cleans, or sloughs off, and becomes  dry, and of
a fiery, deep red colour, sometimes moist, but
very  frequently  having  its  surface  parched
brown towards the  base, and rough to the feel.
The gums and inside of the lips become spongy,
and  of a deep florid red colour, while the lips
externally, perhaps, are pale or livid.  Blistered
surfaces now become red,  as  if inflamed, and
in many cases the  conjunctiva lining the eye-
lids becomes deeply injected with blood.   Blood,
also, of a bright florid hue and watery consist-
ence, distilled, in many cases, from the gums
and  nose,  and besmeared the  tongue,  or be-
coming dry on the teeth and  lips, incrusted
them with a  black sordes.  If the stomach be-
come more irritable, as most usually happened
at this period, the patient complained of a dis-
tressing  burning,  and  incessant, though not
acute,  or darting sensation at the  praecordia,
causing him to wince or cry out on the slight-
est pressure.   Sighs are more  frequent, also
hiccough.  The distress and burning sensation
at the stomach generally increased about the
sixth, seventh, or eighth day, the patient reject-
ing every thing swallowed ;  he now begins to
vomit up, from time to time, a reddish-brown,
turbid-looking, insipid, and perfectly inodorous
matter, resembling coffee-grounds, or blood that
has undergone partial change.   In  this coffee-
ground matter was often observed transparent
pieces of gelatinous matter,  here and there
streaked or tinged with  florid red blood*
  The alvine discharges, which had been dark
and  offensive at first, often became  perfectly
natural in smell,  colour, and quantity, and con-
tinued so to the  last; there was nothing par-
ticularly offensive in the breath, sweat, stools,
urine, or other excretions, as in typhus; nor
was there any foul cadaverous effluvium from
the body, as in that disease.   The restlessness
and  inquietude now  increased in fatal cases;
the face, cheeks, and lips became bloated and
livid, and the respiration hurried and painfully
laborious, as in some cases to resemble asthma ;
the muscular strength is wonderfully retained,
so that the patient is often able to walk about a
few moments before dissolution ; while the in-
tellectual faculties, though somewhat obtunded,
are still retained in comparative integrity to the
close of life.  Frequently the patient lay tran-
quil  and unconscious of danger, and  expired
without a struggle.  As remarked by Dr. Rush,
" in some the last hours of life were  marked
with«great pain and strong convulsions, but  in
many more death seemed  to insinuate itself
into the system with all the  gentleness of nat-
ural sleep."—(See Townsend on Yellow Fever,
p. 143  to 168.)]
  26. II. Appearances after Death.—These
vary remarkably  with  the form  and character
of the malady.—A.  In the most malignant and
rapidly fatal cases, a lemon tint of the  surface,
with livid or dark blotches, is generally observ-
ed.   The ears, fingers, penis, scrotum, and  in
some the hands  and  arms soon become of a
dark or brownish hue.  The muscles are softer
and  flabbier  than natural, of a dirty or dusky
hue, and are  easily  broken down by pressure.
The substance of the heart is similarly changed.
Softening or  greater friability  of the  tissues,
soon after death, is generally remarked, and  is
extended to  all the organs and viscera.  The
body seldom appears to  suffer any  diminution
of its bulk,  as in  other  fevers ;  and when the
  [*  '"When the coffee-ground matter," says Dr. Town-
send, " was examined by the solar microscope, it appeared
to be an inorganic mass.  Strained through course linen,
and dried on paper, it retained its dark brown and red col-
our, and, by the mucus which it contained, adhered to the
paper in streaks.  When the residuum of the fir-st straining
had been passed through fine  muslin, and an impression
taken off with white paper, I found it to be of a dark-brown
powder in fine particles, resembling minute scales of smoky
mica, both in the colour, feel, and general appearance.  I
am inclined to believe that the  matter of black vomit con-
sists chiefly of the red globules of the blood, which, from
the dissolved condition of this fluid when poured out fmm
the exhalants, have easily separated from the other constit-
uents, and become decomposed, or disintegrated by lying
in the stomach, or by the action of the gastric juice or other
secretions of this organ.  There is also more or less of the
same  kind of dissolved blood, which oozes from the gums,
nose, &c.  We see, also, that this blood, which distills from
the nose and gums, acquires the  same colour as black vomit,
but liecomes dry on the  lips and teeth, in consequence of
exposure to the air ; whereas the matter of black vomit ii
held in a fluid state by the heat and secretions of the stom-
ach.  Sometimes the formation of the matter of black vomit
is first announced in the alvine discharges, succeeded sood
afterward by the ejection of the same matter from the stom-
ach."—An Account of the Yellow Fever as it prevailed in
the City of New York in 1821, p. 153.  By P. S. Towm-
send, M.D.] 
PESTILENCE, HAEMAGASTRIC—Description.                 161
fatal issue has been rapid, and the quantity of
black matter vomited not very great, the sev-
eral  viscera  are more or less  congested, and
the body seems even more tumid than natural,
as well as discoloured,  presenting  a marked
putrid or malignant aspect, and  indicating a re-
markably rapid loss of the vital  cohesion of the
several textures.  In such cases as present any
diminution of the bulk of the body, the muscles
are paler, softer, and  more flabby than  usual;
the viscera paler and softer, and even some-
what shrunk; and the blood-vessels contain
very little blood.  In these cases, a very large
portion of the blood has been exuded from  the
digestive mucous surface, and been thrown off
during life, in the  form of black vomit, or of
passive haemorrhages from the  alimentary and
other canals.
  27. The liver  is changed chiefly as regards
its cohesion  and degree of congestion.  It is
almost always softer and more friable than nat-
ural  ; in some cases  congested, in others pale,
according to  the quantity of blood evacuated
during life, in the form of black vomit.   Light
olive-coloured patches are sometimes observed
in it. The gall-bladder most frequently is shrunk,
and contains  little or no bile.  The spleen and
even the pancreas are somewhat softened ; and
the former frequently congested.   The asopha-
gus and stomach present discoloured streaks or
patches, of a dirty purple, dark, or livid colour,
in their mucous surface, and the latter viscus
often contains more  or less of a similar fluid
to that constituting the black vomit.   In cases
where the quantity of this fluid thrown off  has
been great, the stomach, intestines, and other
viscera are  paler, but also  much softer than
natural.  The small and large intestines are oft-
en contracted in parts, and occasionally intro-
suscepted.   In other respects  they offer  the
same appearances as noticed  in the stomach,
but in a less degree.   They often contain small
quantities of fluid  similar to that voided short-
ly before death ; but this presents  neither a
bilious nor a faecal character.   The epithelium
of the digestive mucous surface seems to be
more or less detached  in the  several portions
of the  canal;  and the mucous  membrane is
softened and readily separated from the  ad-
joining tissue.  The follicular  glands are  not
prominently  affected, farther than being some-
what enlarged in some instances.  In  those
cases which present congestion of the chief or-
gans, as of  the brain,  lungs,  auricles  of  the
heart, liver, and kidneys, slight serous effusion,
sometimes sero-sanguineous,  is occasionally,
also, found in the chief cavities,  particularly the
pericardium  and arachnoid, and  but rarely in
the peritoneal and pleural cavities.  The urin-
ary bladder is always empty and contracted.
  28. B. The more protracted cases of this pesti-
lence present  changes depending much upon the
symptoms during life, and most upon the con-
tinuance or amount of black vomit, and of black
fluid discharged by stool.  In many instances
the  appearances  found agree  in all respects
with those above described.  In others, the liver
and  spleen are remarkably congested and soft-
ened.  In some, the liver is changed more or
less  in colour as well as softened.  It is often
of a  pale olive hue, or it presents a mixture of
yellow and green, and of dark green in streaks.
Arkjula mentions a change of colour in the
     III              11
liver to a reddish brown.   But the other chan-
ges detected furnish no evidence of inflamma-
tory action in  this organ.   Dr. Gillkrest no-
tices a remarkably pale colour of the liver  in
females and children, and  a marked absence of
bile from  the  biliary ducts.  The gall-bladder,
however,  frequently contains bile of a  thick
consistence and dark, tar-like appearance.  The
stomach often contains  the matter of the  black
vomit.  Its mucous surface, as well as that of
the duodenum and oesophagus, is frequently dis-
coloured in patches, in a few instances  paler
than usual, and in  all much softened.  The ep-
ithelium of these parts is generally detached ;
and Dr. Jackson remarks that  he has found
the villous coat often  abraded, loose, and par-
tially  separated.  A black, jelly-like substance
is sometimes found in the intestines.  Dr. Gill-
krest  states that this  substance is sometimes
found in the jejunum, but  oftener in the ileum,
and that  it is occasionally found in both the
stomach  and  the  ileum, the intervening jeju-
num not presenting a trace of it.  He  adds,
that he has found this substance in these sit-
uations even  in cases where no black vomit
had existed before death.   The glands of Pey-
er are generally unaffected.   The villous sur-
face of the colon and cacum is generally soft-
ened, discoloured in parts, and covered by an
adhesive black substance.  Frequently, on  re-
moving this substance, the membrane under-
neath is seen paler than natural.  In a few ca-
ses, the fluid  contained in the bowels is of a
reddish tint, and more nearly approaches the
appearance of blood.   The intestinal canal is
often irregularly contracted in parts, more rare-
ly  with portions introsuscepted, and in  some
instances, in addition to the matters now men-
tioned, an albuminous, dirty pale substance is
found in the colon.
  29.  The states of the heart and lungs depend
chiefly upon the quantity of blood exuded du-
ring the last stage  in the form of dark vomit.
When very much has been evacuated, but  lit-
tle change of these organs is observed beyond
collapse and softening.  In other cases  more
or less congestion is frequent, the blood being
fluid,  grumous,  but not  always  very   dark.
False polypi are sometimes found in the  cavi-
ties of the heart.   Within the cranium conges-
tion  is the most common change,  but this is
not constant.   Occasionally slight opacity  of
the arachnoid, with slight serous effusion, and
in rare instances, sero-sanguineous exudation,
are remarked.
  30.  These are the chief alterations found  in
cases of true haemagastric pestilence, when the
examination has been made a few hours  after
death ; but farther changes take  place, and are
often confounded with  the foregoing, when the
inspection has been delayed even some hours
later.   The disease is rarely observed, except-
ing in such high ranges of temperature as pre-
clude  delay in  post-mortem examinations, if the
changes which appertain to the disease are the
objects of investigation.  Doubtless, however,
the circumstance  of rapid dissolution of the
structures  after death, and the ascertainment
of the parts which are the first to experience
such rapid change, are matters of great mo-
ment in estimating correctly the  nature of the
malady ; and so highly do  I consider their im-
portance, that  I am desirous to direct more at- 
162
PESTILENCE, HAEMAGASTRIC—Diagnosis.
tention  to  them  than they have  hitherto re-
ceived.
  31. III.  Diagnosis.—From the  description
now given, it will be perceived that sporadic,
occasional, or scattered cases of  this  distem-
per,  and the earliest of those occurring when
it assumes the form of a devastating pestilence,
will  often be recognised with great difficulty,
and  be  liable to  be mistaken  for the  more
malignant cases of remittent fever (see  art. Fe-
ver, § 233, et seq.); or even for the inflammato-
ry seasoning fever (§ 359, et seq.) to which Eu-
ropeans are subject when  they  migrate  to in-
tertropical or warm climates.  The difficulty is
chiefly owing to the mildness of the symptoms
in some instances, and to the circumstance of
yellowness of the skin, and vomiting of a dark
brown  or black fluid being observed in many
of those cases as  well as in the true haemagas-
tric disease.  The mild character of the symp-
toms in  some  persons, the disease appearing
merely as an ephemeral fever, or in a form but
little more  severe, is analogous  to what  is ob-
served in respect of other  infectious maladies,
which  frequently  assume  a most malignant
character, as smallpox, scarlet fever, &c.; nev-
ertheless, the  infectious effluvium proceeding
from mild cases propagate the malady equally
with that  from the  most virulent, and often
give rise to the latter, while the latter frequent-
ly occasion  cases of the former character, the
violence of attack depending chiefly upon the
predisposition of the individual affected.
   32. There are certain phenomena which serve
more especially to distinguish this pestilence
from the malignant cases  of fever with  which
it has  frequently been confounded, and from
which  it is distinguished with great difficulty,
especially in warm climates and localities, and
in hot seasons.  The former is more silent, in-
sidious, yet rapid in its course ; the latter more
open and phlogistic.  As soon as  the body ap-
pears to be infected by the haemagastric dis-
temper,  there  are furnished indications  of a
greater or  less shock sustained by its vitality,
and  of  a marked contamination of the circu-
lating fluids, and even of the soft solids ; and
these indications  appear earlier and more de-
cidedly  in  this distemper than in the  fevers
for which it is liable to be mistaken.  Jactita-
tion, mental depression, apathy or delirium, ap-
pear much  earlier, and in a more marked de-
gree at the outset.  The  lemon colour  of the
skin is  also earlier; and such also is  the case
with the nausea  and vomiting,  which is more
distressing  than  in those, and the quantity of
fluid thrown off, at first, and sometimes through-
out, colourless, or nearly so, is much more con-
siderable, without reference to  what has been
taken into the stomach.  It is evident that the
fluid ejected is chiefly an exudation  or  secre-
tion from the stomach ; that its great amount
must more or less diminish the serous portion
of the  blood;  and  that in those  cases  which
are  attended by black vomit and discharges of
blood from mucous canals, the diminution of,
and other changes in, the blood,  must be still
more considerable.  In these, more especially,
the  vomitings often occur without retchings or
effort.
   33. The  character of the pulse  is of  impor-
tance ;  and in respect of it, the  rapid rise in
frequency soon after the attack ;  the  soft and
asthenic condition ;  the  weakness, inequality,
irregularity, and  subsequently  the  slowness,
the intermissions and smallness of it, are more
or less remarkable.  The red, suffused state of
the conjunctiva, with brilliancy of the eyes in
the young and robust, but without this brillian-
cy in the aged, and at an advanced stage;  the
lurid redness  or  suffusion of the features, in
the former class of subjects, and the depressed
and anxious expression in all; the severe pain,
deep in the orbits, and the drunken-like appear-
ance of the  eyes ;  the red,  raw, clean, and
smooth, or bloody state of the  tongue ; the pain
and soreness of the throat, pharynx, and along
the oesophagus ; the acrid burning sensation at
the stomach, constriction in the chest, and anx-
iety and burning  pain at the  praecordia;  the
thick, compacted feeling furnished by the skin,
the diminution of its sensibility at  an advanced
stage,  and the dingy tint of it,  with leaden or
livid patches, at last; the singultus ; the scan-
ty secretion, or complete suppression of urine;
the costiveness, absence of bile  from and state
of the  stools ;  and the flaccid, leucophlegmatic,
swollen, and  pallid appearance of the soft sol-
ids, without very evident emaciation in most
instances,  but with  an  appearance  of morbid
plumpness, or turgidity in the more malignant
and rapidly fatal cases,  serve farther to distin-
guish the malady.
  34. Vibices and livid patches are character-
istic both of the pestilence itself, and of the ad-
vanced and fatal period of it, and  depend upon
the alteration  that has taken place in the con-
stitution of the blood, as well  as in the vitality
of the  capillary vessels,  both venous and arte-
rial.  The delirium is generally different from
that observed  in  the worst  forms  of remittent
fever.   It is characterized by  a peculiar imbe-
cility,  fatuity,  and apathy, and by  faultering of
the voice,  or stammering.  Furious or violent
delirium rarely occurs unless in the early stage
of febrile excitement.  The pupils of the eyes
are usually dilated, especially during an  advan-
ced period of the malady, and frequently even
at an  early stage, when the  conjunctiva and
countenance are suffused and  injected—a state
of the  pupils which is not observed in  yellow
remittent fever.   The pains in the legs are also
different from that complained  of in other fe-
vers, and are  generally  felt  where the gastroc-
nemii  and soleus  muscles unite  to form the
tendo  Achilles.
   35.  The yellowness of the skin, in the haema-
gastric pestilence, is either a  pale yellow or a
dingy  tint, often  presenting patches of a dirty
yellow or livid hue : in the yellow remittent fever
the colour is more complete and deep than in
the former, and  more manifestly  the result of
biliary disturbance ; while the discoloration of
the pestilential malady arises from vital exhaus-
tion, manifested  chiefly in  the  capillaries and
in the blood  itself.  M.  Guyon  very justly re-
marks, that in the latter the  colouring of the
skin is owing to the presence of blood  which
stagnates  in the capillaries, or which escapes
from them, and is nothing else  than the tinge
of a contusion;  while in the remittent fever
the colour is owing to the presence of bile, and
is that of true icterus.   This  alteration  of the
blood and of the vital condition of the capillaries
is evidently the source of the  black vomit, and
of the dark colour of the evacuations, in the 
PESTILENCE,  HAEMA<
last stage.   The singular spasmodic force with
which the fluid is often ejected from the stom-
ach ; the presence of hiccough when  the dark
matter is less  copiously thrown off;  the pecu-
liar dark stain which this matter imparts  to
linen, and which is  not easily removed; the
raw and unpleasant  odour, which, as Dr. W.
Barry remarks, " is  so peculiar, that, on enter-
ing the chamber, the state of affairs  becomes
immediately manifest," serve farther to distin-
guish the malady.  The early appearance of a
dingy yellowness on the  neck and chest, and
the state of the patient's mind, even when there
is no delirium, are also worth remarking.  The
sufferer  is  generally either unconscious,  or
quite indifferent to his hopeless condition, and
expresses himself as being much better, until
vitality, receding from the extremities and ex-
ternal surface,  ceases altogether in the central
organs.  During the last flickerings of the ex-
piring flame, there are often  observed incohe-
rent expressions, violent straining of the eye-
balls, and convulsive motions, rapidly passing
into dissolution.
   36. About the end of the second day, or du-
ring the third day, the patient begins  to com-
plain of a violent pain in the testes, with con-
tractions of the spermatic chord towards the
abdominal  ring.  On examination, the testes
feel much diminished in size, are drawn towards
the  abdomen, and the scrotum is flaccid and
empty.   The surface of the scrotum soon after
becomes very painful, and an excoriation  takes
place on the surface, chiefly of the most de-
pending part, from which  much offensive puri-
form matter issues.  At the same, time a sim-
ilar discharge often  takes place from the ure-
thra, which ceases  as the symptoms become
favourable,  but which becomes bloody, ichor-
ous, and insufferably fetid, when dissolution
ensues.  The most  violent attacks are gener-
ally attended, in the last stage, by an  offensive
and ichorous discharge from  both the scrotum
and the penis,  these parts frequently becoming
more or less sphacelated and gangrenous short-
ly before death.
   37. A. Besides the diagnosis depending upon
the presence of certain symptoms character-
izing the haemagastric pestilence, which  are
not observed in the  worst forms of remittent fe-
ver, the origin  and course of the former, com-
pared  with  those of the  latter malady, should
not be overlooked.   Malignant or bilious re-
mittent  fevers, even  in their most intense
grades, proceed entirely from malaria, or ema-
nations from  endemic sources of disease of a
more or less  concentrated kind (see Endemic
Influences),  and present more or less marked
remissions.  In many of the situations furnish-
ing these emanations, dead animal matter, as
well as dead vegetable matter, aided by a deep,
rich, absorbent soil and  great humidity, per-
forms  an important part.  Still  the  resulting
malady does not produce a specific  effluvium,
capable of itself to propagate a similar disease,
at least in ordinary circumstances ; and if ever
such a phenomenon occurs,  it can take  place
only under  peculiar  circumstances, which fur-
nish a new and  superadded cause,  as shown
above  ($ 12,13), this cause giving rise to a very
different malady from that  which arose from
endemic causes, however concentrated or in-
tense.
GASTRIC—Diagnosis.                  163

  38. On the other hand, the haemagastric pes-
tilence appears independently of endemic or ter-
restrial sources or malaria, and proceeds from
an infectious or contagious poison, which, how-
ever formed originally (see, hereafter, $ 139, et
seq.), infects the healthy by contaminating the
air immediately  surrounding  those  already af-
fected ; or which, being absorbed and retained
by other bodies (as shown in  the article Infec-
tion, $ 16, 17), is  afterward given out from
them on exposure to the air, thereby contamina-
ting and infecting the air and adjoining objects.
  39. The course, also,  of haemagastric pesti-
lence is generally different from that of yellow
remittent fevers.  The former malady is not
only much more sudden in its seizure,  but also
more insidious,  silent, continued, and rapid  in
its course than the latter.  The one, even in its
most intense grades, as I have observed them
in Africa, where they are most malignant, very
rarely ending  fatally before the eighth, ninth,
or tenth day ;  the other generally terminating
life before the first of those days, and frequently
as earlyas the second day.  Mr. Fraser, whose
experience of this pestilence in Gibraltar was
frequent and extensive, observes that a variety
of very striking symptoms, rarely seen in the
fevers of the  country—such as tremours and
nervous agitations; singultus;  extraordinary
mental  aberrations; an  unexampled range  of
haemorrhages ; affection  of the urinary evacu-
ation, vomiting becoming seemingly vicarious
of urinary discharge ; a peculiar odour percep-
tible on approaching the  sick, this odour being
presumed  to  occasion  the  infection  of the
healthy ; quick and perfect recoveries from vio-
lent attacks, with little or no risk of relapse, or
of  consequent visceral  diseases—sufficiently
distinguish  this  malady  from all others.   He
farther adds, that the seizure of this malady is
characterized  by peculiar dejection of counte-
nance, pain in the orbits, often attended  by a
peculiar delirium, similar to the effects of nar-
cotics,  or of  poison on  the  nervous  system,
causing algor, tremour, anxiety, sighing, singul-
tus, and sudden death.  The course  of it, he
says, resembles that of the exanthemata,  viz.,
a synochal stage of sixty hours, suddenly ter-
minating in apyrexia, or running into malignant
or putrid symptoms, unattended by remissions,
but with vespertinal exacerbations, and with a
fallacious calm, similar  to that which marks
mortification,  and closing  generally,  in fatal
cases, before the seventh day ; recovery pro-
tecting from a second attack.  While, on the
contrary, endemic or yellow remittent fever is a
disease of high arterial action (fn the Mediter-
ranean), with  that turgescence of countenance
which usually attends pneumonia, with a  gen-
eral sense of fulness in the encephalon, and
throbbing of the temple, hut with little delirium;
is much more prolonged in its course, and ac-
companied with  heat of surface, and often with
bilious  yellowness ;  sometimes  terminates  in
intermittent fever,  or in visceral  disease;  is
very  prone to relapse, and second  attacks are
common.  (See art. Fever, y 225, et seq.)
  40. It is not  only upon  the characteristic
symptoms, continued type, and course of this
pestilence, compared with those of remittent
fevers,  that the  diagnosis is to be based, but
also upon the  cause, origin, and propagation of
it—upon its infectious nature—infectious in the 
AGASTRIC—Diagnosis.
164                   PESTILENCE,  HAEM.

sense which I have attached to the term (see
art. Infection, $ 13, 16), or contagious, with-
out direct or  immediate contact between  af-
fected and healthy persons ;  a property  admit-
ted not to exist in respect of remittent fevers,
even of the  worst forms.  This subject, how-
ever, as it involves the most important consid-
erations, and as having called forth the most
virulent and ungenerous discussions, will  re-
ceive a fuller consideration in its more  appro-
priate place.
  41.  B. Haemagastric pestilence differs from
the plague, in  being attended  by more violent
febrile excitement; in  the absence of carbun-
cles and buboes, the lymphatic glands being en-
larged only in the most intense and fatal  cases,
and in  few instances only;  and in  the  occur-
rence of the black vomit, which  is very  rarely
observed in the latter  pestilence.   Undue im-
portance has been attached to the circumstance
of the former  appearing during  a high degree
of temperature, which  would put  a stop to
plague ; for, although haemagastric pestilence
generally requires a high range of heat,  still it
will often continue to  prevail, after it has be-
come  epidemic, during very temperate  states
of the  atmosphere.  Doubtless,  however, the
plague will continue to prevail during low ranges
of temperature—ranges which will altogether
arrest the progress of  the haemagastric pesti-
lence.
  42.  C. The  milder cases of this malady are
distinguished with great difficulty from common
continued fever, for some of these  not  infre-
quently assume the form of ephemeral fever, or
of simple inflammatory fever; others, that of
bilious or gastric fever ; others, that of the sea-
soning or ardent  fever of Europeans recently
arrived in warm climates; some resemble ad-
ynamic  fever,  and others true  typhus.  The
predominant affection  of a  particular organ ;
the more sthenically inflammatory character of
all the symptoms, especially  of the pulse ; the
more diffused pain in the head and forehead; the
states of the eyes, of the evacuations, and of
the skin, attending inflammatory fever, will read-
ily distinguish  it from this pestilence.   When
this fever occurs in  Europeans  lately arrived
in a warm climate, or assumes a more intense
form, or that of seasoning fever, the diagnosis
may be much more difficult;  especially  when,
as is not infrequently the case, much biliary de-
rangement and gastric irritability are present.
In these  cases the conjunctiva and skin may
become yellow; and blood may be  exuded in
some instances from the digestive mucous sur-
face, and impart a black grumous character to
matters ejected from the stomach, or evacuated
from the bowels.  Here the diagnosis is diffi-
cult, particularly when such cases occur only
occasionally.   Still, the close observation  of
even a few cases will enable the physician to
recognise the  character of the disease,  which
is always preceded  by distinct  praemonitory
symptoms, is inflammatory at the commence-
ment, and is attended  by a  free discharge of
bile—phenomena which are  not met with in
this pestilence.  Seasoning fever is, moreover,
of longer duration than this malady; and in
many localities, or during or subsequent  to the
rainy season, generally presents more or less,
or lapses  into, a  remittent type, and is often
followed by visceral  diseases — occurrences
which are  not met  with in the haemagastric
malady.
  43. D. Haemagastric fever can hardly be con-
founded with  typhus or typhoid fevers, for the
prominent symptoms, the course and duration
of each, are  altogether  different.  Dr. Ban-
croft, whose  writings on this pestilence, and
on the causes of pestilential diseases, have mis-
led the inexperienced, and long mystified many,
has stated the circumstances in which the for-
mer differs from the latter ;  but his statement
(see p. 51 of  his work) betrays a remarkable
ignorance both of true yellow fever and of ty-
phus.  Indeed, I doubt much his having seen a
case of true haemagastric fever when he pub-
lished his Gulstonian Lectures, delivered at the
College of Physicians in 1805,  and which con-
stitute the  substance of his  work on yellow
fever ; or, if he had seen any cases of this pes-
tilence, he must  have confounded them with
the more malignant cases of remittent fever,
as his remarks on the diagnosis, and  much of
his description of the former, are much more
applicable to  the latter  than  to it; indeed,
throughout his work he evidently confounds the
haemagastric malady with malignant remittent
fever, and considers them identical diseases;
for he nowhere  attempts to  distinguish be-
tween them ;  and he  merely points  out, in a
manner the most  imperfect, certain points of
difference between yellow fever, plague, and
typhus ; but in a way altogether worthy of the
Coryphaeus of the  non-infectionists.
  44. The  symptoms which  have been  above
enumerated (§ 7, et seq.) solely appertain to this
pestilence,  and so certainly indicate  it,  that,
should a patient present them in a country lia-
ble to be afflicted with it, or in an European
sea-port, holding  intercourse  with  parts in
which it is epidemic, during warm or temperate
seasons, we may be assured that a case of it
has occurred ; and this assurance should give
rise to measures hereafter to be indicated.  If
the case be a solitary one, or if only a  very few
such  occur—and if  isolation  and other early
precautions  be taken, this may be the result—
the fact may be disputed in the special-pleading
mode in which the subject has been  recently
discussed ;  and the more especially if the pa-
tients recover, or if no examination of the bod-
ies of those who have died has been made; for
in these the black vomit and several of the oth-
er pathognomonic symptoms  may have been
wanting.   The circumstance  of  the  disease,
particularly  when  epidemic,  frequently  assu-
ming  a mild form, should not be overlooked;
for  among  a certain number of cases at the
outbreak of the pestilence, a small proportion
may only present  the black  vomit, several of
the rest appearing only as a simple ephemeral
fever.  As M.  Louis  has well observed, in re-
spect of the Gibraltar epidemic of  1828, al-
though some of the symptoms of other diseases
are similar to those of yellow fever, the symp-
toms  taken  together, and their progress, are
very different.
  45. In typhoid  fevers  vomitings  are  rare,
while  in this  malady they are very common,
frequent, and urgent; and, in the worst cases,
they are peculiar (y 8).  Diarrhoea, more or less
abundant, occurs  in a large  proportion of the
cases of typhoid fever, and  often also at the
commencement of the disease  ; while an op- 
PESTILENCE,  HAEM AG A STRIC—Pr og no sis.
165
posite condition of the bowels is observed in
true yellow fever.  The stools are also very
different, both in colour and character, and are
never so dark or blackish as in the latter mal-
ady.  The form of the abdomen is  natural in
haemagastric fever; there  is usually more or
less meteorismus  in  typhoid fevers.  In true
typhus there is a peculiar eruption on the sur-
face of the body, a characteristic delirium and
other febrile symptoms, and extreme prostra-
tion, not observed in the other malady.  While
typhus and typhoid  fevers are  slow in their
course, the haemagastric pestilence is rapid.
  46. E. Gastritis may, in  some  circumstan-
ces, especially in warm climates, or when asso-
ciated with  hepatitis, be mistaken  for haema-
gastric fever.   In both diseases there are more
or less frequent vomitings, attended by burning
epigastric pains, anxiety, &c. ; but the duration
of gastritis is generally longer than that of this
fever, and the anxiety is less.  The yellowness
of the skin  is absent, unless when gastritis is
complicated with hepatitis  or with disease of
the biliary ducts ;  and when such is the case,
the yellowness is a true jaundice, and not that
of this pestilence.  Besides, the intense pain
of the orbits, the appearance of the eyes,  the
blackish stools, the suppression  of urine, and,
in fatal cases,  the black vomit of this  latter
malady, are not present in the former.
  47. In hepatitis  there is yellowness of the
surface, but with these  are also more or less
severe pains in  the right hypochondrium, and
an increase  in the volume of the liver, as may
be  readily ascertained by examination of the
trunk and by percussion, no  such increase ta-
king place in this pestilence.  Then the severe
pains in the orbits and the injection of the eyes
at the commencement, the anxiety, and the sev-
eral nervous symptoms, so constant in this lat-
ter, are not  observed, while the course of it is
so much more rapid than that of hepatitis.
  48. G. In fatal cases the post-mortem exami-
nations generally will decide the question as to
the existence of the haemagastric malady ; for
in them the presence of the peculiar black mat-
ter in the  stomach or intestinal canal, or in
both ;  the absence of material alteration of
Peyer's or Brunner's glands ; and the usually
yellow colour of the liver, independently of other
very manifest organic changes,  are  especially
characteristic of this malady.   M. Louis  ob-
serves, " that if the liver be found of a more
or less  pale yellow, its cohesion and consist-
ence natural or increased,  all doubts as to the
disease should be removed." But the consist-
ence of the liver is not infrequently diminished,
and  the  colour  of the liver is rather that of
rhubarb than a pale yellow, and is often such
as described above (§ 27, 28). The pale yellow
colour of the liver, considered so diagnostic of
this pestilence by M.  Louis, was also insisted
upon in the very excellent work of MM. Fran-
cois, Bally, and Pariset on this malady, as
they observed it in Barcelona in 1821 ; but in
the numerous  dissections  they made during
that epidemic—one of the most  prevalent and
destructive on record—they particularly notice
the rhubarb colour of this organ.
  49. iv. Prognosis.—It is only from a very
close and  attentive  scrutiny of the  several
symptoms individually, and  of their combina-
tion, as constituting the general state of the
patient, that a correct, opinion can be formed of
the event in this malady.—A. The  expression
and appearance of the eyes, the general aspect
of the countenance, the torpor of the system,
the depression of the spirits, and the imbecile
state of the mind, described under the last stage
of the malady (§ 16), afford the worst, and the
reverse of these symptoms the  most favoura-
ble,  prognosis.  Tremours  of the hands and
lips ;  restlessness ; violent spasmodic contrac-
tions of the legs or arms ;  apththae, resembling
curd, on the  tongue  or gums ;  dark spots or
specks around the mouth or on the  upper lip;
haemorrhages  from the  nostrils, mouth, anus,
urethra, or vagina,  or from the  eyes, ears, or
pores of the skin, especially when the blood is
dark, decomposed, or ichorous, or has an offen-
sive  odour, and  the parts from which  it pro-
ceeds have a raw or a sphacelated appearance,
and sphacelation of the scrotum or penis, are
fatal symptoms.
  50. Pain in the fauces and throat, descend-
ing in the course of the oesophagus, with red-
ness of the tongue  and pharynx ;  a burning
pain  in the region of the heart, especially when
attended by great agitation, or by an expres-
sion  of despair in the countenance ; a change
of voice, from the usual manly sound to a weak
treble, or to a tone much weaker, softer, lower,
and shriller than the natural one, the words be-
ing drawled out in a strange whining manner,
particularly when this change of voice occurs
early in the disease ; very scanty, offensive, and
discoloured urine, or its dark, greenish,  black-
ish hue, or its suppression, or its passage in
drops with severe pain above the pubis and in
the urethra, with retraction of the penis;  pe-
techiae, vibices, livid spots and patches on the
surface; enlargement of the glands  of the
groins, armpits, and angles of the jaws ;  vom-
iting of black, grumous,  or flaky fluids, are,
even  when  existing  singly, most  dangerous
symptoms ;  but  when  several  of  them are
present, they preclude hopes of recovery.
  51. When  the disease  appears with  early
symptoms of malignancy ;  when the pain in the
head is intense, and confined chiefly to the low-
er part of the  forehead, the orbits, and  eye-
balls, the  conjunctiva being red, and the face
deeply flushed ; when a violent or a melancholic
or despondent delirium occurs early, or a fixed
opinion that  death  will  ensue is entertained ;
when the pulse is full, very soft and very rapid ;
or irregular, unequal,  intermittent, or, at least,
slower than natural, small and weak; when the
skin  is very harsh and hot at the commence-
ment, and cold at an advanced period, the pa-
tient  complaining of burning internal  heat ;
when the tongue is red, smooth, flabby, or cov-
ered by a sanguineous exudation ; when yellow-
ness  or a mottled state of  the skin, patches of
discoloration, and black  vomit appear, and es-
pecially if either  or all supervene early  in the
disease;  when  exudations  of  uncoagulable
blood take place from the mouth or other out-
lets of the body, or the quantity of black fluid
thrown up is great; when singultus is attended
by extreme anguish  and restlessness, or with
muttering, moaning, or with a weak, sharp, or
wild, unnatural tone of voice ; when the urine
is  suppressed, or the evacuations are  black,
grumous, or watery; when the extremities be-
come livid, cold,  or mottled, and the patient 
166
PESTILENCE,  HAEMAGASTRIC—Prognosis.
lies on  his back; then, whether these symp-
toms appear either singly or combined, recov-
ery very rarely takes place, and never when the
lips are  cherry-red and tumid, the eye glassy or
glistening,  the  skin damp, flabby, torpid, and
presenting streaks or patches of a livid, green-
ish, or violet colour, and when a nauseous odour
issues from the body.   Recovery is also never
observed after violent hiccough occurring late
in the distemper, especially if it be attended by
discharges  from the stomach without effort, or
with loud, flatulent eructations.
  52. B. On the other hand, hopes of recovery
may be  entertained when the distemper is mild
at its outset, or during the first  three  days;
but even in some such  cases the malady pro-
ceeds so  insidiously  as suddenly to present
many of the most unfavourable symptoms on
the fourth or fifth day, more especially yellow-
ness of the skin, black vomit, suppression of
urine, &c.  The longer the stage of excitement
continues, provided  that the symptoms do not
increase in severity, the event is the more like-
ly to be favourable ; and this may be expected
with more  reason when an agreeable, warm,
and general diaphoresis breaks out;  when the
irritability  of the stomach  ceases ; when the
eyes become more  lively or natural, the dis-
charges more  healthy,  and  the  urine  more
abundant.  On the contrary, when the stage of
excitement quickly or abruptly passes into the
state of apyrexia preceding the stage of vital
exhaustion, the worst form of this  last  stage,
with delirium, coma, and the several signs of
malignancy above enumerated  (§ 23), may be
expected.   If unfavourable symptoms do not
appear  before the fifth or sixth day, very rea-
sonable hopes of recovery may be entertained.
Mr.  Eraser, whose experience of this   pesti-
lence has been most  extensive, states that he
" never had reason  to be apprehensive of the
issue after the sixth day, unless fatal symptoms
had already set in."
  53. If epistaxis occur early, or  during the
stage of excitement, and be moderate, and at-
tended by amelioration of the cerebral or other
symptoms ; if the pulse is neither  very  rapid,
nor very weak, nor very soft  during the sec-
ond  day ; if the skin  remain at an early  stage
soft, and without the  caustic heat above men-
tioned ; if a miliary eruption  break out; if a
quiet sleep takes place, uninterrupted by vomit-
ing ; if the patient  lie on the side, and draws
the clothes around him ;  if the  urine be voided
in some quantity, and without pain in the ure-
thra or glands ; if the evacuations become more
copious, feculent, or bilious ; if the tongue, from
being dry, turn to moist, hopes of recovery may
be entertained ; yet a guarded prognosis should
nevertheless be given.
  54. C. Dr. James Clark, one of the earliest
and  most experienced writers on  this malady,
observes, that if the yellowness appeared in 24
hours or 36 hours after the first attack ;  if the
case had been left to nature, or the patient had
been bled, and no powerful remedies attempted,
recovery never took place.  The  sooner the
febrile stage ended, he adds, when the case was
left  to  nature, or only simple  remedies were
used, the greater the danger ;  and, on the con-
trary,  the  sooner the fever was  subdued by
powerful remedies, acting in an evident and de-
cisive  manner, the greater chance  the patient
had to recover.  If the debility was not great
after the febrile stage, and the yellowness did
not appear before  the fourth or fifth day, the
sick generally recovered.  Many also recovered
after the yellowness, and even after bleeding at
the nose; but in all his practice he recollected
only four  patients  who recovered  after black
vomit  had  appeared  (p. 18). Of the  cases
which  I had  an opportunity of treating  many
years ago, one only recovered after this symp-
tom had fully and  unequivocally manifested it-
self.  It should, however, be remarked, that
vomiting  of a dark  grumous fluid, occurring
with or after yellowness of the skin, not infre-
quently occurs in the last stage of malignant,
bilious, or remittent  fever (see Fever, § 233, et
seq.);  and that recovery occasionally  takes
place in that fever, even after these symptoms
have appeared.   But the case is very different
in the true haemagastric pestilence.  Most of
the instances of recovery which we hear of
from the black vomit, are recoveries from these
states of yellow or remittent fever which have
been confounded with this pestilence.
   55. Dr. Chisholm  states that the critical pe-
riods or days are more distinctly marked in this
malady than in any other observed in warm cli-
mates.  The cessation of the disease, and the
death of the patient, he remarks,  always hap-
pened on  the odd days ;  but the change in the
state  of the symptoms which preceded either
event took place on the even days.  Thus, if
the patient was  worse on the evening  of the
second day, he would die on the third ; if worse
on the fourth, he would die on the fifth ;  and so
on as far as the fourteenth day.  In the same
manner, if the  patient was  better on the sec-
ond, fourth, or sixth day, the resolution of the
disease would happen on the following days.
   56. Pregnant females always experience abor-
tion, which is  attended by excessive haemor-
rhage, when attacked by this pestilence, and
very  seldom recover;  and when women are
seized by it the first fortnight after delivery, re-
covery rarely or never takes place.  Dr. James
Clark states that, during the epidemic in Do-
minica in 1793  and 94, children, adults, and old
people, labouring  under smallpox,  were gen-
erally  attacked  by this  pestilence " about the
time that the secondary fever usually  comes
on; and  that none  recovered but  those who
had begun to take  bark and wine after the erup-
tive fever, and  continued this remedy and a
nourishing diet  for some time after.  It made
no matter whether  the  smallpox were  of the
confluent or distinct benign kind.   All fell vic-
tims to this disease who were not treated in
the manner just mentioned."
   [The individual  prognosis in this disease, a3
Dr. Dickson  truly remarks, is much  modified
by circumstances.  In  the  sanguineous and
plethoric  the disease is apt to attack with more
violence,  and run  its course with  greater ra-
pidity.  The intemperate, with scarcely an ex-
ception,  succumb  beneath an attack.   It is
even  controlled, in  some degree, by national
habits and modes of life.  The Germans, Scotch,
and Irish stand a much poorer chance of recov-
ery than  Spaniards, Italians, and Frenchmen.
The Englishman and the American from north-
ern latitudes occupy  a middle ground, generally
speaking; the more recently a person is from
the north, in places where the disease prevails, 
PESTILENCE,  HAEMAi
the more severe will be his attack.   The mal-
ady proves extremely fatal among young chil-
dren.
  Dr. Dickson has also called  attention to the
state of the stomach, as of paramount impor-
tance in  inflammatory cases ; every thing de-
pending on its  powers of retention  and  tran-
quillity.  Where there is great burning at the
epigastrium, with nausea and retching, and ten-
derness on pressure, the prognosis is bad.  The
pulse is not much to be depended on ; but when
it becomes small, quick, and irregular, it indi-
cates danger.   So  also does a moist and relax-
ed skin.   In bad cases, the febrile paroxysm is
very short;  after this has subsided, the super-
vention of febrile  excitement  is a favourable
sign.   But a  sudden collapse,  or gradual  sink-
ing of the strength at this crisis, attended with
black vomit,  shows a fatal result.   A  sponta-
neous suppression  of urine, the defect of renal
secretion, is almost uniformly a fatal sign.  The
black vomit, though not pathognomonic of yel-
low fever, is  always, nevertheless, a most un-
favourable sign, whenever it occurs in this dis-
ease, whatever may be the condition of the pa-
tient in other  respects.   Dr.  Dickson states
that he has met with as many as ten recoveries
of patients who had black vomit;  he has met
with it, also, repeatedly  in bilious  remittent
fever,  gastritis,  and enteritis,  in one case  of
varioloid,  one of catarrhal fever, one of preg-
nancy, and two of  dropsy.  We have observed
it in several  instances in other affections, and
recently in a  fatal  case of peritonitis.]
  57. V.  Mortality.—But little can be stated
respecting either the numbers attacked in a  lo-
cality where  this pestilence prevails, relatively
to the  amount of population, or the proportion
of deaths  to recoveries.  It is  obvious  that, as
regards the extent of diffusion  of the distemper
among the community, much will depend upon
the means resorted to of guarding against it.
As respects the epidemics which have occurred
in Europe, and in some other places, the great-
est fatality has been remarked among the early
cases, or when the spread of the disease is
reaching, or has  reached, the utmost  limit.
Toward  the  decline of the epidemic the pro-
portion of recoveries increases ; and this may
be owing either to the less predisposition of the
affected ;  to  the depression of the temperature
about  the close of an epidemic; to the  most
susceptible, the most timid, and most exposed
to the exciting and concurrent causes, having
been the earliest attacked; or to the joint  op-
eration of these circumstances.  Much,  how-
ever, will depend upon the ventilation, cleanli-
ness, and measures of prevention adopted; and
more especially upon the  avoiding of all those
causes which tend  to contaminate the surround-
ing atmosphere, and even of those articles which
the foul air may imbue.
  58.  Dr. Rocheaux states, that at Barcelona,
during the early part of the epidemic there, in
1821, the mortality amounted to 19 out  of 20
attacked; but it diminished to much less, and
at the close  of the  epidemic  was two thirds.
Dr. Killkrest remarks,  that at Gibraltar, in
1828, very few recoveries occurred among  the
earlier cases in the Civil  Hospital.   " Of  the
first 35 Jews received  into the establishment,"
but one recovered.  The unusual rate of mor-
tality among this people may partly be  referred
GASTRIC—Mortality.                  167

to their very general (constitutional 1) despond-
ency when attacked by dangerous or epidemic
maladies.  In this  epidemic  at Gibraltar, one
half the cases died in several of the military
corps.   It is stated by the physician just quoted
that, of the first 134 cases treated in Murciain
1803, not more than three or four recovered.
   [In 1804, in Gibraltar, out of a  population of
9000 civilians, but 28 persons escaped an attack,
and the mortality was one in three.  The dis-
ease proved nearly  as fatal in Antigua, in 1803.
Three out of four died of it in Jamaica, under
the care of Dr. Hume.   In  Philadelphia, in
1820, 83 out of 125 died of it, which  is about
two out of three.   In the  city of Charleston,
according to Dr. Dickson, the average mortal-
ity is about one in five or six of  all attacked.
But, as  in cholera, the fatality of the disease
varies greatly in different localities of the same
city.  Thus, in Philadelphia, in 1820, out of 12
reported cases in one vicinity, there was only
a single recovery ; of 70 in  another locality, 30
recovered, and three out of four  recovered in
another  vicinity.   The  general   average of
deaths from yellow fever where  it prevails is
about one third.]
   59. The greater malignity, and  consequently
the greater fatality, of the cases have been ob-
served not only at the commencement, but also
at a  far-advanced period, of some epidemics;
as if the violence of the distemper  had received
a fresh impulse.  Dr. Townsend  states this to
have obtained in New-York  in 1822,  the  pro-
portion of deaths to the affected being, as late
as October,  as three to  four.  On the other
hand, a  milder form of the malady has been
more  frequently observed in some epidemics
and  localities than  in others. This  circum-
stance may be partly attributed to  the intensity
and concurrence of those causes which predis-
pose to, and determine or aid the more efficient
and specific  cause  of the distemper, especially
of a warm, confined, stagnant, and humid at-
mosphere; want of ventilation and of cleanli-
ness ;  crowded sleeping  apartments,  &c. ($
71); dread of the  disease; the  season, tem-
perature, and  situation.   Much,  however, of
the different degrees of malignity said to exist
in different epidemics, and in different climates
and places, may be imputed to the  circumstance
of the malignant states of remittent fevers on
the one  hand, and the inflammatory remittent
and  continued fever on the other, being often
confounded, by  some writers, with haemagas-
tric pestilence, when either of the former has
become remarkably prevalent, and has been at-
tended, as they sometimes are, by yellowness
of the skin.
   60. Some of the epidemics of  yellow fever
said to have occurred in the West India Islands,
and  in parts of the American continent, have
been much milder  than the visitations of this
pestilence have been in Spain during the early
part of the  present century.  But it  is by no
means fully ascertained whether all the epidem-
ics observed in the western  hemisphere were
actually the true yellow or haemagastric fever,
or merely an unusual prevalence of endemic or
remittent fever, rendered more  continued by
intensity of attack, predisposition  of the  affect-
ed, and other circumstances.  No  doubt several
of these epidemics were the pestilence under
consideration.   Their  symptoms, remarkable 
168                    PESTILENCE,  HAEMAGASTRIC—Causes.
 prevalence, and  fatality proved that some of
 them were this distemper ;  but others were of
 a different nature ;  and probably some of them
 resulted from the crowding of a number of hu-
 man beings in a  confined space, either  in bar-
 racks, or in transports, or between the lower
 decks of ships of war, in a high range of tern-.
 perature, and  without sufficient renewal of the
 air.   Numerous  instances  of malignant and
 even of pestilential fever of an infectious nature
 have  occurred in this  manner, and have been
 recorded by writers, and some of them have
 been  noticed in the articles  on Epidemics.
  61. Still the degree  of mortality has varied
 much in most of the visitations of this pesti-
 lence which have been observed during the last
 half century, and  must  be attributed to the con-
 currence of several  causes, especially  to  the
 predisposition of  the attacked, the season and
 locality,  to crowding of the population  and of
 the sick, and to the amount  of ventilation both
 before and after  the seizure.  The extent to
 which treatment  may influence the proportion
 of deaths can hardly be  estimated;  and yet it
 doubtless, also, has very considerable  effect.
 A recourse  to "  heroic remedies," in the lan-
 guage of some contemporary foreign writers, is
 certainly not  attended with marked  success ;
 but much depends upon the nature of such rem-
 edies.  For many years past medical practice
 was considered excellent in proportion  to its
 activity,  or, more justly speaking, to its vio-
 lence  ; copious blood-lettings, large  and fre-
 quent doses of calomel, &c,  constituting sound
 and judicious, as  it was no doubt active, prac-
 tice in the eyes of the inexperienced.
  62. All that can  be  said  as to the rate  of
 mortality in various epidemics and visitations
 of this pestilence, as far as the data have been
 furnished, may be  stated as follows: 1st. Where
 the infection  has been  introduced among  the
 natives of temperate countries, either removed
 to a warm climate, or during a very warm sea-
 son, and especially  if the population thus pre-
 disposed be  dense, or living in a close, crowd-
 ed, and ill-ventilated locality,  and if the air be
 very humid  as well  as very warm, and  much
 more  so  if it be stagnant or imperfectly renew-
 ed, the distemper has been not only the more
 violent, more  rapid  in  its progress, and more
 fatal,  but it also has been more rapidly spread.
 Thus  the results  have been  most disastrous in
 towns where these  circumstances have exist-
 ed ; and  in ships of war, and in transports, par-
 ticularly after storms or states of weather which
 induced the  closure of gun-ports and hatches,
 thereby preventing the renewal of the air, and
 favouring the development of concomitant caus-
 es.  The spread of the distemper has been the
more  general  or almost universal, and the pro-
portion of fatal results has  been the greater,
ithe more the above circumstances have pre-
 dominated, the more  completely  ventilation,
 segregation, and cleanliness were neglected, or
 imperfectly attained ; and the greater the panic
■or dread of the distemper.
  63. 2d. When  the distemper has appeared in
 a population of which a greater or less propor-
 tion has  been  formerly attacked, or has resided
 long in  a warm  climate, or consists of dark-
 skinned  races, although such residence and
 race by no means confer immunity, as  proved
 -on many occasions  ; also when it has appeared
in more temperate countries, at a time when
the cold season is fast approaching, and where
due ventilation, segregation, and other due pre-
cautionary measures have been taken, and con-
fidence has been secured, it is much more lim-
ited in its diffusion, milder in its character, and
less fatal.  Thus removal to a more open and
elevated locality,  the strict quarantine of the
infected,  free ventilation, a  lower range  of
temperature, and a cooling regimen, have sev-
erally tended both to limit the extension of the
malady, and to diminish the proportion of fatal
cases ;  while opposite circumstances have in-
variably increased both the one and the other.
  64.  VI. Causes.—Although this distemper is
owing to a certain specific cause—and the ex-
istence of this cause will be demonstrated in
the sequel—still the infection of the previously
healthy will be favoured by other causes, which
either predispose the system to  the invasion of
the specific cause, or determine or aid the de-
velopment of this cause, if the system have pre-
viously been  exposed to  it.   Thus the same
influence may either predispose the frame to the
reception of the  infection, or determine the de-
velopment of the malady, the infection having
been received, but not manifested.
  65.  A. Of these causes or influences, which
are rather predisposing than determining, the
most important are age, sex, constitutional pe-
culiarities, mental emotions, temperature, sea-
sons, &c.  The influence of these is apparent
not merely in  certain epidemics, but more  or
less in all, whether occurring within the trop-
ics or appearing  in temperate countries.  Cer-
tain  of these predisposing and  determining
causes are intrinsic, or appertain  to the indi-
vidual ; others are extrinsic, and implicate more
or less whole communities.
  66. a. Age has a considerable predisposing in-
fluence in this as well as  in several other epi-
demic distempers.   Adult age presents a great-
er degree  of  susceptibility to infection than
either childhood  or old age ;  and this is mani-
fested both at the commencement and during
the height of an epidemic.  Towards the con-
clusion  of very  general  and devastating epi-
demics, a larger proportion of children and aged
persons is observed to be attacked than at an
earlier period of the epidemic ;  but this is ow-
ing, as in the  epidemic of Barcelona in 1821,
to the circumstance of the  increased propor-
tion of these classes remaining unattacked, or
liable  to be infected towards the close of the
epidemic; nearly all those of adult and middle
ages having caught the distemper.  The more
rapid and general infection of adults, and those
at the prime of life, is probably in part owing
to their greater exposure to the existing cause
of the  distemper; nevertheless, more or less
of increased susceptibility of infection appears
to exist during these epochs of existence, than
in any other.  A similar circumstance obtains in
other infectious fevers, and shows that the pri-
mary impression of the exciting cause is made
upon the  organic  nervous system; for if this
cause acted directly on the blood, the aged and
debilitated, the susceptible and the non-suscep
tible, the protected and the unprotected, would
be equally liable to the contamination.  Never-
theless, when  the  infectious effluvium is con-
centrated, or the exposure to it is more than
usual, both children and old persons are attack- 
PESTILENCE, HAEMAGASTRIC—Causes.
169
ed, and  some infants at the breast do not es-
cape.
  67. b.  Sex.—The frequency of seizure in the
two sexes differs much in different epidemics,
owing very probably to the varying degrees of
exposure of each to the exciting cause.  In the
epidemic of Barcelona, females were as fre-
quently  infected as males, but a greater propor-
tion of the former recovered.  Much will ne-
cessarily depend upon the state of society in
the place where the distemper prevails ; but in
most epidemics a less prevalence, as well  as
less  fatality,  is remarked  among  females,  as
well as  among children, than in adult males.
This is  probably owing in part to  the state  of
the female constitution during  the period  of
uterine  activity.
  68. c. Constitution, Habit of Body, and Race.—
It has been remarked in almost every epidemic
that persons of a robust constitution, those  of
a rigid fibre, the plethoric, and sanguine  tem-
perament, were the most  frequently attacked,
and had the disease in the severest form. How-
ever, when the pestilence  became general  in
any locality, it  has  spared  no  constitution nor
habit of body,  excepting that which  had pre-
viously  been attacked.  The greater immunity
of the negro race has been often  remarked, but
with insufficient precision.   Individuals of this
race have, however, not infrequently been at-
tacked,  both in  the West Indies, Africa, and in
America ; but  the distemper  in them has as-
sumed a milder character (y 6).
  69. d. The depressing  passions,  more  espe-
cially fear of the disease, the loss  of relations,
anxiety, disappointment, &c,  all tend remark-
ably to  predispose  the system to the operation
of the exciting cause.  Irregular modes of liv-
ing, excesses of any description, prolonged ab-
stinence, fatigue of body or mind,  and want  of
the requisite repose, exert a similar influence,
although not so remarkably as the depressing
emotions of the mind, and, with these, act both
as predisposing and determining causes.
   70. c. Pre-existing disease,  and  general fee-
bleness of constitution, or debility  in any form,
certainly have  no  influence in predisposing to
an attack, but  rather prevent  it.   MM. Bally,
Francois, and  Pariset state that this was very
obvious in the epidemic of Barcelona ;  and that
in their numerous inspections of bodies dead of
the distemper, old visceral or pulmonary dis-
ease was very  rare.  They, however, remark,
that syphilis did not protect  from an attack ;
and that setons and issues  appeared not to pos-
sess a prophylactic influence.  They found that
a few of the patients in the portion of the gen-
eral hospital set apart for  the insane were at-
tacked, showing that insanity did not prevent
the seizure of this  pestilence.  The chief  of
the intrinsic influences now mentioned, which
seem to act also  as  determining causes,  or
which  appear to aid the operation of the spe-
cific cause on the frame subsequently to expo-
sure to  this cause, are, the depressing emotions
of the mind,  excesses of any description, want
of the  natural  repose, fatigue, and prolonged
abstinence.
  71. B.  Of the extrinsic influences or agents,
which tend not  merely to predispose the system
to the action of the specific cause of haemagas-
tric pestilence, but also to aid  in developing the
effects of this cause, warm, humid,  and stagnant
states of the atmosphere are the most remarka-
ble.   This  pestilence has generally prevailed
during high ranges of temperature, and at that
season, and in those localities, in which consid-
erable humidity was associated with warmth ;
and these with a still or calm state of the air,
or with crowded habitations and imperfect ven-
tilation.  Such has more particularly been the
case when  this distemper has become epidemic
in countries without the tropics.  Within the
tropics all sheltered situations near the level of
the sea, or near the  sea-coast,  present at all
seasons the conditions, in respect of warmth
or of humidity, requisite to the epidemic prev-
alence of the malady.  Still, although these
conditions  are required for the development
and dissemination of the infection, they are not
either individually  or conjointly  capable  of
producing the  distemper, without the operation
of the specific  exciting cause.   They are mere-
ly the atmospheric conditions required to give
the infectious  germ activity.
  72. The  seasons which are  characterized by
a high range of temperature and much humid-
ity, as summer and autumn, are those in which
this  pestilence has become prevalent in tem-
perate climates, when the infection has  been
imported or conveyed thither.  A low range of
temperature and dryness  of the air, although
attended by much heat, have been found,  on
the other hand, to check the propagation of the
distemper,  and even to  prevent its develop-
ment.  When the infectious seminium has been
introduced  in a crowded locality during degrees
of atmospheric warmth and humidity favoura-
ble to the evolution and propagation of its  ef-
fects, and when the  consequent  epidemic has
become very general, the distemper often con-
tinues to rage, although the temperature of the
season has fallen  much below  that observed
during its outbreak, or even below that which
is believed requisite to its development.   This
has been remarked in respect of epidemic vis-
itations of  the pestilence,  both in Spain and in
the United States.   That unusually high ran-
ges of temperature have no influence  alone in
producing the malady, may be inferred from the
facts observed in  connexion with the preva-
lence of it, both in hot and  temperate climates ;
for the periods of its appearance in the one,
and the seasons of its occurrence in the other,
have not been always, or even generally, char-
acterized by unusual warmth.  Indeed, a care-
ful  perusal of facts  connected  with the out-
break of the distemper in  Africa, the West In-
dies, in Spain, and in America, fully convinces
me that excessive warmth is not concerned in
its production more than a somewhat  lower
grade, a  high  degree of heat, as I have just
stated, being only one of the  conditions requi-
site to its prevalence, but then the presence of
the efficient agent—the infectious seminium—
is indispensable : this is the seed ; warmth and
humidity are merely the conditions  of the soil
requisite to its germination ;  and although the
former may lie dormant for  a tfme until the
latter give  it activity, still it is not less the ef-
ficient, the  specific, and the undoubted cause of
the pestilence.
  73. C. Infection.—According to the defini-
tion I have given of this term in the article In-
fection, there can be no doubt in the mind of
the unprejudiced, after a  due examination of 
170                    PESTILENCE, HAEMAGASTRIC—Causes.
the evidence respecting it, as to the dissemi-
nation of this pestilence by infection.  My lim-
its will  not  permit me to detail, circumstan-
tially, or even fully, all the  facts which  have
been adduced by most respectable authorities,
proving the  propagation of this  malady by in-
fectious emanations proceeding from  the  af-
fected, but I shall adduce sufficient evidence to
show that  the  true  haemagastric  pestilence
spreads in this manner, and  that the evidence
of its infectious nature is similar  to  that by
which the infectious nature of scarlet fever or
smallpox is  proved and admitted.   But small-
pox, scarlet fever, and some other infectious
diseases, are among the most common maladies
in our climate, and can no longer be prevented
by measures in any way tending to embarrass
traffic  and mercantile speculation,  while this
pestilence, plague, and pestilential cholera  are
foreign to this and most European countries,
and the only modes of preventing their exten-
sion to these countries hitherto attempted have
been such as more or less hamper commercial
undertakings at certain seasons and with  some
foreign parts.  It cannot be  denied by any one
who has attended to the subject  of quarantine,
especially as it has been agitated in recent times,
and with a due knowledge of the influence which
the  ruling  passion—the  desire of  amassing
wealth—exerts upon all the more generous and
social emotions of the mind, that the  restric-
tions imposed  upon trade, arising out  of pre-
cautions against the  introduction of pestilen-
tial infections, have been  the chief causes, di-
rectly or indirectly, producing the opposition to
the doctrine of the infectious properties of pes-
tilence ;  and that  all that  has been written to
disprove this doctrine—and written with no
small virulence by some—has not proceeded
from a firm conviction of the justice of  the
cause  espoused, but are  either  special plead-
ings subservient to sordid  purposes, and to the
gratification of disappointed feelings or of  pri-
vate resentments, or the outpourings of minds
teeming with mistaken views, arising out of
imperfect observation and hastily-formed opin-
ions, and excited  by a desire of acquiring no-
toriety in a contest involving the interests of
the whole community.
   74. Let any one altogether unprejudiced as to
the infectious or contagious properties  of pesti-
lential maladies, attentively peruse most of
what has been  written respecting them in  this
and in  other countries, carefully examine  the
evidence adduced  before  committees of  the
House of Commons, or in other places,  and
critically weigh the  import  and truth of the
conclusions arrived at by  commissions sent to
investigate  facts on the spots of their occur-
rence, and the various circumstances connected
with the facts  adduced—let  any one who pos-
sesses sound common sense, with some share
of science,  but who  is at the same time en-
tirely free from the undue influences of  preju-
dice, of temper, and  of interest, inquire  into
the  matter—and I cannot believe that he  can
arrive at a  different conclusion from that to
which I have arrived, after the best attention
I have been able to bestow upon this most im-
portant and much-discussed subject. Whoever
may enter upon this very  unpleasant investiga-
tion with these moderate  qualifications, which,
 however necessary, are quite sufficient  to the
formation of just conclusions respecting it, will
be surprised to find that, among members of a
learned profession, so much  ignorance should
be displayed in the literary character of some
of these writings,  in the scientific and profes-
sional execution of others, and in the illogical
inferences of many of them.  The duly quali-
fied and candid investigator  will detect state-
ments made without proof, facts assumed with-
out evidence, and supposititious agents believed
in as real existences, and these made the bases
of reasonings altogether inconclusive even as
regards the conduct of the argument.  He will
find things, facts, and diseases dissimilar from
one another, and presenting  no connexion ei-
ther as to nature or to sequence, viewed as
identical with each other.  He will detect the
suppression of important facts and circumstan-
ces, and an  undue prominence given to others
of a doubtful character.  He will remark the
imputation of motives which  did not exist, and
ignorance of those which influenced, if they
did not impel the writers. He will observe the
precipitancy with  which the young, the  inex-
perienced, and the ignorant  have rushed into
print, and attacked, with disgusting flippancy
and intemperance, much abler and better-in-
formed writers.   In every medical periodical
existing during the late war, he will find ac-
counts  of a disease never seen by the descri-
bers, their own mistakes proceeding from pro-
found ignorance of the name and nature of the
malady seen  by them, serving as the basis of
their  lucubrations and of  their  arguments.
And he will, moreover, be grieved to remark
the opinions of learned and experienced  men
either  misrepresented or impugned in jejune
and paltry performances, evincing  a most re-
markable ignorance of  the language in  which
they are written, and a still  greater ignorance
of that  from which they profusely and inappro-
priately quote. In thus attempting to reach
the pure spring of truth at the bottom of the
deep well of research, he will have to penetrate
not only through  the rubbish thrown in by un-
faithful, by mistaken, and by ignorant inquirers,
but also through the accumulated  filth of un-
candid  and intemperate controversy.
   [We stated, under the  article "Infection"
(p. 405, vol. ii.),  that  the weight  of medical
opinion in this country is opposed  to the doc-
trine of Mr. Copland, that  yellow fever  owes
its spread to a specific infection of an impalpa-
ble nature, emanating from the bodies of those
already infected.   It may, after all, appear that
the controversy in relation to the mode in which
yellow fever is propagated is merely one  about
words ; that it originates in  not agreeing upon
the meaning of the terms employed ; and that,
if these were  logically  defined, and then  used
only in the sense  of the definition, there would
really  be found to be no difference of opinion
in the  profession, but,  on the contrary, entire
harmony.  It is very evident that Dr. Copland
uses  the terms infection and contagion  in a
sense  different from that in which they are em-
ployed by American  medical writers, making,
 as he does, the former a generic term, and con-
tagion  merely one of the modes  in which it
takes place.   Now, if we understand by a con-
tagious disease,  one which  is  communicated
 under any circumstances of atmosphere, wheth-
 er pure or impure, by contact or otherwise, as 
PESTILENCE, HAEM,
smallpox, measles, hooping-cough, &c. ; and by
an infectious disease, one whose communica-
tion depends on an impure or vitiated state of
the air, there  would be  perfect unanimity of
opinion as to what category yellow fever would
properly belong : no one would think of calling
it a contagious disease ; but, like plague,  chol-
era,  and typhus  fever, it would at  once  be
ranked  under  infectious maladies.    If these
diseases are ever communicated in a pure  at-
mosphere, it is only an exception to a general
rule, and, as such, should not be considered a
valid objection to such distinction, exceptio pro-
bat rcgulam.   Let it  then  be  admitted  that
yellow fever is propagated, or, if you please,
communicated through an impure atmosphere
only, whether  it be by a process analogous to
fermentation  or assimilation  it matters not,
yet, if the above distinctions are followed, the
disease  should be called an  infectious,  not a
contagious one.  In using this latter term we
unnecessarily open a wide door to  controver-
sy, and become involved in discussions mere-
ly about words.   But if we give that latitude
to the meaning of the terms employed, as indi-
cated by our author,  we are at  once involv-
ed in an endless sea of controversy, without
a pilot or a helm.  As then,  after all, there
is not that difference  of sentiment which is
generally  supposed on  this subject,  it  being
rather apparent than real, we regret to notice
the seventy of language employed by Mr. Cop-
land  toward those who seem to differ  from
him in relation to this matter.   We do not be-
lieve that there is any good reason for impeach-
ing the motives or doubting the sincerity and
honesty of those who  have expressed opinions
apparently at variance with those of our author  ;
we shall regret to find that the example here
set, of vituperating those who  seem  to differ
with us in opinion, finds many imitators in the
profession.]
  75. a. The history of the  various  manifesta-
tions of this  pestilence conveys  to the expe-
rienced physician a certain  degree of evidence
as to their infectious  characters, although the
circumstances connected with them have been
very imperfectly recorded.  The earliest notice
of the appearance of the haemagastric pesti-
lence in the West Indies is made by Ligon, in
his " History of Barbadoes."  He states that it
broke out early in September,  1647, and  that,
before the expiration  of a month, the  living
were hardly able to bury the  dead.   After the
year 1647, no  mention is made of this malady
until 1686, when it was said to have been im-
ported to Martinique from Siam, and was then
called the "Maladie de Siam."   M. Desportes,
who practiced  during  many  years  in St. Do-
mingo, says that it appeared in Martinique in
consequence of a  large fleet from Siam which
arrived there with a " malignant or pestilential
fever, of which a great number of the sailors
perished;" and several  French writers  state
that, having been communicated to the inhab-
itants of Martinique, it was afterward carried
to St. Domingo.   Captain Phillips  states that
this  malady prevailed  in Barbadoes in  1694;
and Mr. Hughes, on the authority of Dr.  Gam-
ble, mentions  the prevalence  and fatality of it
in 1695;  and the circumstance of its being
called the new  distemper, or KendaVs fever.  Dr.
Trapham, in a work on the health of Jamaica
AGASTRIC—Causes.                    171

 in 1679, says, that "about eight years since,
 when  the  victorious  fleet.returned from the
 signal Panama  expedition, they then  brought
 with them a high, if not pestilential fever, of
 which many died throughout the country ; but
 this being a foreign  distemper brought from
 abroad, the causes of which I could not so well
 jugde  of, but conclude Jamaica more happy
 than  to be  annoyed  therewith, directly and
 originally" (p. 81).
   [Dr. Dowler, of New Orleans, remarks, that
 " Mr. Webster, who  has  collated the various
 authorities in relation to  the origin of yellow
 fever in America, shows, in his work on Pesti-
 lence, that when the whites arrived  in New
 England, in 1620, some of the Indian tribes had
 been  reduced from 30,000  to  300, two years
 previously.   The survivors  asserted that the
 sick bled from  the nose, and  turned  yellow,
 like a garment of that colour, which they point-
 ed out  as an illustration.  Their statement as
 to the great mortality which the malady caused
 was fully confirmed by the number of recent,
 unburied skeletons  strewed about their towns.
   "This author, at a later  period, after more
 thorough  investigation, reiterates  the state-
 ment, ' that a pestilential yellow fever prevailed
 among the nations of New-England, about two
 years  before the settlement made toy the Eng-
 lish, is a fact as well attested as any historical
 fact on record.'
   " The settlement of Virginia preceded that
 of New-England.  Some of the colonists in the
 former, before those of the latter arrived, had
 witnessed the almost entire destruction of many
 Indian  towns by an  epidemic, which, though
 vaguely called the plague,  was  probably the
 yellow fever.  No diagnostic criteria have been
 transmitted to our times by which this conjec-
 ture can be  satisfactorily decided.  With re-
 spect to the New-England epidemic alluded to,
 the case is different;  three of the most salient
 characteristics of yellow  fever, viz., great fa-
 tality, yellowness of the skin, and hemorrhages,
 are enumerated distinctly.  There is  nothing
 improbable in admitting this statement, fatal as
 it may be to the doctrine of imported contagion.
 The Indians, even the Southern Indians, are, as
 I know from personal observation, sometimes
 the victims of yellow fever, when recently from
 rural situations.  It is almost certain that the
 native  Indians of the South, constantly resi-
 dent in large towns, would  be  little, if at all,
 liable  to this disease, while the same  descrip-
 tion of persons in northern towns  would, like
 the whites of the North, enjoy no such protec-
 tion.   The localities which develop yellow fe-
 ver are urban, not rural.   Hunting and war,
 the elements of savage life, are but little fa-
 vourable to a dense town  population.  Hence,
 savages seldom suffer  from this disease.  It
 cannot, however,  be  denied that  very small
 towns are liable to suffer.
   " The infrequency of yellow fever among the
 savages of America cannot  be inferred from
 the silence of authors on the subject, with but
 few exceptions, for nearly  two centuries.   The
 difficulty of getting information from them in
 relation to their maladies will, in a great meas-
 ure, furnish a sufficient explanation.
   " In 1746 the Mohegan  tribe  was wasted by
 this malady, which began with pain in the head
 and back, followed by fever, and on the  third or 
1715     PESTILENCE, HAEMAGASTRIC—Its Infectious Nature Demonstrated.
fourth day with intense yellowness of the skin,
black vomiting, and bleeding from the nose and
mouth.  This fever commenced in August and
ended with the approach of cold weather.  Al-
bany, in  New-York, was at the same time the
theatre of a similar visitation, as was the Sen-
eca nation of Indians the year before.   If the
circumstances of savage life were equally fa-
vourable to  the production of yellow fever as
those of civilized life, still, however, the diffi-
culty of obtaining from hostile savages  any au-
thentic information in relation  to  it will ex-
plain one of the causes which have clouded its
early history among the  nations of North and
South America, together with those of the isl-
ands  washed  by  the  Caribbean Sea and the
Gulf of Mexico."]
  76. Don Ulloa  affirms that this pestilence
was  unknown at  Carthagena and  Porto Bello
before the year 1729.  Medical  literature fur-
nishes very few instances of the  appearance
of this pestilence in the West Indies during the
eighteenth century, until the dreadful outbreak
in 1793.   Still we  are not to infer that occa-
sional visitations  of it did not take place,  al-
though no published record of them exists;  in-
deed, imperfect notices of such visitations are
to be met with in  several works ; still they ap-
pear to be few and far between, and evidently
prove that they have  not been the results  of
endemic  causes, or of circumstances connected
with locality or season, and to have been alto-
gether different from  the maladies arising out
of these causes and circumstances.
  77. Dr. Currie, in his work  on  Bilious Fe-
ver, states that " a contagious fever, called the
yellow fever, has  occurred at Philadelphia six
times since the first  settlement of the city;
viz., in the years 1699, 1741,  1747, 1762, 1793,
and  1797."  Gough, in his history of the So-
ciety of  Friends, says, " that the fever which
prevailed in 1699  had, for a considerable time
before, been very mortal in the West India
Islands."  Dr. Lind states  that, in the year
1741, "the disease was  introduced by means
of a  trunk of wearing apparel  received from
Barbadoes, which had belonged to a gentleman
that  died of it in that place ;  and that the dis-
ease spread from the family that received the
trunk into the town, and destroyed above two
hundred  of  the inhabitants."   Mr. Lardner,
mentioning its prevalence in 1747, adds, " that
many, whose business and families would per-
mit them, fled from the city."   In an account
of the prevalence  of  this pestilence in 1762,
communicated to the College of Physicians by
Dr.  Redman, it is stated that the disease was
introduced about the end of August by a mar-
iner, who arrived  from the Havana ill of it,
and took lodgings near the new market, below
Pine-street.   It was confined principally to the
vicinity of the new market and the street west
of it, spreading gradually from  one family to
another,  till toward the end of September."
  78. Dr. Lining, of Charleston, has described
this  distemper in  a letter to Dr. White, and
given the following account of its appearance
in that city up to the period at which he wrote :
" This fever does not seem to  take its origin
from any  particular condition of the atmosphere,
independent of infectious miasmata ; for with-
in these twenty-five years, it has been only four
times epidemical in this town, viz., in the years
1732, 39, 45, 48, though none of those years (ex-
cepting that  of  1739, whose summer and  au-
tumn  were  remarkably  rainy)  were  either
warmer or more rainy (and, some of them, less
so) than  the summers and autums were in sev-
eral other years, in which we had not one  in-
stance of any person being seized with this fe-
ver.  But that this is  really an infectious dis-
ease seems plain, not  only from this, that  al-
most all  the nurses caught it and died of it, but
likewise, as soon as it appeared in town, it soon
invaded  new-comers, those  who never  had  the
disease before, and country people when they
came to town, while those who remained in the
country escaped it, as likewise those who former-
ly felt its dire effects, although they walked about
the town, visited the sick in all the different
stadia of the  disease, and attended the funerals
of those who died  of it.  And, lastly, whenev-
er the disease appeared  here, it was  easily
traced  to some person who had lately arrived
from the West Indies, where it was epidemical."
(Essays,  Phys. and Lit., &.C., vol. ii., p. 370.)
Dr. Warren gives similar  testimony to that
now stated by Dr. Lining respecting this pes-
tilence as it occurred in Barbadoes and adjoin-
ing islands during the  early  part of the last
century.   (See Treat, on the Malignant Fever in
Barbadoes and neighbouring Islands, &c, by H.
Warren, M.D , 8vo.  Lond., 1740.)
  79. Although this pestilence has frequently
broken out in the  West Indies and in several
of the seaports of the United States during the
last century,  still considerable intervals, espe-
cially as regards individual towns and  locali-
ties, intervened between its appearance.  Dk
La Fosse makes no mention of its occurrence
in St. Domingo  between  the years  1775 and
1785.  Dr. Chisholm asserts  that no conta-
gious fever, nor any epidemic of the character
of this pestilence, appeared in Grenada from
the year  1763 until 1793 ;  and Dr. Gilpin, who
resided many years in  this island previous  to
1793, confirms his  assertion.
  80. That the West Indies were not very un-
healthy for many years previously to 1793, is
shown by the testimony of Dr. Davidson, who,
in a letter to  Dr. Mease, of Philadelphia, states
that, in the more healthy islands of St. Kitts,
St. Vincent, and Barbadoes, soldiers have ar-
rived from Europe  and  remained  there  for
years in the enjoyment of good health, notwith-
standing their debaucheries.   And Dr. Weir,
director-general of army hospital, states "that
he arrived in  Jamaica in 1785, from which time
till 1792  only one officer died out of four regi-
ments quartered in that island ; that the troops
were in general healthy; that although  fevers
were frequent, they were not fatal," and that
no fever of a bad  type occurred during these
years, until 1793, when this  pestilence appear-
ed.  Dr.  Theodore Gordon served  in  Barba-
does, Dominica, and Jamaica during five years
preceding the occurrence of this malady in 1793,
and considered the health of the troops remark-
ably good, the chief diseases  being  remitting
and  intermitting fevers, dysentery, and affec-
tions of  the  liver.  That this malady is not a
constant resident in the West Indies, although
frequently  appearing there, is farther shown
by Dr.  J. Hunter,  Dr. Franklin, Dr. Gordon,
and others, who have found troops remain du-
ring several  yeaTS remarkably  healthy; and 
PESTILENCE, HAEMAGASTRIC—]
yet, in the most healthy seasons and localities,
this malady has occurred and swept off many
hundreds in a very short period.   Its outbreak
in these islands, after many years of immuni-
ty from it, occurred in February, 1793, in Grena-
da, at a time when bilious remittent fever does
not prevail ;  at which time, also, and for a con-
siderable period afterward, all the other islands
continued  healthy.  But after the appearance of
this pestilence, every station, however healthy
before, suffered severely from the contagion.
It did not reach Dominica until the end of July.
Barbadoes was unaffected until the beginning
of 1794; and St. Domingo did not suffer from
it until late  in this year ; and then in conse-
quence of the introduction of the contagion by
a detachment of troops from the island of Gua-
daloupe, where it was raging.  This pestilence
appeared in Philadelphia in the month of July,
1793, and during the latter part of that year and
1794 it reached most of the West India islands.
  81. The reappearance of this  malady in the
West Indies, after an immunity from it during
many years, was  attended by many distressing
results,  owing to  the circumstance of its hav-
ing been confounded, by superficial and  inex-
perienced observers,  with the common  remit-
tent fever of the country.   We frequently find,
upon referring to reports of medical officers,
that the pestilence broke out and was most de-
structive among regiments which had marched
into barracks in which it had already prevailed.
Thus the 35th regiment landed in Guadaloupe
on the 12th  of May, 1795, and on the 30th of
June of the same  year,  in six  weeks, it had
lost 136 men.  The 2d regiment landed at Mar-
tinique  in March, 1805, and in  the following
May it had  lost 97 men.   These men landed
during the prevalence of this pestilence in these
islands, and, without any  exposure, they  in-
stantly, and without  marching or service, oc-
cupied quarters in which this malady had pre-
vailed ;  but, as it was supposed  not to have
been infectious, the highly-predisposed  troops
were instantly introduced to the operation of
its efficient cause.  The distemper was viewed
as having been free from infectious properties,
and as being  the common seasoning fever of
the  climate, and  no precautions  were taken, in
these instances  as well  as in  many others,
against its  dissemination.   Numerous  other
instances might be adduced of the dreadful ef-
fects resulting from monstrous  ignorance on
the  part  of those who ought to  have been in-
formed by the  experience and  judgment of
those who had gone before them,  if they were
incapable of arriving at rational  inferences by
their own unassisted reason; but the subject
is humiliating to human nature, especially when
viewed with reference to medical doctrine and
to professional character.  In those days, and
even down  to the  present day,  the arrival of
Europeans within the tropics was generally in-
ferred to produce what was called a seasoning
fever—a name imposed upon all fevers, howev-
er occurring,  within  the first twelve or eigh-
teen  months  after the change  of climate—a
name, moreover, applied  very   frequently  to
conceal ignorance, or even to  mislead.  But
fever solely depending upon change of climate
merely, irrespective of infectious  or other mi-
asms, is neither so immediate in  its invasion of
new comers, nor so rapid in its course, nor so
rs Infectious Nature Demonstrated.     173

malignant, nor so fatal, as the pestilence now
under consideration.  In this I speak from ob-
servation in two quarters of the globe.  But to
proceed with the evidence as to the infectious
nature of this distemper.
  82. Dr. J. Stuart, who practiced during many
years in  the island of Grenada, both before and
after the prevalence of the pestilence in that
island in the years 1793, 1794, and 1795, states,
in a letter to Dr. Chisholm, "As to the charac-
ter of this fever, my experience has fully satis-
fied me  that it was specifically distinct  from
every form of the indigenous bilious remittent
which I had ever observed, because it appeared
at  a  season  of the year which I had  always
found healthy during a period of nineteen years'
residence in the colony ; because it  did not ap-
pear particularly in those situations where bil-
ious remittent fever usually prevailed during
the unhealthy season of the year; because there
was an evident difference in the character and
type of the two diseases  ; because I never knew
this fever terminate in  intermittent, as remit-
tent or bilious fever commonly does ;  and be-
cause I did not find the same mode of treat-
ment successful in both kinds of fever."  Dr.
Stuart  goes  on to remark, " that a thorough
belief existed in the minds of all the medical
gentlemen in Grenada that the malady  was in-
fectious," one only, and he merely at first, doubt-
ing this property; that he himself and several
other medical  men contracted the  disease in
their attendance on the sick; and "that the
malady, in his decided opinion, was propagated
by  visiting infected apartments, or by the near
approach to, or  contact of, people labouring
under it."  (See Dr.  Chisholm's  Letter to Dr.
Haygarth, p. 24.)  Dr.  Gordon, of St. Croix,
government physician to the Danish West In-
dia Islands, concludes his  remarks on the ma-
lignant pestilential fever prevalent in these isl-
ands and in North America near the close of the
last century, by stating  his belief in the impor-
tation and diffusion of infection, " by ignorance,
perversity, selfishness, or the abstraction of the
sentiment of public good ; by the abuse of all
preventive measures  in the promotion of the
speculations of cupidity and the calculations of
venal men ; by the prostration of truth  and hu-
manity, and the eluding the laws of quarantine."
   83. Dr. Dancer, of Jamaica, after a close ex-
amination of the opinion emitted  respecting
the malignant pestilence of 1793-6, states most
decidedly " that it is an imported disease, and
is  communicable by contagion."   He adds,
" that it has no apparent connexion with local
causes ;  that  it has appeared in the healthiest
seasons  and localities, and has prevailed least
in  unhealthy and marshy places."
   84. b.  Dr. Charlton,  president  of the Medi-
cal Society of New-York, states,  in a letter to
Dr. Hosack,  of the 9th of  September, 1803, "I
have practiced physic  in this  city since the
year 1762.   The  fevers that have usually oc-
curred in summer and autumn during  this pe-
riod were intermittent, bilious remittent, and
nervous or typhous fevers.  I never  saw a case
of  yellow fever in the  course of my practice
before the year 1793."  He adds, that he always
considered the yellow fever as " a  disease of
foreign origin ;" and that he " never met with
a case of it in the country but which could be
clearly traced to infection from the city." 
Its Infectious Nature Demonstrated.
 174     PESTILENCE, HAEMAGASTRIC—:

   85. Dr. S. Bard,  who  commenced practice
 in New-York in 1766, remarks that, although
 he observed hospital and jail fevers there du-
 ring the  revolutionary war,  he  never saw a
 case of true yellow fever until 1795; that he
 considers it a distinct idiopathic disease, and
 not a variety or grade of any other; and that
 he believes  it to have  been an imported mala-
 dy.  Dr.  Hosack  states that Dr. Ledyard at
 first, believed this pestilence,  as it appeared at
 New-York,  was generated in the place ; but
 subsequently had  reason  to change his belief,
 as all his  observations at  the  health office sat-
 isfied him that it was exclusively derived from
 the West Indies (p. 32).*
   86. It has been supposed that the fatal prev-
 alence of the pestilence chiefly in cities, towns,
 and localities near the level .or on the margin
 of the ocean is a proof of its origin in such sit-
 uations, and that it does not  admit of appear-
 ing at  any  considerable distance from  these
 places ; but that it would frequently be propa-
 gated through inland districts if the malady pos-
 sessed infectious properties.  The truth, how-
 ever, is, that it has not unfrequently been con-
 veyed to  places around, and  inland, from the
 sea-ports  where it broke  out and prevailed in
 Africa,  America, and  the south  and  east of
 Spain.  Dr. Stratton  met with numerous in-
 stances of  the propagation of the pestilence,
 when it appeared at Philadelphia  in 1797 and
 1798, to persons  residing at considerable dis-
 tances,  and  who had not visited the locality in
 which it prevailed.  Thus he  states that twen-
 ty-seven persons had retired from Philadelphia
 and Washington with  the disease, and fifteen
 received the infection  by communicating  with
 them.   "  One young lady fled from Wilmington
 into New Jersey,  was attacked about a week
 after, and communicated the malady to her un-
 cle, her nurse, and a  young man who visited
 her.  Two  of the four died."  And he adds,
 "there  have been many instances  of the pesti-
 lence being  brought  from  Philadelphia to Jer-
 sey, and of its being communicated from the
 persons thus infected to others ; and, if it may
 be thus conveyed from  the former to the latter,
 I see  no difficulty in supposing that it may be
 brought from some other place  to Philadelphia."
  87.  The College of  Physicians  of Philadel-
 phia,  in 1798,  came to the following conclu-
 sions : " 1st. That the  pestilential  yellow fever
 lately prevailing in that city differs essentially
 from every other disease which is common to
 North America, and  agrees in its  most essen-
tial symptoms with what  is called the yellow
fever  in the West Indies.   2d.  That it has
been regularly traced  to the  vicinity of some
vessel or vessels from the West  Indies, or to
persons or clothing connected with them.   3d.
That the  principal peculiarities of this  fever
are its contagious  nature, the progress of the
symptoms, and the mortality consequent on it.

  [* The statistics of our quarantine establishment at Staten
Island have  an important bearing on the subject of the in-
fectious character of yellow fever.  From the year 1806 to
 1844 inclusive,  there were 101 arrivals of sickly vessels at
quarantine, that is, of vessels on board of which there had
been one or more cases of the fever.  155 cases of the dis-
ease were introduced from these vessels into the hospital,
 and 174 sailors or passengers sickened after their arrival.
Of those who communicated with the vessels from on shore,
31 sickened, and five only who had no communication with
them.  Of the total number, 329, 179 were cured, and 150
died.]
4th. That to prove the contagious nature of this
disease would  be equally  useless as  to prove
the contagion of the plague.  5th. That, in all
their observation and practice, they  know of
no case where the  autumnal bilious remittents
of the country have proved contagious.   6th.
That, although these are  sometimes  attended
by violent and dangerous  symptoms,  this stri-
king  characteristic of contagion being always
absent, they never become an object of public
dread or  concern."  Preceding these conclu-
sions, these physicians  put the following perti-
nent  questions :  "  Where  do we see  the  first
appearance of this pestilential fever 1   Is it
among the marshes  to the southward of our
city, or in the neighbourhood of our  wharfs!
Is it in the confined alleys, or on the salubrious
banks of the Delaware  at  Kensington 1  Is it
not always near those places  where vessels
from  foreign countries are found?   Do the fe-
vers common to  the country steal on  insensi-
bly,  infecting one  person  after another in a
family and in a  neighbourhood'!   Are  they
equallv  severe in  seasons so  opposite as in
1797 and 17981"  They likewise remark, " that
very erroneous opinions have arisen from con-
founding this pestilential fever with  the malig-
nant remittents of the West Indies and Amer-
ica ;" and  they further subjoin proofs of the
importation of the infection in 1798.
  88. Dr.  Bancroft insinuates that  Sir  W.
Pym had formed his ideas as to  this  pestilence
from the accounts furnished by Dr. Chisholm,
of its introduction into Grenada.  Sir W. Ptm,
however, witnessed its appearance in  Martin-
ique in  1794, before he had even heard of Dr.
Chisholm ;  and his extensive experience of it
in the West Indies fully confirmed this physi-
cian's account of it.  Indeed, when Dr. Ban-
croft first  wrote upon this  distemper, it is
even doubtful whether or not he had ever en-
countered  it, or seen any other fever than the
remittents of  warm climates,  which  he had
confounded with it; at any rate, his experience
of it was very limited.  Sir W.  Pym's  account
of his experience of this pestilence, both in his
own person and in  the  several armies  and ex-
peditions with  which he served in  the West
Indies, conveys the strongest internal evidence
of his thorough knowledge of the origin and
nature of it.  Of his later  experience in Spain
and the Mediterranean, and of  the successful
measures  which  were  on  several  occasions
adopted in  order to extinguish this calamity, it
is unnecessary  here to speak, as they will partly
appear in the sequel.
  89. Sir W. Pym distinctly states that, when
this malady broke out in the islands where he
served,  in  1794  and 1795, other physicians,
both English and French, considered  it  distinct
from  the endemic  of the  country.  He men-
tions, respecting one of these isles, that it ori-
ginated  in  three  companies  of  the 70th regi-
ment, quartered in bomb-proof barracks, and
extended from them to men  in hospital with
other complaints,  and,  in  succession, to  the
surgeon and hospital attendants.  It next in-
vaded the  troops quartered in more elevated
situations in the  same fortification ;  while the
only persons in the town  of Fort Royal  that
suffered from the distemper were officers who
had joined  the mess or visited the sick officers
of the 70th regiment.  Sir W. Pym advised the 
        PESTILENCE,  HAEMAGASTRIC—L

men to be encamped on  an elevated and airy
place at a distance from the  town ;  and in a
few  days  the malady disappeared from  the
camp, and the regiment continued free from it
until the arrival of convalescents from the hos-
pital with their blankets and knapsacks, which,
having been  distributed  among the different
companies, communicated the  pestilence  so
very generally that, in a very short time, none
escaped it but those officers who either had it
very slightly, or had resided some years in the
West Indies.
  90. This was the first regiment which had
suffered from this distemper in that campaign ;
but the infliction  was  viewed as a seasoning
fever by some ; as the endemic of the country,
aggravated by fatigue, by others ; as the result
of malaria, or of any thing else under the sun,
excepting what it really was, by many.  The
few who entertained correct views were disre-
garded, and were  not  in positions to procure
attention from ignorant superiors, and the re-
sults were exactly what  might have been an-
ticipated.  The distemper extended, " and soon
ran through every corps that  had arrived from
England, and even through the regiments that
had  been some years in the West Indies ; with
this difference, that the last-mentioned suffered
a smaller mortality."   Nevertheless, the total
loss of the army, in the course of a few months,
was not less than 6000  men.   "The inhabi-
tants, also, suffered severely; but the mortal-
ity was small among the natives and those long
resident in the island ; but the newly-arrived,
sea-faring persons, and men belonging to trans-
ports, suffered in  as great a proportion as the
military."  He adds, that people of colour also
suffered from fevers,  but in  a much slighter
degree, and  less  dangerous  form.   " During
1794 and  1795, re-enforcements continued to
arrive, and,  from  occupying the same barracks
and  quarters with the troops which had suf-
fered from the disease, the contagion  was fre-
quently communicated  to them immediately
upon their  arrival, and  there were  many  in-
stances of officers and men  not surviving a
week after debarkation."
   91. The opinions of several physicians are
adduced by Dr. Bancroft in favour of the non-
infectious nature  of this pestilence ; but, upon
referring  to  them,  it  will  be found that they
actually support a very opposite doctrine ; and
that their ideas, as to a non-infectious charac-
ter,  had reference entirely to  the remittent en-
demics of which they  were treating, and not to
epidemic  yellow  fever—a piece of sophistry
of the most  dishonest and contemptible kind.
Thus Dr. GiLLEsriE,  who is thus misrepre-
sented by this author, and adduced by him as
an evidence against infection, states that " in-
fection could in many instances  be traced, and
appeared to operate as well through the medi-
um of terror as that of the effluvia emitted from
the bedding and persons of the  patients.   Of this
a melancholy instance happened in an armed
sloop, into which  a draft of about fifty men had
been judiciously sent to cruise, and thereby to
be preserved from sickness ;  but the contagion
having been carried on board  previously to her
sailing, and being destitute of medical aid, the
men were attacked in succession, and three
fourths of them died;" while in other armed
vessels in which  similar drafts had been sent |
rs Infectious Nature Demonstrated.    175

 with the same intention, the people continued
 in  good health.   Dr. Pascalis, who is  also
 quoted by Dr. Bancroft in favour of  non-con-
 tagion, states as follows : " It has appeared to
 me, as well as to many practitioners, that a
 considerable number of the  cases could not be
 traced but to a contagious power of the fever it-
 self: such were the  cases of whole  families,
 who seemed preserved as long as they had no
 patient in their houses,  and who all perished
 or were sick, without exception, as soon as
 they  admitted among them  any one affected
 with the disease.   This deplorable effect has
 been seen in the most wholesome parts of the
 town (Philadelphia), and at  any period of the
 season ; so that, in many instances, where the
 disease seemed most universal, by care and
 precaution,  people were  preserved;  while  in
 the country they  fell victims to their unre-
 served intercourse with patients when the epi-
 demic was fast decreasing in every part of the
 town."  Dr. Lempriere, another of Dr. Ban-
 croft's authorities, testifies,  in opposition  to
 the special  pleadings of this writer, that  " he
 could  not admit a  doubt in his own mind of the
 disease being of a  contagious nature ;" and M.
 Gilbert adds, that " he cannot deny that the
 malady may be communicated by the  expired
 air, or by the contact of matters impregnated
 by the miasms exhaled from those affected."
   92.  Of the several outbreaks of this pesti-
 lence  in the United States, it is unnecessary to
 state  more  than has been  already advanced,
 especially as the details connected with one of
 them  are in every respect similar to those of
 the rest,  as  well  as to those connected with
 the appearance of the distemper in Europe.
 The localities in which the  malady first broke
 out in North America have been viewed as the
 sources from which it emanated, independently
 of importation or infection, by those who argue
 against this property, and who  consequently
 consider it incapable of being thus propagated
 or imported; and, however small the grounds
 furnished them for believing that these locali-
 ties were or are capable of  furnishing the ex-
 halations, miasmatous or terrestrial, or how-
 ever denominated, still they contended that it
 acknowledged this and no other source—that
 it was propagated by the  air of the locality,
 contaminated by exhalations from the soil and
 matters covering  or existing in that soil, and
 not by emanations proceeding directly from the
 bodies of the sick,  or imbibed  by substances
 capable of retaining them for a time and after-
 ward  imparting them to the  surrounding air.
 That the distemper, however, appeared in vari-
 ous places in that country where no evidence
 of terrestrial exhalation could  be produced, and
 even  where the presumption of such having
 ever existed seemed absurd, unless, indeed, it
 can be credited that a specific flatus or gaseous
 poison may be exhaled at certain  particular
 parts  of the earth's surface, without  affecting
 the senses in a perceptible manner, or all who
 may  be within its sphere, and produce a cer-
 tain specific effect, identical in every respect,
 on all occasions,  and in all quarters of the
 globe.  However  gross and  absurd this as-
 sumption may appear,  it actually forms the
 base upon which  the non-infectionists found
 their doctrine.  If the truth of this doctrine  be
i for a  moment conceded, it necessarily follows
—I 
176     PESTILENCE, HAEMAGASTRIC—:
•s Infectious Nature Demonstrated.

   93.  c. Of the earlier occurrences of this pes-
 tilence in the south of Europe, but imperfect in-
 formation has been furnished.  It appeared in
 Lisbon in 1723, black vomitings being the most
 prevailing and fatal symptom.   Dr. Kennedy,
 physician to the  English factory there,  states
 " that it was very contagious in the lower parts
 of  the city, going through  a family,  and very
 few families escaping,"  especially in the  ill-
 ventilated  streets.   It  showed itself at  Cadiz
 in  1764, and did  not again  appear in that city
 until 1800.  A vessel  arrived there in August
 of  that year from the West Indies, and  on
 board of her some persons  had died of the yel-
 low fever on the passage.  After  her arrival
 at Cadiz, the whole crew, passengers, and pilot
 were landed, and died of the disease.   The in-
 fection rapidly spread throughout the city, and
 extended to several neighbouring  and inland
 towns.
  94.  This pestilence  appeared at Malaga* in
 1803.   The governor of that city informed his
 relative, the consul-general of Spain in  Lon-
 don, that it was brought there by a French ship
 from the West Indies.  After disappearing du-
 ring the winter, it reappeared in the following
 summer.  In this year,  1804, it spread  from
 Gibraltar to Cadiz, and to several parts of the
 Mediterranean, to Leghorn  and St. Lucar.  Sir
 W. Pym, then superintendent of quarantine at
 Gibraltar,  met with one case of the distemper
 in  this fortress  in  1803 ; and, as Dr. Hennen
 remarks, this may not have been the only case;
 for many attempts were  made to impose upon
 the authorities and keep them in ignorance, and
 the malady  was at that time prevailing at Ca-
 diz and Malaga,  cities  not far removed from
 Gibraltar, t
  * The introduction of the pestilence into Malaga in 1803
is stated by Dr. Arejula to have commenced in the house
of C. Verduras, a noted smuggler, who  had brought from
one of the vessels in the bay, and  secretly conveyed to his
house, a person labouring under a disease of which he soon
afterward died.  It was subsequently discovered that the
body was privately buiied  in the adjoining church of St.
Peter. On the 26th  of August, and next three days, the
son of the smuggler and two other men, associates of his,
were attacked, and two died.  Soon after the death of the
son, on the 3d  of September, his mother and two sisters
sickened with the same symptoms, according to the report of
the physician.  Verduras the father died  on the 15th of Sep-
tember, and his daughter and another son, who also had been
attacked, died on the 19th. While the distemper was thus
running through this family, persons adjoining and friends
of the family were seized, the malady spreading gradually
from this house and locality.  Dr. Arejula states that the
person who was secretly landed and died in Verduras's house
was buried by and with the connivance of the curate, who
was himself taken ill a few days afterward, and died, to-
gether with the physician who attended  him ; " and in like
manner, every person  connected with the curate's family
was taken ill and died ; even the sacristan and his wife, as
well as the boy who attended the priest at the altar."
Those, also, who entered  the Church of St. Peter, where
this person was buried, to hear mass on  St. Michael's day,
were  all taken ill, and a great part of them died.  This
church was, therefore, shut up, and continued closed until
December, 1805, when Dr. Arejula entered it, and di-
rected the fumigation of it.  The account furnished by this
physician was confirmed by the researches of Sir J. Fel-
lowes, who obtained the  same information as he had ob-
tained, and traced the distemper to the same source.
  t The facts connected with the introduction of the pesti-
lence into Gibraltar in 1804 are thus stated by Sir James
Fellowes : " From the confession of Santos,the person first
attacked, and from the oath of a respectable witness, it ap-
peared that Santos had recently left an infected house at
Cadiz; that he had been three times invcompany with a
person actually labouring under the disease on the 23d and
24th or August; that he  arrived at Gibraltar on the 25th,
was taken ill on the 26th, and was seen  by a French prac-
titioner, Mr. JaRG, on the 27th, and that in less than eight
days  after his being attacked, his mother, two aunts, one
that this terrestrial  exhalation or poison may
proceed from any situation, soil, or place, with-
out reference to physical condition  or geolog-
ical formation, seeing  that its specific effects
have appeared in all kinds of locality whenever
the range of temperature favoured their evolu-
tion.  The yellow, or haemagastric, fever broke
out in  September, 1811, at  Perth Amboy, in
New Jersey,  U.  S.,  a town  and  surrounding
country presenting none of  the endemic sources
of disease, but holding frequent communication
with the West Indies.  On this  occasion, the
Board  of Health  at  New-York, consisting of
several of the most  eminent men  and  physi-
cians of that city, recommended  the mayor to
issue his proclamation interdicting all commu-
nication between  the city  of Amboy and  the
city of New-York  ; and to appoint a committee
to inquire respecting the malignant  and infec-
tious fever which had appeared in the former
city.  Dr. Manning,  physician in Amboy, re-
ported to the committee that it was the  pesti-
lential yellow fever ; that " there was but one
opinion with either the inhabitants or  physi-
cians as to its origin, namely,  that it was de-
rived from some  of the West India vessels
which  had been lying at the wharfs;  and that
the brig Ocean, from St. Bartholomew's, and
the ship Favourite,  from  the Havana,  lying
alongside of the  Ocean, were generally sup-
posed  by the inhabitants to have introduced
it."  He stated that there were no local causes
to which this  calamity could  possibly  be re-
ferred ; that  the city is very elevated ; the soil
chiefly composed  of sand ;  free from all lodg-
ments  of water;   the  streets  wide;  and  the
houses  for the most part  spacious ; and that
the whole town exhibited an uncommon degree
of cleanliness.  He further reported that  the
citizens were so  perfectly convinced that  the
fever was imported in the vessels at the wharfs,
that they were  removed to  the  stream; and
that the persons first attacked were  frequently
on board of the vessels above named.   The
committee,   after  visiting Amboy,  reported,
" that other persons taken ill  had  been exposed
either directly by being on board the vessels,
or by visiting those  who were ill of the dis-
ease."  About this time,  also, the Board of
Health  of Philadelphia issued  a proclamation,
prohibiting all communication between Amboy
and  the city and county  of Philadelphia, on
account of a pestilential disease prevailing in
the former city, and  imposing  a quarantine of
fourteen days on all persons  after leaving Am-
boy, before they could be admitted into Phila-
delphia.
  [In 1820, Dr. Becic, of this city, was sent by
the Board of Health of New-York to Middle-
town,  Conn., to  investigate the nature and
origin of a malignant fever  which had prevailed
in that place to some  extent,  and which was
reputed to be yellow fever.  Dr.  Beck reports
that thirteen cases had occurred in that city,
seven of which proved fatal.   The disease was
pronounced  to  be unequivocal yellow fever,
and  to have been introduced by the brig Sea
Island, from the  West Indies,  on  board of
which three persons had died of the disease.
Dr. B. states that, in his opinion,  the existence
of the  disease was owing  to the presence of
this vessel.   (Hosack's Med.  Essays, vol. ii.,
p. 61.)] 
        PESTILENCE, HAEMAGASTRIC—h

  95. The deaths among the military and their
families during the two preceding years were
35 in 1802, and 56  in 1803 ;  but in the last four
months of  1804 the  deaths  were  as  follow,
from this  pestilence :  Officers,  54; soldiers,
864 ; soldiers' wives and children,  164 ; civil-
ians, 4864 ; being altogether 5949.   Dr. Nooth
and  several surgeons, both military and naval,
believed that this  pestilence, which had thus
in four  months carried off nearly half the pop-
ulation, to have been local as to origin, and non-
infectious ;  while  Sir W. Pym and Sir J. Fel-
lowes,  and the surgeon of the artillery, gave
their decided opinions that it was highly infec-
tious, and that it  had  been  introduced from
abroad. But  the  scientific and experienced
reader—especially if  he have ever seen cases
of this  pestilence—will  be much  surprised, and
at once know how to estimate Dr. Nooth's
opinions on these topics, when he reads in that
physician's first official report that  he  consid-
ered the fever " as decidedly inflammatory as
it possibly could be ;" that he believed  many
of the  medical officers to have lost their sen-
ses  for believing the malady contagious and of
a putrid character ; that  he laboured  to con-
vince the public that there was nothing to be
dreaded from a communication with the sick ;
and that he (evidently then a stranger to the
malady !) dictated  peremptorily to the  medical
officers below him (for, most  unfortunately  for
thousands,  he was at the head of the  medical
department) the mode of treatment they ought
to pursue.   In his second official report some-
thing of the results of these hastily-formed opin-
ions and measures becomes apparent; for he
states  the losses in certain corps to have been
"enormous,"  and, among the inhabitants, the
ravages of the distemper " as beyond  descrip-
tion terrible." He, moreover,  now begins to
waver  as to  the  source  of  the malady,  and
either  gives very  opposite opinions, or is alto-
gether ignorant of the  meaning of the terms
which  he employs.  Thus, after  stating that he
had himself " contracted the fever in that fo-
 cus of  contagion,"  he adds that " the disease by
 no means seems to be infectious, but the whole
 atmosphere on the rock is pestiferous; and I
 am inclined to think that, in addition to the or-
 dinary causes of contagion, we may consider a
 large limekiln in  the upper part  of the town as
 aid and part  in the  general  mischief!"  And
 this is  Dr. Bancroft's great authority for  the
 local and marsh origin of this pestilence, and
 for  its non-infectious nature!   The whole of
 the four letters to the  surgeon-general written
 by this physician—this infliction on the profes-
 sion and  the  military service—abounds with
 similar drivellings and peculiarities.   How ad-
 mirably successful his endeavours to restore
 " the lost senses" of his " weaker brothers in
 medicine !" and " to convince the public that no-
 thing was to be dreaded from communication with

 brother, and two sisters, all residing in the house, were also
 seized with a disease of a similar nature" (p. 103).  " The
 malady spread from the house of Santos to the adjoining
 buildings, while the rest of the garrison were totally exempt
 from it.  For several  days the distemper was  confined to
 the  range of buildings to which it had been traced, and
 where Santos lived ;  and it was observed to make a grad-
 ual  progress among  the  different  families who resided
 there, and to spread to the  sheds in the neighbourhood."
 The farther  progress  of the distemper  to the  military as
 well as civilians may be learned in Sir James's work,
 (See p.  104, et seq.)
     Ill              12
s Infectious Nature  Demonstrated.     177

Ike sick," must have proved, may be inferred
from the fact that, out of the civil  population
of this important fortress, amounting to nearly
14,000, only twenty-eight escaped an attack of
the pestilence, and twelve of these had  pre-
viously been affected either in the West Indies
or in other parts of Spain.  Fortunately for this
place,  at the height of a sanguinary war, Sir
W. Pym and Sir J. Fellowes  arrived to save
1200 of the soldiers, by segregation, from an
attack of the distemper.  Mr. Kenning,  sur-
geon to the royal artillery in this fortress, pub-
lished  a detailed account  of the introduction
and subsequent progress of the pestilence;  and
Mr. Burd, who was at the  head of the medical
department  of the navy,  wrote officially to
Lord Nelson commanding the fleet, cautioning
him  against  communication with ships from
Gibraltar.   But, although Dr. Nooth's " weak-
er brothers  in medicine" were bound to obey
their superior officer, as  to his measures,  they
were not constrained to conform to his opin-
ions.
  96. Although this pestilence had appeared
several times at Cadiz, after long intervals, and
at Malaga, places only about forty or fifty miles
east and west of Gibraltar, when it might have
been inferred that  this fortress could  not have
escaped  if the cause of the mischief had ex-
isted in the  atmosphere, and that no  police or
quarantine regulations could have excluded it;
yet we find that this place, as well as many ad-
joining places in Spain, had escaped up to 1804,
owing to such regulation in parts, if  not  alto-
gether.  Measures  of purification were adopt-
ed after the subsidence  of this epidemic,  and
proved successful,  so that the garrison enjoyed
perfect health from that time until 1810.   In
this  year the pestilence ravaged  Cadiz*  and
Carthagena  ; and  during its prevalence there,
four transports from  the  latter port, two of
them  having  on  board  deserters from  the
French army, anchored in  the bay of Gibraltar.
Sir W. Pym put them in  quarantine, and the
distemper appeared in  all of them in  a  few
days.   He instituted measures for the separa-
  * In September, 1810, the harbour of Cadiz was crowded
with ships from several ports of Europe and America, and
several regiments of British troops were in the town.  On
the 11th the physician  to the Board of Health discovered
some  persons with fever similar to that of 1800 and 1804;
and it appeared from the reports that this malady was in-
fectious, having spread gradually in the quarter where it
broke out, four out of five of the first family attacked hav-
ing died, the only surviving individual not having been
seized ; and it having been ascertained that he had passed
through the disease in 1800.  Sir J. Fellowes communi-
cated this information to the British authorities ; and meas-
ures,  such as the circumstances of affairs allowed, were
adopted to preserve the health of the army and of the
crews of British ships  ; but these precautions, owing to
various circumstances,  could  not be sufficiently enforced.
The British troops, however, continued free from the dis-
ease,  although it surrounded them until  the end of Octo-
ber.  Dr. Snow, physician to the  army, in his official re-
port states, that, " as far as his experience extends, and
from  all the information he has been able to collect, he
thinks this disease contagious; and that nothing but tho
ven active measures which were taken to check it in the
beginning could have  prevented its destructive influence
from  being more severely felt by the troops."  Dr. Plen-
derleath, physician to the forces, had charge of the hos-
pital at the hospicio  at Cadiz, and he reports that the fever
then prevailing was  identical with that of 1800 and 1804 ;
that it was violently contagious ; and that the dangerous
consequences to the army were prevented  by the timely
precautionary measures adopted ; the army having lost only
25 men, although upward of 4000 were carried off by it
from among the inhabitants.  The Spanish physicians also.
believed the disease to be contagious, and imported. 
178    PESTILENCE, HAEMAGASTRIC—Its Infectious Nature Demonstrated.
tion of the healthy, and for preventing commu-
nication with  the  fortress.  Notwithstanding
these, the disease  appeared on  shore ;  but a
strict supervision was instituted, and the sick
were separated from the healthy, and removed
to the neutral ground.  A cordon of troops was
placed around the infected part, and proper per-
sons appointed to superintend the purification
of houses, furniture, &c, and to report the ap-
pearance of the distemper.  Owing to  these
measures, the pestilence was arrested before it
had infected many in the fortress.  In 1804 the
infectious  nature of the distemper was denied
by the head of the  medical department, and
communication with  the sick encouraged, and
nearly  all  were infected, and nearly one half
died.   In  1810 the infectious  character was
recognised, the infected were segregated and
removed to an airy locality, communication
with these was prevented, the healthy protect-
ed, and the mischief was very soon arrested.
  97. In 1813 the  disease  again made its ap-
pearance, and its commencement and progress
were described by Dr. Gilpin and Mr. Fraser,
deputy inspector  of hospitals.   The persons
who brought the pestilence into the garrison
were ascertained.  One'of  them was ill  when
he arrived, and he  communicated the distem-
per to those residing in the same house ; thence
it extended to  both sides of the street in which
the house  was situated.  All escaped who cut
off communication with the infected.  Of 500
persons confined to the dockyard, not one in-
stance of infection  occurred, although this was
the spot most likely to be productive of terres-
trial effluvia,  and  that suffered the most in
1804, owing to communication having been then
unrestricted.   When the pestilence appeared
there were about 5000 persons within the walls
who had been subjects of it at a former period ;
and, after a careful  inquiry, there did not appear
to be one  well-authenticated case of a person
having been  infected a second time, at  the
termination  of the  epidemic.   At its  com-
mencement nearly  8000 persons left the  garri-
son, the greater part of them encamping upon
the neutral ground.  Very few cases occurred
among them, and these chiefly after their emi-
gration, and from  previous infection.   The
strong breezes and current  of air in this place
were expected to prevent the accumulation and
concentration  of infectious  effluvia, especially
in tents, and, consequently, to arrest the prog-
ress of the malady ; and  the results proved
the correctness of  the inference.
  98. In August, 1811, the disease appeared at
Carthagena, and Mr. Vance, who had been in-
fected  by  it in the West Indies, was sent to
that city to report respecting  it.  He stated
that it had not been confined to any particular
part of the town, and that no persons were ex-
empted from it but those who had been  previ-
ously affected by it.  He, however,  mentions
the important facts,  that bilious remittent  fe-
ver, which has been so frequently confounded
with this distemper, also prevailed at this place,
and that many soldiers were in the Royal Hos-
pital  labouring  under  the jail  fever.    Mr.
Vance imputed the appearance of the malady
in Carthagena this year to  the general neglect
ofdestroying the bedding, clothes, &c, of those
who had died of it  during the previous autumn,
the infection  lying  dormant during the cold
weather, and until called into activity by the
summer's heat.  He farther states, that the mal-
ady was introduced into Murcia, where it be-
came destructive, by refugees from Carthage-
na, and that these  cities  had been  placed in
quarantine by the Spanish  authorities.
  99. Of the haemagastric pestilence that ha»
appeared on several occasions in Gibraltar and
other parts of Spain, and has created so much
interest and controversy, it may farther be re-
marked, that much additional information to
that already furnished by Sir W. Pym, Dr. Gil-
pin, and Sir J. Fellowes has been  adduced by
Dr. Hennen, Mr. Redmond, Mr.  Fraser, Ac,
and by the reports of the several commissions
sent to inquire  into the nature and source of
the outbreaks of this pestilence in the south of
Spain and Barcelona.  And it may be premised,
that the several epidemic manifestations of it
which  have occurred in the West Indies, in the
ports of the  United States, in Africa, and in
several places in Spain, being admitted to have
been identical as to nature, it necessarily fol-
lows that the  evidence as to its  source and
propagation in one locality or epidemic equally
applies to all other localities and epidemics.
Mr.  Redmond states,  in his letter to Sir W.
Pym, that the fever under which the 54th regi-
ment suffered in  Gibraltar  in 1804, and  again
in Jamaica in 1808, was the same disease, and
that it was infectious on both occasions.  Of
this he adduces the  most  convincing proofs.
He notices the circumstances of the fever hav-
ing been introduced by infection into the regi-
ment in Jamaica in 1808;  that it infected al!
who had  not previously been attacked by it;
that, in a few weeks, his two assistants, and
twenty out of twenty-one  hospital  attendants,
were infected ; and  that  none of those who
had had the disease in Gibraltar were attacked
in Jamaica.
   100. In the reports made by order of the
governor as  to the first appearance of the pes-
tilence in the fortress, Mr. Kennedy, who rec-
ognised its  nature, and watched its progress
from the  commencement, adduces the follow-
ing evidence: At the beginning of September
of 1804 the distemper appeared in the vicinity
of Boyd's Buildings ; and a bombardier and his
wife, residing next door to the  house of the
person Santos, said to have imported the mala-
dy  from Cadiz, where it then prevailed, and
who was then  labouring  under it, were  the
first attacked in the artillery.   Those who vis-
ited the bombardier and his wife were the first
taken  ill in  that corps; and that  part of the
corps quartered nearest to their residence was
the  most unhealthy.  Mr.  Redmond,  surgeon
of the 54th  regiment, traced the disease from
man to man, and reports as follows : Whenev-
er a man was admitted into hospital his com-
rade or bed-fellow soon followed.  When an
officer was  affected, the servant was also af-
fected ; the same could be said of husband and
wife.  Of twenty-six persons employed as the
hospital servants of this regiment,  not one es-
caped.   When  officers and  familie's in  this
corps  avoided  communication no  disease ap-
peared, but  the moment they neglected  this.
precaution they were  no  longer  safe.   Two
families lived in  seclusion  at Europa, and es-
caped until, on the setting in of the rains in
November, they returned to town, when the 
Its Infectious Nature Demonstrated.      170
         PESTILENCE, HAEMAGASTRIC—:

whole were attacked, excepting one who had
been in the West Indies.
  101. Dr. Hennen states the following demon-
strative and undenied facts:  1st.  The deaths
among the military in Gibraltar on the 1st of
October, 1804, were upward of 130 ; and among
them the garrison chaplain, who was attacked
three days after attending a woman in her last
moments.  The five persons who carried  the
body to  the grave were  attacked on the fourth
day, together  with eight others who  attended
the funeral.   Colonel Fyers, who at first had
considered the malady non-contagious, was in-
duced by these  proofs of infection to change
his opinion.   He removed his family, consist-
ing of fourteen  in number, to Europa, estab-
lished a  strict quarantine, and they  all escaped ;
while De Rolle's regiment, who were encamp-
ed within forty yards of them, but not prevent-
ed  from communication with the inhabitants
and  the rest  of the troops, had no less than
442 cases out  of a strength of 635, the mortal-
ity being 197.   2d. Capt. Dodd's family, seven
in number, and  Mr.  Straith's, three in num-
ber, lived  in detached houses, and avoided all
communication, the distance between the hous-
es being 300 yards.  On this intermediate space
the 54th regiment was encamped.   Of this regi-
ment, consisting of 747  men, 456 were attack-
ed, and upward of 100 died ; and yet not an in-
dividual of Dodd's and  Straith's  families on
each side of this corpse  was affected.
  102.  It should be recollected that Dr. Hen-
nen was no partisan ; but he adduced the facts
which came officially before  him at Gibraltar
with praiseworthy candour.  He farther states
other circumstances  resembling the foregoing,
and remarks, " That the sole cause, therefore,
oould not have existed in the atmosphere breath-
ed in common by all, whether soldier or civil-
ian, is rendered highly probable."   The follow-
ing facts farther demonstrate the truth of this
inference.  The Spanish troops doing duty at
the Lines, 3000 in number, within one mile and
a quarter of the garrison, had no sick.  At San
Roque,  five miles distant, with a population of
6000, no sickness appeared during  this epidem-
ic period at Gibraltar.   At Algesiras, ten miles
distant by land,  and  five or six across the bay,
the disease appeared on the 7th  of October,
1804, the  prevalent  opinion being that it was
imported from Malaga and Cadiz.   At Los Ba-
rros, four or five miles from Algesiras, no pre-
cautions were used, and the disease extended
thither  and to  Smeras,  another  small town
about twenty miles distant; while  at  San
Roque, and in the Lines opposite Gibraltar, all
communication with  Gibraltar, on the one hand,
and with Algesiras, on the other, was complete-
ly cut off, and the distemper never appeared.
Dr. Hennen*  adds, " if these facts are not in

  * Dr. Hennen, who was at the head of  the medical de-
partment  of the garrison  at Gibraltar when the epidemic
pestilence of 1828 broke out, and who died of the distemper
at an advanced period of this epidemic; must have seen
enough in the course of the early part of it to confirm his
opinion as to the infectious nature of it, or  to establish his
belief in this property if it were previously not quite  de-
termined; for in  an official communication to the military
secretary of the governor, he writes us follow*:
     " Gibraltar, Hith Sept., 1828, 9 o'clock.  Immediate.
  " Sir: Nothing hag yet been done about the infected bed-
ding at the naval  hospital.  Pray allow ine  to order it over
the  line wall at Camp Bay instantly, as much loss of life
may be the consequence.  The barrack master's plan of
favour of segregation and moderate quarantine,
I know not what can be deemed so;  at least
they convey to my own mind the most perfect
conviction upon  these  points."  (P. 107.)  It
was stated, moreover, by Sir J. Fellowes and
by Mr. Benyon, surgeon of the 10th regiment,
" that every master of a transport who had bu-
siness in the house of the agent for transports,
whose family was attacked with  the  malady,
caught the fever, while  all  those vessels in the
mole, which had no communication with  the
shore,  escaped."
  103. That the clothes and bedding of  the
sick will propagate the distemper is shown  by
the following circumstance : A quarantine  en-
campment of those who  had not passed through
the fever was formed in Gibraltar on  the  9th
of November, 1804.   These men, with the  ex-
ception of the  13th  regiment, took  their bed-
ding with them ; but the  13th, by the precau-
tion of their colonel,  left their old  dirty bedding
behind, and  brought clean blankets in lieu :  not
a man of this corps was  attacked; while  on
the 22d of this month, five  men of other corps
were seized, and within the three following days
every regiment, except the  13th, had men taken
ill.  (Hennen, p. 40.)  In  whatever light this
fact may be viewed, it suggests a most requisite!
precaution ; and that such  a precaution should
have been neglected  may be viewed  as one of
the many evil results arising out  of the doc-
trine so assiduously inculcated by the heads of
the  medical staff on the outbreak of the pesti-
lence (see § 95).  The non-infectionists argue
that the  malady is not  propagated by emana-
tions from the sick, either direct or by fomites,
and hence that no such precaution as the one
now stated is requisite.   That it was most re-
quisite—that the neglect  of it in this and  on
numerous occasions  in America, the West In-
dies, Africa, and in Southern Europe, was most
calamitous—even most murderous, is apparent
to any reflecting mind.   Ten times as many
lives have been sacrificed during the last sixty
years by the abettors of a most erroneous doe-
trine—by following the  false glare of what has
been ignorantly deemed the lights of science,
instead of adopting the suggestions of common
sense—than have been lost on the field of battle.
  104. Mr. Fraser, the  experienced chief med-
ical officer at Gibraltar  during the epidemic of
1813 and 1814, writes as  follows: "The fea-
tures of the epidemic; its course  through fam-
ilies ; the early and  almost universal seizure
of the  medical officers,  clergy, and rabbis, and
of those immediately employed about the sick,
if not emancipated by a previous attack;  the
sickening of washer-women, the good effects
of seclusion, and  the remarkable escapes  of
those who took  particular  precautions, led to,
and finally confirmed the belief of the infectious
nature of the malady."   He farther states, what
my own  observation has confirmed, " that,  of
the number of medical authors who deny  the
contagious properties of the disease in their
closets, many yield to the ineffable impression
made by the immediate view of  the epidemic
calamity," and  acknowledge the communica-
bility of it by their fears, by their acts rather
taking it direct to the sand-pit is fraught with danger.  It
should be steeped in the sea for sixty hours at least before
it goes to any place, when it may be mixed with other beds.
                    (Signed)  J. Hennen, M.D." 
Its Infectious Nature Demonstrated.
180      PESTILENCE, HAEMAGASTRIC—]

than by their words—by " their personal man-
ners ; their care of those dear to them ; the
placing of their patients under observation ;
and the adoption of other means, which could
originate solely in a latent belief of infection."
  105. Dr. Arejula, an  eminent Spanish phy-
sician, and author of a work on this pestilence,
states, that " a regiment of dragoons  in the
centre of  infected places in 1800, continued  in
uninterrupted good health  during the  whole
time of the continuance of the epidemic,  guard-
ed from its  dangers by the  good sense and
vigilance of its commanding officers, who form-
ed a cordon from the  corps itself for the pro-
tection of its own quarter."  This fact is quo-
ted by Dr. Jackson from Dr. Arejula's work,
with the remark, " that  it is imposing, and,  if
the truth  of it were authenticated officially by
the signature of the officer who commanded,
it would go  far  to decide the question under
discussion."   But the fact respecting the im-
munity of those shut into the dockyard in Gib-
raltar in 1813 (§ 87) is equally strong and ad-
mits of no doubt.  Why does Dr. Jackson throw
doubt upon a fact  stated by so  respectable a
physician  as  Dr. Arejula  is  known to have
been, when he might have ascertained the ac-
curacy of it when  he  was at Cadiz not many
years afterward 1  It is, however,  duly  credit-
ed by Mr. Fraser, who  must  have possessed
some means  of ascertaining the  truth of it.
Indeed, the fact does not repose upon the tes-
timony of Dr. Arejula  alone, nor does it re-
quire the confirmation  of Mr.  Fraser, for  it
should be known that  it  was witnessed  by the
French commission  sent to the south of Spain
in order to investigate the nature  of this epi-
demic, and was adduced, in the report of that
commission,  with many other facts, proving
the introduction  and infectious nature of this
malady ; which report  is published in the origi-
nal French in Sir W. Pym's work on this pes-
tilence, and ought to have been known  to Dr.
Jackson*  long before he either went  to the
south of Spain  or wrote upon this distemper,
seeing that it  was published both in Paris and
London long  previously, and  again noticed by
the French commission sent to Cadiz to report
on the epidemic there in 1819.
  106. M. Pariset, in his report of the progress
of the pestilence in Andalusia in 1819,  states,
that it was in all respects that of an epidemic
diffused by contagion.   That, having appeared
at a single point, it extended itself like an in-
  * Dr. Jackson was sent to the south of Spain in 1819
to inquire into the pestilential epidemic prevailing there at
the time.  He returned to England and wrote a very la-
boured work respecting this distemper, in which the vari-
ous modifications of it, according to the temperament and
habit of body, are described, with numerous arguments,
pleadings, <fec, against infection, now and then, however,
with certain  admissions, proving the opposite doctrine to
that for which he argues.  What reliance may be placed
upon his opinion as to the matter I shall leave the reader
to determine, after having read a paragraph, to which I
have already referred, actually  admitting the presence of
infectious properties in this pestilence, and which concludes
as follows : "I was indisposed myself on various occasions,
never in health, though my visits to the sick were desulto-
ry and comparatively few."  (See p. 49 of his work.)  This
having been the case, as Dr. Jackson admits of himself,
how was he enabled to describe so fully, I cannot say so ac-
curately, this distemper? and how came he to support  a
most important, but dangerous, doctrine as to the origin and
nature of a pestilence, the occasions of his seeing and judg-
ing which he admits to have been " desultory and compara-
tively few ?"'
undation, and gained in succession places near
its source, and  progressively those more dis-
tant, respecting only such places and persons
as protected themselves  from communication
with those already infected.  Thus, appearing
first in the Isle of St. Leon, it pervaded Cadiz,
where no means of arresting its progress had
been taken ;  attacking two thirds of the inhab-
itants, it was conveyed  to  Xeres and  Seville.
In the last named  of these  cities, measures
were  employed to arrest its  diffusion, and  in
Xeres similar measures were adopted,  but not
so strenuously carried out  as in Seville; and
the results in both these cities were  propor-
tionate to the vigilance  and promptitude with
which those measures were  enforced.  M. Par-
iset farther states, that the pestilence appear-
ed in  no town or village adjoining Cadiz, Xeres,
or Seville, without previous  communication
with  one or  other of those infected cities, or
with some other place already infected; that
in populous towns the distemper prevailed in
proportion  to the freedom  of communication
with those primarily attacked ; and that, wher-
ever all communication was  cut off in due time,
no instances  of the malady occurred.  (Pari-
set, &c, p. 64-67.)  It may be mentioned that,
in the case of this epidemic, as well as of oth-
ers, the distemper did not  appear in distinct
and separate points or localities at the same
time, unless communications had previously ex-
isted between those and  some other places al-
ready infected.   M. Pariset goes on to remark,
that in 1819,  as well as in 1820, wherever the
distemper appeared, it commenced in some in-
dividual  who communicated it to those who
waited upon or nearly  approached him, and
that those sickened with it either in succession
or together.  Thus the inhabitants of the same
apartments, then those of the same house, then
the adjoining houses and those opposite, then
the adjoining streets, &c, were  infected in
succession.   One quarter of a town, or street,
or house, being infected, persons  proceeding
thence into other quarters or streets, or coming
from these into the infected houses, either were
themselves infected, or carried the infection
with them.   This able writer farther observes:
" Open the work of Dr. Arejula,  a treatise
founded on the most authentic documents and
the most enlightened observation ; read what
this very eminent physician has adduced re-
specting the origin and progress of the malady
in Cadiz in 1800;  in Medina Sidonia in 1801;
in Malga in 1803 and 1804 ;  and pass on to the
appearances of it in the last  year (1804) in Ron-
da, Antequerra, Montilla, Espejo, Rambla, and
Alicant, in all which places it was introduced
from Malaga ; follow his recitals respecting the
epidemic of  Carthagena in 1804, showing the
transmission of the infection to Vera, by the
wife and daughter of an  officer who arrived at
the latter place  during the prevalence of the
pestilence in the former, and who were taken
ill soon  after their arrival  at Vera ; the rela-
tions of them, the inhabitants of the same house,
and those  of adjoining  houses, being succes-
sively infected ; peruse other facts of a  similar
nature adduced  by this physician, and compare
them  with  those which have  occurred in An-
dalusia and elsewhere, and  it will be impossi-
ble for the candid mind to resist the conclu-
sion  that this malady is eminently contagious, 
PESTILENCE, HAEMAGASTRIC—Its Infectious Nature Demonstrated.      181
inasmuch  as  it rests upon  evidence  the most
conclusive that can be offered ; and upon facts
as positive and incontestable as historical facts
can be."
  107.  Don J. A. Ferrari, physician  in Xeres,
in his account of this pestilence as he observed
it in that city, has offered some very judicious
observations  and recorded several important
facts respecting the topics  now under consid-
eration.  " Xeres,"  he states, " is situated at
an elevation of about sixty  feet above the  lev-
el of the sea.   It experienced the yellow fever
in the years  1800,  1804, 1819, 1820, and 1821.
There  are no morasses,  marshes,  or other
sources of insalubrity within its boundaries."
Whence,  then, did  this distemper proceed in
those years 1  If it is proved that heat alone,
however excessive, cannot  produce it; and if
this city is free from those local causes to which
it has been imputed by the anti-contagionists,
no other source or cause of it proper to  this
city having been shown to exist, whence did it
arise 1   It is satisfactorily  proved that, in all
these years, the distemper  existed, previously
to its appearance in Xeres, in Cadiz, Malaga,
San Fernando, and Puerto Santa Maria;  and
Dr. Ferrari shows  that Xeres  was infected
from these places.  In order to decide the ques-
tions of importation and contagion, he remarks,
" it will be necessary to prove, in the first place,
the arrival of some infected  person in some  par-
ticular quarter, and this is precisely what I shall
endeavour to demonstrate from the facts which
took place in  this city during the five epidemics
which have been experienced in  it since 1800,
and which have fallen under my observation.
In all these the mode of invasion has been the
same.  The malady had appeared  in some of
those towns, from which the infected  person,
who introduced the contagion  into Xeres, had
removed;  as fully proved  by the municipal
Board of Health in this city (the evidence and
documents to this effect being lodged in the li-
brary of the board);  and it has uniformly  hap-
pened that the fever began  in that quarter only
where such person had lodged."  " At the  time
of its appearance, or before its progress had
extended, the malady existed only in the quar-
ter in which  it was first seen.  Confining itself
to that for some days, its  progress slowly in-
creased, following the direction of the street in
which it first appeared ; and of the houses ad-
joining the first infected.  When it had spread
through the  city its propagation increased in
proportion to the great number of communica-
tions which  the increase of sick occasioned ;
and during all these periods it was uniformly
observed  that the  disease began with units,
proceeded by tens, and concluded by hundreds.
When we consider," he adds, " that  the dis-
temper has always  appeared  in  the seacoast
towns having intercourse with the West Indies,
and extended itself to the adjoining towns and
villages having had a communication with these,
and not  in those  which have no such inter-
course, or with which all  communication has
been cut  off; nor with those  in the centre of
the peninsula, nor in any other save coast
towns, although the latter may be less  exposed
to heat than the former ; if it has been observ-
ed that its prevalence in Xeres took  place only
at the period when its importation could be
traced; that during the  time when the inter-
course was less and the navigation less com-
mon, the disease was also less frequent;  and
if the patient suffers the distemper only once,
as in the case of the smallpox, can we doubt
of its importation and contagion 1"
  108.  Dr. Ferrari thus states the results of
his  observation :  " 1st. That the cause of pes-
tilential yellow fever is a poisonous miasma of
a peculiar kind.  2d. That this contagious  poi-
son is the effect of the union of certain causes,
developed by a high range of temperature.  3d.
That the high temperature is only a necessary
condition, but not the  exciting cause.   4th.
That as, in  this city (Xeres), there  does  not
exist, nor has  ever existed, that union of cir-
cumstances  necessary for its production,  this
distemper is not spontaneous, but has been im-
ported  as often as it has  been experienced.
5th. That, from its mode of invasion, commu-
nication, and propagation in this city, we are
necessarily led to consider it contagious ; and,
6th. That, although it is certain that contagion,
and not heat alone, may reproduce this pesti-
lence, the reproduction is neither so frequent
nor so  easy as is supposed."
  109.  This pestilence appeared in Barcelona
in 1821, and extended to several places in the
vicinity, and a commission was sent out by the
French government, consisting of four eminent
physicians, to  inquire into its source and na-
ture ;  and in 1823 a very detailed  account of
it was  published  by  the commission, forming,
perhaps,  the best treatise extant on this  dis-
temper.  This commission  consisted of MM.
Bally, Francois, Pariset, and Mazet, the last
of whom died at Barcelona.   Barcelonetta  first
experienced  the malady, although  this suburb
is remarkable for its cleanliness and dryness ;
and soon afterward the port; these places hav-
ing the  most  frequent intercourse  with the
shipping.  About the end of April,  1821, many
vessels left the Havana and Vera Cruz, where
this pestilence was then prevailing, for several
destinations;  a large  number proceeding to
Barcelona, where they arrived about the  end
of June  and in  July.  During  the voyage to
Europe many of the sailors died with the black
vomit; their clothes and bedding being gener-
ally preserved and brought in the vessels.  Not-
withstanding these occurrences, free commu-
nication became established between the  port
and the ships, and between the  ships them-
selves.   These facts, as well as the following,
were furnished by the authorities in Barcelona
to the  commission, but were mostly verified by
it in various ways.  The ship  " Grand Turk"
had conveyed  a number of negroes from Africa
to Cuba ; these negroes suffered severely from
malignant dysentery.  Having  landed them  at
the Havana, she departed thence for Barcelona,
and arrived  in sixty-one days, having  lost  sev-
eral of her crew by yellow fever on  the passage.
Soon after her arrival the captain  received on
board his wife, children, and a servant.   The
whole of this family were very soon  afterward
taken ill, and died at Barcelonetta.   The mate
also entertained on board of this vessel his wife,
and his wife's  sister  and  brother.   Twenty-
four hours afterward his wife's sister and broth-
er were attacked with fever, and both died with
black vomit; several other persons  were  also
seized after visiting this vessel.   Now the com-
mission  assert that they went on board this 
182     PESTILENCE, HAEMAGASTRIC—Its Infectious Nature Demonstrated.
vessel and heard these facts stated by the cap-
tain  and mate ;  and  they, moreover,  furnish
farther details of the infection conveyed in other
vessels  which arrived either about the same
time as this or soon afterward, and communi-
cated to persons holding intercourse with them ;
and of the various circumstances which occur-
red in connection with the appearance  of the
pestilence in the city, all tending to explain the
rapid  extension of it, and the very inefficient
measures taken to restrain its progress.  It is
impossible for me to  advert to the numerous
facts and circumstances bearing on the topics
under discussion adduced  by this  commission
They may be perused in  detail in  their able
work.   From these they contend, 1st. That
the pestilence which desolated  Barcelona and
several  places in  the vicinity in  1821 is  the
same distemper as the malignant yellow fever
of the West Indies, and as  the epidemics which
have desolated the  south  of Spain  at various
periods since 1800.  2d. This pestilence is em-
inently contagious.  3d. That it was imported
into  Barcelona by  the vessels  which left  the
Havana on the 28th of April, 1821, and soon
afterward.  4th.  That the germs of this dis-
temper conveyed by these  vessels reside either
in those actually sick  of it, or in their  clothes
and bedding or other effects similarly contami-
nated, or in the air respired in these vessels by
those visiting them.
   110. Now  these  facts  have surely  either
been unknown to, or, if known, entirely sup-
pressed by Dr. O'Halloran, who has professed
to give an account of the  Barcelona epidemic,
and who has  espoused the doctrine  of local
origin and non-infection.   This writer states
that persons sickened  of the pestilence who ob-
served the strictest seclusion ; and that the  at-
tendants on the sick, the nurses in the hospi-
tals, and the washers  of  clothes  and bedding
"generally escaped the impression of the mal-
ady."  Notwithstanding this most  unblushing
assertion, the facts, as verified  by official doc-
uments and by medical men of  high character,
are of the most opposite description ; namely,
that very few of the nurses and attendants  on
the sick escaped ;  that next to these confessors
and  priests  in attendance on  the  sick were
most  frequently attacked  ; and next  to them
medical men.  Thus the Capuchins were con-
stanly engaged in assisting and confessing the
sick, and their whole number, sixty-three, were
infected, and  twenty  died; and, so far from
his assertion being correct as to the failure  of
seclusion, I may state  that the  evidence of its
success is the most complete.  The following
convents, the Capuchins,  Los Angelos, Santa
Theresa, San Juan de Jerusalem,  the Hierony-
mites, and the Carmelites, observed the strict-
est seclusion, and not one of them had a single
inmate infected ; while all the  other convents
which communicated with the city  had  the
greater number of the sisters attacked.  Thus
the Magdalen, consisting of fifteen sisters, lost
ten, all  having been infected.   The sisters  of
Jerusalem, consisting of twenty-eight, had elev-
en deaths, and the others in nearly the same
proportions.   The  French  commission state
that at least twenty-two  physicians  and sur-
geons died at Barcelona of" the pestilence,  be-
sides medical pupils, assistants, and  apothe-
caries.   In  the military hospital almost none
of the assistants to the  physicians and  sor-
geons escaped the disease, and many of them
died.   One of the members of the commission
stated, that the great mortality among the med-
ical men at Barcelona was an illustration of
what  he had witnessed  during the epidemic
yellow fever of St.  Domingo in 1802, which
carried off, in eighteen months, 206 physicians
and officers of health.
  111. In consequence of a decree of the Cortes
of the 13th of  December, 1821, requiring the
authorities of Cadiz, Malaga, Barcelona,  and
the principal cities  which suffered from the
haemagastric pestilence to consult the scientific
bodies, and the most celebrated physicians, re-
garding the existence of contagion, medical
juntas were formed in these cities and several
other places; and all these convocations de-
cided that this distemper is unquestionably con-
tagions ; that it is exotic and  imported ; and
that the best means of preserving the country
from its ravages is the establishment of regu-
lations which may prevent the entrance of the
pestilential infection.
  112. It is of the utmost importance  to the
community, as well in  temperate countries as
in tropical regions, that the subject so long agi-
tated as to the nature of this pestilence, should
be put to rest.  The questions, as to the origin
and diffusion of it, have  been explained in so
different, and even so opposite a manner, during
the early part of this century, and discussed so
frequently  and  so variously—in a calm  and
philosophic temper by a few, with intemperance
and an incoherent want of argument by many,
with manifest ignorance of the subject and even
of the language in which they wrote, by not a
few—that they have been received as matters
of the utmost doubt and  uncertainty by those
who have mere authority only to guide them to
a just conclusion, without having suffered that
experience and toiled in that field which might
have  enabled them  to judge for  themselves.
Much that has been written upon the subjects
embraced by the questions at issue has tended
to mystify, rather than to enlighten ; to involve
in utter confusion when  attempting to explain
what was already clear and unmistakable; and
to gloss with a false science what was man-
ifest to common sense.   Let the writings of
the apostles of non-infection, especially as re-
gards this distemper, be  adverted to, and the
mode in which they handle a very simple ques-
tion be considered.  In our simplicity we be-
lieve that, when one subject becomes infected
with smallpox; or measles, or scarlet  fever a
short time after  having  been near to one or
more persons  already  affected by  either of
these maladies, the infection has been commu-
nicated by these persons, whether the disease
in question be epidemic at the time or not; and
that, when persons who have recently experi-
enced  either of those  maladies,  or when the
clothes of some one who has recently died of
it, have  been conveyed into  places where the
disease did not then exist, but  where it soon
afterward broke out and prevailed, the infection
of that particular malady was actually intro-
duced.   Now, observing  these  occurrences so
frequently as to become familiar  in respect of
these distempers, and knowing that occurren-
ces  identical  with these in every particulai
have taken place in regard to this pestilence 
PESTILENCE. HAEMAGASTRIC—Its Infectious Nature Demonstrated.     183
can we be so blinded by a false doctrine or by J
prejudice as not to infer that the latter belongs
to the same category as the former—that the
one is  infectious  as well as the other; more
especially when, like them, it attacks the same
frame only once, as long since stated by many
observers,  and now satisfactorily  determined
and admitted 1  But the enlightened observers
of what  is going  on in the " bowels of the
earth" consider this view of a scientific subject
too common-place for their  credence, and see
it  otherwise ;  and, in one sense of the word,
although not in that which they would attach
to it,  much more profoundly.  They  either
avoid allusion to this mode of communication
altogether, or endeavour to explain it conform-
ably with  what  they would  term  scientific
views ;  and in place of what  is based on incon-
trovertible evidence—upon  what  is palpable
and unmistakable—they substitute hypothesis
and mystery, and adduce vague and unintelli-
gible explanations to veil what is manifest, and
to prevent the adoption of measures  which
alone can protect  the lives of thousands, how-
ever they may for a time affect the pecuniary
interests of the few—of the speculator and the
capitalist, the modern curses of the  general
community.  With no other object than  the
promulgation of truth, the surest basis of na-
tional prosperity, as it is of all human science,
I proceed to notice  the last appearance of this
pestilence in Gibraltar, respecting which  the
closest inquiries have been instituted both by a
board of British officers and by a commission of
physicians sent by the French government; and I
shall adduce nothing but what has been satisfac-
torily proved by the most irrefragable evidence
   113.  By the official returns there arrived at
Gibraltar between the 1st of June  and 1st of
September,  1828,  several  vessels  from Cuba
and ports of Spanish South America, on board
which  at least ten deaths occurred during the
passage.  The ships more especially suspected
were the Meta, the Hyperion, and the Dygden
They had come direct from  Cuba and  the Ha-
vana ;  having been from forty-six to fifty-four
days on the passage.   Shortly before  leaving
the Havana, where  this pestilence was then
raging, the Dygden lost four or five of her crew
by the distemper ; and at least one of the men
engaged to supply their places came  directly
from the hospital, where he had laboured under
this malady.  During her passage  to Gibraltar
of forty-six days, nine persons were ill, and two
died.   This vessel was put in  quarantine ; but
the quarantine appears not to have been rigidly
enforced ; for, during its continuance, she  was
visited by smugglers ; and at its termination, if
not before,  dirty  clothes were landed to be
washed ;  and two sailors were admitted  into
the civil hospital  from this vessel evidently ill
of this  distemper, although  it was either  not
recognised, or not entered in the  books of the
hospital  as  such,  by  the medical attendants.
From the smuggler and washer-woman, to whom
the foul clothes were sent, and from their fami-
lies, the disease spread ; and to them, as well
as to others who held communication with the
importers of infection, it was traced much more
correctly than it could be possible to trace the
early progress of an epidemic  of smallpox or
scarlet fever, the infectious nature of which is
undisputed.
  114. It was satisfactorily proved to the boards
of inquiry and to the French commission, as
shown by their reports, that, in addition to these
facts, the mate of the ship was ill while in quar^
antine, and not reported to the inspector; that
one of the men who went on board to assist in
navigating her to Cadiz was taken ill a few days
afterward; that  the clothes  of  the men who
died  on board this  ship were sold to  sailors
who  landed from her about the  6th of August
while at Gibraltar;  that the  sister of a sailor
who  had landed from this vessel, and who had
had the black vomit  fever in the Havana im-
mediately before he embarked from that place
for Gibraltar, received a bag of foul clothes be-
longing to that sailor, and  fell sick on the 20th
of August; that the  health guard, Teste, who
was  placed on board this ship on the 27th of
July,  declared to  several  persons that  she
brought the yellow fever to this garrison ; that
the sister of this health guard, who, on the 11th
of August, assisted to wash his clothes,  which
he brought from this ship, fell  sick on the 21st;
that  the first persons attacked were the con-
nexions of sailors and health guards, and per-
sons who had recently been on board ships, and
washer-women ;  and that the ship Dygden was
admitted to Pratique on  the 6th of August, and
the first case  of the pestilence occurred  on the
12th  of the same month.   It cannot be  dis-
puted that, when the sailors of this ship landed
at Gibraltar with  the clothes of the men who
had died of this distemper on  board her,  all the
collateral circumstances favourable to the prop-
agation of it  were present, namely, the  sultry
calm  of a  southern autumn ;  the  peculiarly
sheltered, unagitated, and humid state  of the
atmosphere at this season ;  the steady high
range of the  thermometer, and the abundance
of subjects liable to receive infection from not
having experienced the  protecting influence of
a previous attack.   From the above evidence;
from the circumstance of this fever being iden-
tical with the black vomit fever of the West
Indies, and with the epidemic fever, which have
committed such ravages in this garrison  and in
the south of  Spain  at different periods; from
the fact that it is  essentially different from
every fever indigenous in any part of Europe in
its mode of attack, its symptoms, its duration,
its consequences, and  its anatomical charac-
ters ;  and, above all, from its affecting the same
individual only once during life,  it was ration-
ally inferred that this malady was imported, and
was  not of local origin.
  115. These inferences were further support-
ed by the considerations: 1st. That not one case
of fever identical with this pestilence had  occur-
red in Gibraltar within  the thirteen  years pre*
ceding 1828, excepting four, which occurred in
lightermen and Jews who had been in the habit
of having intercourse with West India  ships ;
although it is presumable  that during that pe-
riod  all the physical causes  inherent  in  the
place, and capable of generating disease, had
been in as full action as at the breaking  out of
the epidemic ; and although the population was
more dense, and the houses less commodious
during these  years than in 1828, as proved by
undoubted evidence.  2d.  That  there was no
evidence to show that there  is any source of
malaria within the Gibraltar  territory, or that
the effluvia arising from dra;na, even when they 
\H     PESTILENCE, HAEMAGASTRIC—Its Infectious Nature Demonstrated.
were most offensive, had any share in producing
the distemper.  The general conclusion, that
this pestilence was imported into Gibraltar in
1828, and that it was afterward propagated by
direct communication, and by  means of the
clothes of persons affected by it, is conformable
with facts observed in  numerous other places,
and with the results of enlightened observation
and rational reflection, with the dictates of good
common sense.
  116.  Dr. Jackson, in  his work on this pesti-
lence, especially as it appeared in the  south of
Spain in 1829, evidently considers, and in  this
respect  errs with many others in thus consider-
ing it identical with the endemic of the West
Indies,  and differing  merely in its  epidemic
form ; that it is the endemic heightened in de-
gree, and rendered more prevalent owing to the
intensity and diffusion of the terrestrial cause.
It is painful to observe how injuriously this im-
pression has acted on his mind while describing
the true pestilential disease; for in  that de-
scription he has mixed up many of his  recollec-
tions  of the West Indian endemic,  and has
wandered into lengthy lucubrations as to the
type of  the malady, and as to the influence of
temperament in modifying its form, and has fur-
nished the most  undoubted internal  evidence
that he entertained no distinct views of the dis-
temper, inasmuch as the whole is laboured, and
in many places quite unintelligible.   He  re-
marks, that " there is  not  one practitioner  in
one hundred, who has resided for years in -the
West Indies, who  believes  that the concen-
trated  endemic of that  country, usually called
the yellow fever, is a disease which possesses
the power of propagating itself from person to
person within the tropics."  Certainly there is
not.  It is well known that all the writers on
West India diseases during the last and present
centuries  admit  this, but many of them—nay,
the majority—also admit, what is the  fact, that
the severe endemic of that climate is not this
pestilence ; that the former is liable to be mis-
taken for the latter;  and that both are often
confounded together, although they are  as dis-
tinct, indeed  more distinct, from each  other
than measles and smallpox.  And in this Dr.
Jackson errs with the minority,  using  at  the
same time terms which involve a theory,  or
mean nothing.   Thus  his "concentrated  en-
demic" must either mean the more malignant
form of remittent, which I have described, from
frequent observation of it in warm climates, in
the art.  Fever, by the name of malignant remit-
tent, and  which I know well is neither infec-
tious nor the pestilence now under considera-
tion, the differences between which have been
long since pointed out by many very intelligent
and experienced observers (see §39,121, et seq.).
   117.  Those who rightly contend for the in-
fectious nature of this pestilence view it  as
entirely distinct from the endemic and sporadic
malady or remittent which resembles it, in some
respects,  as shown above ($ 39).   The non-in-
fectionists, on the other  hand, consider  both
diseases to be the same ;  the endemic or spo-
radic malady being, as they believe, heightened
in degree under peculiar circumstances of the
 soil and situation, and of the atmosphere.  They
 contend that these circumstances are sufficient
 to account for the phenomena observed in the
 epidemic or true pestilential disease without
calling in  the  aid of infection.  As  the infec-
tionists themselves  admit the  non-inlectious
nature of the endemic or sporadic fever which
occurs in warmer  climates, and which  often
appears in more temperate  countries, during
hot seasons, and assumes many of the charac-
ters of haemagastric pestilence, the problems to
be solved are :  1st.  Is the latter distemper also
non-infectious 1 2d. As it is admitted that the
former arises  from  terrestrial emanations  or
malaria, during high ranges of temperature and
a humid state  of the atmosphere, altogether in-
dependently of infection, does the latter distem-
per also  acknowledge  only the same sources,
when they are rendered more intense ?
  118. What has already been adduced may ap-
pear to the unprejudiced sufficient to solve the
above problems.  Phenomena, circumstances,
and facts cannot be annihilated by special plead-
ings, by confident assertions without proofs, and
by vague  hypotheses ; and when we find that
these have been chiefly confided in by the non-
infectionists, and that  they have confounded
together two diseases  possessing very distinct
and altogether different characters, and, in their
various pleadings, have imputed to one malady
that which does not belong to it, because it ap-
pertains to the other, are we not compelled to
believe either  in the innocence of their igno-
rance, or in the guilt of their sophistry and un-
fairness?   I shall  leave  the reader to  adopt
either alternative he pleases after perusing the
following  coquettings  with infection by  the
greatest authority which this party can boast
of,  desiring only that  the postulates, and the
terms either  of "  no-meaning," or involving
some crude hypothesis, may not be overlooked.
Dr. Jackson ruminates as follows: "The gen-
eral atmosphere of an epidemic circle is charged
with  a material of an  unknown quality, dis-
tinctly offensive to health and animal life.  The
epidemic influence is general throughout a given
district, more concentrated at some points of
the district than others,  from causes totally
unknown to us, or  only partially known.   The
atmosphere in the apartments of the epidemic
sick, particularly if these apartments be crowd-
ed  and ill-ventilated, may be supposed  to be
charged with  this offensive material in a com-
paratively higher proportion than the common
atmosphere, inasmuch as it has there less op-
portunity of being diffused.  That, however, is
only  supposition;  the  following is  fact:  Per-
sons of every habit, but more especially persons of
susceptible habit, who enter into the apartments of
those who are ill of the  epidemic fever, rarely fail
to  experience unpleasant sensations at  stomach,
viz., distention  and irksomeness ;  not infrequently
uneasiness in the bowels; suspension or change in
the naturul functions ; headache, heat, pain of the
eyes,  thirst, white tongue, disturbed  sleep,  and
dreaming,  amounting to revery.   These begin-
nings of the morbid act are local; and, as such,
they  are  for  the most part removable by the
 prompt application of remedies that  act locally,
that is, by emetics, purgatives, or others, which
 produce decided changes in  the secreting sur-
 faces of the alimentary canal."   " It is not said
 that the impressions which produced indisposi-
 tion on these occasions were impressions from
 the cause of yellow fever ; it is evident that the
 general atmosphere was epidemic ;  and  it was
| probable that the atmosphere of the sick ward 
PESTILENCE, HAEMAGASTRIC—Its Infectious Nature Demonstrated.
185
was so in a higher degree than elsewhere ;  or,
if not so, that the diseased act was there suf-
fered  to explode  with more facility, in conse-
quence of the diminished coercive energy  of
the atmosphere  which filled  the  sick  apart-
ments" (p. 49).
  119. I have copied the above verbatim ; the
postulates  and  nonsequiturs  will  be  readily
recognised without  much  logical aid.   If the
passage which I have put in  italics is not a
convincing proof of  infection, especially when
recorded so  innocently, so unconsciously,  by
the arch non-infectionist, I know not what else
can be considered  as such.   But  wherefore
should Dr.  Jackson  say as above, that "emet-
ics, purgatives, or others which  produce deci-
ded changes  in  the secreting surfaces," act
only  locally!  His  experience surely should
have  proved  the contrary.   The  reader will
farther perceive the  " no-meaning," or absurd-
ity into which  he lapses  at  the  conclusion,
when he attempts to escape from the very ob-
vious, the palpable effects admitted by himself
to be produced by  the  emanations  from the
sick.   But he goes on farther to admit as fol-
lows : " The yellow fever, during the reign of
epidemic influence,  often strikes like a pesti-
lence by the  mere  concourse of people in a
close place ;  and, if a mass of sick persons be
collected into a  hospital during the epidemic
season, the common emanations from the sick
bodies, whether saturated with contagious par-
ticles  or not, often act offensively on those
who enter the circle, and often appear to be
the cause of the  explosion of a disease which,
without such accessory or changed condition
of the medium in which men  live, would have
probably remained  dormant  for a  time,  and
perhaps  forever.  The  instances  of persons
who have lived in apparent good health in sim-
ple epidemic  atmospheres, and who have  be-
come sick soon after they entered into the cir-
cle of a crowded assembly, or the crowded
wards of a hospital  of sick, are numerous, and
so well marked that they stagger, on a  super-
ficial view, the opinion here contended for, of
the non-contagious  nature of the yellow fever"
(p. 44).  To  be sure they do, and, being admit-
ted by Dr. Jackson, they become evidences of
infection as strong as " proofs from holy writ."
But the superficial view, which he  here depre-
cates, may, nevertheless, be  the just one;  at
all events, I  leave the more profound doctrine
of the fons et origo  mali e profundis, which he
considers the truly scientific and credible one,
for the adoption  of those who,
        " By the glare of false science betrayed,
     That leads to bewilder, and dazzles to blind,"
can see no truth in that which is  a topic of
general belief, which has good common sense
to recommend it, and which is based on estab-
lished facts,  and supported by numerous col-
lateral evidences and analogies.
   120. I have already, and perhaps sufficient-
ly, adverted to the circumstances of the great
majority, if, indeed, not all of those  who believe
in the non-contagious nature  of the haemagas-
tric pestilence, having confounded this distem-
per and the more malignant forms of remittent
or endemic fever with each other (§ 121-123),
and of the  infectionists having considered that
this pestilence is distinct from the latter; that
it  is infectious, but that the endemic is non-in-
fectious, and  of local origin ;  and that, while
the same person  cannot  be infected  by the
former oftener than once,  he may be attacked
by the latter twice, or even oftener, especially
under circumstances which will appear in the
sequel.   To these topics it is necessary more
particularly to advert.
  121. d. That this pestilence is  not identical
with the endemic or remittent yellow fever of Afri-
ca and America, I can assert, from my own ob-
servation and the testimony of the most expe-
rienced writers.  The results of my observa-
tions are certainly in accordance with the evi-
dences furnished by Mr.  Boyle,  and  several
of his contemporaries in  the  British settle-
ments in  Western Africa,* in  so far, at least,
as that  the former  distemper is distinct  from
the endemic fevers of Sierra Leone and the
west coast of Africa.  The haemagastric pesti-
lence appeared at  Sierra  Leone  in  1823 and
1829, presenting identical characters, in its in-
vasion,  progress, and termination, with those
observed  in the West Indies,  North America,
and  the south of Spain; and although it was
most fatal among the crews of vessels, and
those recently arrived, yet  it carried off many
of the old residents and  coloured population,
and of those who had undergone the seasoning
and  remittent of the country, and  who  were
considered safe from any return of these.  The
above writer and Dr. W.  Barry agree in sta-
ting this to have been " a fever, not entirely
new, but extremely rare" in that country; and
that it  appeared during the healthy season,
when the endemic remittent fever is not prev-
alent. , That this pestilence was infectious at
Sierra Leone is shown  by the conviction to
this  effect of the educated and respectable part
of the population ;  by the history of it in the
Bann and Eden ships of war, and in many
other vessels; and  by its extension from the
Bann to  the military in the Isle of Ascension,
and  to other ships.  There is  generally much
difficulty in distinguishing the malignant remit-
tent of Africa from this  pestilence, owing to
the imperfect remissions of the former, and to
the  presence,  at an advanced stage of fatal
cases, of many of the symptoms characterizing
the  early  and rapid progress of the  latter ;
and  hence the epidemic is generally advanced,
or has extended to  many, before its  nature is
recognised.  Opinions as to the origin of these
two epidemics  in  Sierra  Leone  were by no
means consistent with each other.  The dis-
ease was said to have commenced among the
inland native  population, and to have extended
to this town  and the shipping, as well as to
places to the northward of it on  the coast.
  * Misstatements having appeared,  although of slight
consequence, respecting the author's visit to Western Afri-
ca, he thinks it due to himself explicitly to state that he
never had the honour or advantage of  being in any public
service, or in any service whatever; that his  passages to
and from Africa were altogether at his own private cost,
and were dearly paid for before embarking, in both instan-
ces ; and that his travels between the several British set-
tlements and other places, as well as his residence in the
former, were also at his own charge and expense.  He may
farther state that, having obtained his  degree in medicine
after a continued residence of seven years at the university,
he has exercised his profession in no  other capacity than
that of physician;  and that he employed the  time which
intervened between that of leaving the university and that
at which he joined the College of Physicians of London,
and commenced practice in the metropolis, in travelling,
un.tided and unpatronized, in  various  countries, with  the
vidw of obtaining medical knowledge. 
188     PESTILENCE, HAEMAGASTRIC—Its Infectious Nature Demonstrated.
 There can be no doubt of the fact of the prev-
 alence of this distemper among the natives of
 those places before it appeared at Sierra Leone,
 but it was milder, less prevalent, and less fatal
 among them than  among Europeans.  On the
 other hand, the grand jury of this port state in
 their presentment, as respects the epidemic of
 1829, " that they  attribute  the   present un-
 healthy state of Freetown to the  practice of
 landing slaves from the prizes in the centre of
 the town, where they are necessitated to re-
 main under the disease with which they are
 afflicted in a small yard, not more than 120
 yards square."
   122.  It would be more tedious than instruct-
 ive for me to  adduce even a part of the evi-
 dence now before me of the distinct nature of
 this pestilence from the endemic remittent yel-
 low  fever of warm climates.  Every writer,
 from Lining to the present time, who has es-
 poused the  infectious nature of the former, and
 all those whose opinions I have noticed above,
 both British and foreign, agree in admitting the
 distinction, while many of the non infectionists
 either cannot recognise a difference, or do not
 choose to do so, as it militates against their
 doctrine.   I shall only adduce the opinion of
 M. Guyon, one of the chief physicians attached
 to  the French army which occupied Cadiz  in
 1827 and 1828 ; because he states that he for-
 merly believed in the identity of this pestilence
 with the  malignant form of remittent fever;
 but that  his observation and  experience  in
 Spain had convinced him that he was wrong
 He remarks : " Not that, with all my belief as
 to these diseases being  identical, I had failed
 to  perceive well-marked  differences between
 the one and the other; but it must be owned,
 such is  the influence of an  opinion already
 formed, that, of the facts connected with it, we
 see only the side favourable to that opinion.
 The differences between  these two maladies
 are many ;" and he forthwith  proceeds to point
 them out with  much  accuracy.   Much of the
 misconception which formerly existed respect-
 ing these maladies was owing to  the unfortu-
 nate names given  to them, especially to the
 application of the term yellow fever, which, as
 will be seen from what has been adduced from
 Various writers, was generally applied to this
 pestilence, although the yellowness of the sur-
 face was more  remarkable in the severe en-
 demic remittents, not only of Africa and Amer-
 ica, but also of the south of Spain and shores
 of the Mediterranean.
   123. The  remittents, whether bilious,  gas-
 tric,  malignant,  &e.  (see Fever, Remittent),
 with which  this  pestilence has been confound-
 ed, are diseases depending upon the nature of
 the locality—upon exhalations from the earth's
 surface and its productions, varying, however,
 in character and severity, with the tempera-
 tare, humidity, and stillness of the atmosphere,
 and most  probably  also  with  the electrical
 states.  But this pestilence is produced in all
 cases by an  animal poison—by an infectious
 miasm generated by, and emanating from, the
 affected ; and contaminating the immediately
 surrounding air, and various animal  or other
substances capable  of imbibing  it and of im-
parting it to the  atmosphere, but requiring cer-
tain states of the air as regards temperature,
humidity, and stillness for its dissemination;
 and thus, as it  will be more fully seen  from
 what has been stated respecting remittents, and
 from what has been already adduced as to this
 pestilence,  the one  proceeds from  a distinct
 and specific cause, the other arises from ter-
 restrial exhalations, of various grades of con-
 centration, producing co-ordinate effects.  This
 pestilence,  wherever it appears, presents cer-
 tain prominent features, like smallpox or scar-
 let fever, however it  may  vary like thern  in
 severity and in certain subordinate characters.
 If it proceed  from terrestrial exhalations, as
 the non-infectionists suppose, how is it that it
 does not appear in many situations where these
 exhalations are  the most  indisputably  pro-
 duced, and  are  as remarkably favoured by a
 humid, warm,  and still atmosphere as in those
 places  where  it  has occurred the most  fre-
 quently!  And  wherefore is it not observed
 within the  tropics, in the  eastern hemisphere,
 where  the most malignant as well as the most
 mild forms of  remittent fever are prevalent at
 some season or other!
   124. Dr.  Wilson, who  observed  this pesti-
 lence in the West Indies,  states that 117 cases
 occurred within a few weeks, and that " though
 they varied much in  violence, and in many
 other points,  they were uniformly  continued,
 and that nothing  like  remission could be de-
 tected  in any  of them"  (p.  180).   Jacksok,
 Bancroft,  Fergusson, and others,  however,
 believe in obscure remissions, confounding this
 malady with remittent fevers; and hence ar-
 guing  most illogically against the  protection
 from it afforded by a previous attack.  They
 farther contend that reasons for not detecting
 remissions  are to be found in the " violence of
 cerebral  action and speedy gangrene  of  the
 stomach ;"  or  in the circumstance of the func-
 tions  having  been overwhelmed  and  extin-
 guished.  Now cerebral action is often not vio-
 lent.  The  power of the brain is  rather de-
 pressed than excited; and  it is well  known
 that the stomach is  not found gangrenous in
 those cases in which the examination of the
 body after death is not too long delayed.   Be-
 sides, in a  large  proportion  of cases, there is
 neither overwhelming  nor extinction  of  the
 functions, but a slight grade of febrile action!,
 in many instances followed by quick recovery;
 and yet, even  in  these, no remissions occur.
 But this topic  requires no farther illustration.
 Another important circumstance evincing the
 marked distinction between this pestilence and
 the worst forms of endemic fever,  is the fact
 that recovery  from  the  former is  generally
 rapid and complete, without the visceral en-
 largements  and obstructions so frequently ob-
 served  to follow the latter.   The morbid ap-
 pearances after death are  also different; for,
 while the liver  and spleen are generally more
 or less congested, enlarged, and softened  by
 the endemic remittent,  these organs are even
 paler and less  vascular than  natural, although
 often somewhat softened in common with the
 rest of the textures, in the ha;magastric pesti-
 lence.*

  * Dr. ImraY states that, in the epidemic of this pesti-
lence which he observed in Dominica in 1838, the ytll"*
hue extended over the body, hut was deepest in the neck,
shoulders, and breast, with here and there dark irregularly-
shaped spots and blotches, these parti and the  scrotum as-
suming, immediately after the extinction of life, a greenish
colour and livid appearance, while the yellow tinge over 
        PESTILENCE,  HAEMAGASTRIC—:

  125. e. That this distemper attacks the same in-
dividual only once, a previous  infection protect-
iiig the system more decidedly from a future
seizure than  even smallpox or  scarlet fever
from  a second attack of these maladies, has
been  remarked by every experienced  writer
since Lining, and is an additional proof of the
two propositions which I have  endeavoured to
establish, namely,  1st.  That this  malady is
propagated, like them, by an infectious emana-
tion  or animal poisOn ; 2d. That  it is different
from the more malignant forms of remittent or
endemic fever, which is produced by terrestrial
exhalations, which is non-infectious, and which
attacks the  same individual oftener than once,
especially if he have had a change of climate
after  the first  attack.  Dr. James Clark, who
had  great experience of this  malady in  the
West Indies during the latter part of the last
century, and who has carefully distinguished it
from  the remittents  of these  islands, states,
" that those who recovered of this fever were
never attacked a second time, at least no in-
stance occurred of it in our island, nor in any
of the other islands, as I have been informed"
(p. 19).   The  truth  is, that .no recent  writer
has denied this fact, excepting those who have
confounded  this pestilence with  remittent fe-
ver, and who, having seen repeated attacks of
this latter malady in the  same  person, and be-
lieving both maladies to be identical with each
other, have fallen into the sophism of believing
that what was true of the one was also true of
the other.  The protection afforded by a first
attack, although recognised by  several writers
before Sir W. Pym, was  never  duly insisted
upon  and turned to  a beneficial account, until
his services were so  usefully  exerted in  the
early epidemics of Gibraltar.  About the  same
time that he was acting upon this knowledge
to the advantage of many thousands, the Span-
ish physicians  also became aware of the fact,
from observing that all those  who had suffered
from  the distemper  during former epidemics
were not infected by it subsequently.   Notwith-
standing the numerous evidences of this im-
portant fact, adduced both in Europe and Amer-
the whole body was deepened.  Black vomit was not so
constant as the yellowness of the surface ;  but it occurred
in the majority of the fatal cases. " On examination after
death, even when black vomit had not occurred, the stom-
ach was always found to contain that fluid ; and, in all
probability, in most of those cases that ended very Irapidly,
with  but little gastric disturbance, dissection would have
revealed the  presence of that fluid in the stomach.  This
deadly symptom  usually occurred on the third or fourth,
sometimes on the second day."  When the dark vomit
came in contact with the patient's linen or  sheets, it left a
dark, indelible stain.  In the endemic remittent of the isl-
and (he  adds), "yellowness of the skin not unfrequently
takes place, but is unaccompanied with that peculiar livid-
ity of the neck, shoulders, and breast" which is so frequent
in this pentileuce ; black vomit occurring very rarely in the
endemic remittent.
  To the above distinctions. Dr. Imkay adds that this lat-
ter disease is  seldom so sudden in its attack as the former,
is usually ushered in by chills or rigours, and is marked
throughout by distinct remissions and  exacerbations ; but
in this pestilence, any sensation of cold was seldom experi-
enced, either  at the commencement of the attack or subse-
quently ; and no remission was ever observed until the pe-
riod of deceitful  calm, when all pain  and febrile excite-
ment subsided.  " This state, however, was never followed
by an exacerbation, but seemed to proceed from loss of ex-
citability and exhaustion of the vital energies."  The above
is a very correct and precise diagnosis of the two maladies,
which have been so ignorantly, if not dishonestly, con-
founded  with  one another by so many writers against the
infectious nature  of the hasmagastric distemper.         J
ts Infectious Nature Demonstrated.     187

 ica, and by the  French medical commissions,
 still the truth of it was disputed by the non-in-
 fectionists ; for they believed, and believed tru-
 ly, that the admission of it would be the sur-
 render of one of the strongest positions which
 protected  their  doctrine.   But  the determina-
 tion  of this fact, so  as to place it beyond  the
 cavils  of a party and the special pleadings of
 the prejudiced, was undertaken by Sir W. Pym
 at  Gibraltar ;  and, notwithstanding the opposi-
 tion of writers already passed into oblivion, is
 now established as one of the most undoubted
 truths in medicine.   He acted upon it in Gibral-
 tar in  1810, and was thereby enabled to  cut
 short  at once  an  incipient  epidemic   " He
 separated the  first sick and the suspected from
 the healthy population,  using,  as his instru-
 ments  of separation, those  who had acquired
 the necessary immunity  in some  former epi-
 demic.   This  proceeding  now forms the basis
 of the sanatory law in Spain, and has been suc-
 cessfully repeated in Barbadoes, in  1821, by
 Mr. Green."   (Sir D. Barry,  loc. cit., p. 97.)
   126.  /. Much, indeed the  greatest, part, of
 the numerous calamities  of which this pesti-
 lence has  been the cause has arisen from  the
 manner in  which the crews  of ships have been
 disposed of in respect both of the appearance
 of  it in ships  while at sea, and of the commu-
 nications of the crews and of their personal
 effects  with the ports to  which they are des-
 tined.  Of the latter of these topics sufficient
 notice  will  be taken  hereafter;  but  it will be
 necessary to  the full consideration of the  in-
 fectious nature  of this distemper, that some
 notice should be taken of its appearance in ships
 of  war, in  transports, and in other  vessels.   I
 have perused most of the accounts of the out-
 breaks  of  this malady on  board of ships  to
 which  references are made in the Bibliogra-
 phy to  this article, and I have been particularly
 struck, not only by the very imperfect manner
 in  which so very important  a topic as the ori-
 gin of  the distemper on  shipboard  has  been
 considered in  most instances, but even by the
 neglect of it altogether, the reader being either
 left quite in the dark and to his own inferences,
 or  he has intruded upon him  various supposi-
 tions or false facts in the  shape  of foul ballast,
 bilge-water, chips, shavings, &c, which  have
 been considered quite sufficient to  account  for
 the accumulated horrors which have  been wit-
 nessed. Amid the numerous distressing de-
 tails through  which the reader who wishes to
 investigate the  subject will be  doomed to  la-
 bour, he will find very few  who impute this dis-
 temper to  any other  source  than to the above,
 or  to some other cause  equally  absurd, and
 quite as inadequate as they are to  explain the
 results.  Although the ships which have  been
 the subjects of these  dreadful visitations  have
proceeded very  shortly before  from ports  in
which this  pestilence was prevailing, or have
recently received persons on board  from,  or
otherwise communicated with, these ports, or
with other vessels containing cases of the mal-
ady, or  even although they have  been actually
lying in the harbours of the towns where the
pestilence  was prevailing, still  these writers
could see nothing to account for the appear-
ance of it on board the ships of which they had
the  medical care than some one  of the suppos-'
ititious  causes  now mentioned, which, even if 
188     PESTILENCE, HAEMAGASTRIC—Its Infectious Nature Demonstrated.
proved to exist altogether in their fullest force,
are quite inadequate to the production of the
effects, often too weakly or too lightly noticed.
Let any one who feels duly the responsibilities
of the medical character read the accounts so
frequently furnished us by the chief actors in
the scenes  which  they describe — the  state-
ments of black vomit or yellow fever having
broke out; of the greatest  part,  or the whole,
of the crew having been attacked, and of near-
ly the half having  died—without any rational
explanation of the occurrence being attempted,
without any idea of or reference to infection
being  entertained,  without  any evidence  to
show the absence of infection, or that it had
not been introduced;  and,  what is  still more
monstrous,  without any satisfactory attempt,
or even without any attempt at all, having been
made to limit the mischief, or to prevent the
extension of the infection to the  healthy ; and
having  thus read the dry details of facts thus
furnished him—facts barren as to the minds
of most of the narrators, and of them only—let
him then come to  the conclusions, if he can,
that all has been correctly observed and rightly
inferred, and that measures  of prevention have
been sagely, or even at all adopted.
   127. This pestilence appears in the crews of
ships of war,  or transports, or  other vessels,
and is readily recognised by the rapidity of the
fatal result, by the black vomit, &c.   The ships
are at the time either in a port, or have recent-
ly left a port in which  it was prevailing.  One
ship  is provided  with pig-iron  ballast,  and,
therefore, as it cannot be viewed as the cause,
bilge-water, or chips,  or shavings, below the
limber-boards, which generally exist in all ves-
sels, are most  logically inferred to be the cause
of the distemper.  Another ship has shingle
ballast,  and  lo !  the source  of mischief is dis-
covered.  A  third has  neither  shingle, nor
chips, nor shavings, nor even bilge-water  to
furnish  an explanation, and as the idea  of in-
fection  cannot for  a moment be tolerated by
the very  scientific surgeon, he  therefore ar-
rives  at the very  transcendental  conclusion
that the pestilence which has seized the whole
crew, himself, and assistant, and killed nearly
half, is nothing else than the effects of a " lig-
neous  principle" developed from wood by a high
temperature!   While  the men are dying like
rotten sheep—in equal numbers and with equal
rapidity with these not very sagacious animals
—the commander is alarmed, all are amazed,
explanations are required of the learned doc-
tor, and in almost  every case the reader will
find that some one or other of the above caus-
es is  assigned  by him.   Infection suggests it-
self to common-sense  people, and probably to
the commander; but the unfortunate surgeon's
common sense is overlaid, is smothered, by
vicious authority and worthless writings.  Be-
sides, he thinks infection a " vulgar error," and
its recognition  below the dignity of  science;
or, if  it intrudes itself upon his  mind as the
pestilence progresses,  he feels that he has al-
ready committed himself, and cannot retract
without  practically exposing his  ignorance.
He therefore sticks to his  explanation, even
acts upon it, and afterward, perhaps, writes a
book to  prove his sincerity.   All  the while, as
the imputed cause is supposed to  have already
produced all the bad effects that will ensue,
I either nothing is attempted to get rid of it, or,
I if any attempt be made, the measures connect-
 ed with such attempt tend only to diffuse, or to
 concentrate the infectious poison, which either
 was  not dreamed  of, or  not guarded  against,
 nor  in  any way restrained nor  counteracted.
 Indeed, on too many occasions the prevention
 of disease in the public  service is considered
 beneath notice: it has formed no part of pro-
 fessional education ; and when  the information,
 which has been acquired chiefly with the view
 of passing an examination, has  to be  applied
 to great or pressing emergencies, the  cure of
 cases as they rapidly occur  is  attempted by
 certain heroic remedies, while  measures of
 prevention are either never thought of, or very
 imperfectly employed.
    128. Now the reader may suppose that the
 above is an extravagant, an exaggerated state-
 ment of singular or rare occurrences, and of
 the notions which  they have suggested to the
 very  scientific observers.  But let him peruse
 the voluminous writings  on the  subject, if he
 can command the  patience or  the temper ne-
 cessary to the  drudgery,  and then let  him de-
 cide.   In some instances he will find it admit-
 ted that no cause for  the evil  could be detect-
 ed in the ships themselves, and that, therefore,
 there was no cause  for the existence of the
 pestilence; or, in other words, that the most
 terrific  effects were produced  without  agents.
 They will, however, think that I am now actu-
 ally  doing the celebrated persons who have
 thus distinguished themselves a gross injustice
 by this statement;  but they are themselves the
 perpetrators of the act.  In Dr. Wilson's book
 on this  pestilence  he will find sufficient evi-
 dence to this effect.  This writer has favoured
 us not only with his own opinion, but also with
 the official opinions of Dr. Bancroft, Dr. Adol-
 phus, and  Dr.  Macnamara  as  to the  appear-
 ance  of this pestilence  on  board of  certain
 ships of war.  Now these physicians held the
 highest medical appointments in  the West In-
 dies ;  and, as  we  ought to find the  highest
 amount  of medical knowledge in the  highest
 places, their opinions deserve respect—at least
 until we know them ;  but, unfortunately, after
 that knowledge is acquired all respect vanishes
 in spite of the most anxious efforts to retain it.
 As the reader may  be fortunate in this respect,
 let him  peruse the official reports of these phy-
 sicians  in Dr. Wilson's work (at p. 141-147);
 and let him endeavour to give  as  much credit
 as the amount of his  credulity may  permit to
 this writer's  doctrine of the " ligneous origin"
 of this  pestilence ; for he avers  that,  if this
 origin be not admitted, " we shall be under the
 necessity of contemplating  and endeavouring
 to counteract a disease regarding  the origin of
 which we know nothing; we must look upon
 this sweeping pestilence as an effect without a
 cause, excepting such a cause as that which
 smote  the fourteen thousand  Israelites in their
 tents."  One would have supposed that, after
 this apparent endeavour to  discover a  cause,
 some  attempt would have been made to show
 that the malady did not arise from infection or
 contagion,  either directly or indirectly intro-
 duced on the occasions in question, before the
 " ligneous origin," or "principle," or product not
 arising from dry-rot—this something proceeding
| from wood, but not  recognised by the senses— 
PESTILENCE,  HAEMAGASTRIC—]
this essence not seen, but believed in, nor de-
tected chemically or otherwise—this ignis fa-
tuus so  alluring to the doctor, yet so destruc-
tive  to  his patients—could  have become the
object of a devoted faith, of a firmly-rooted be-
lief.  But  no such attempt  is made; and al-
though  the ships of war  were lying at Port
Royal, Jamaica, when this pestilence first ap-
peared in them ; and although it is well known
that it was more or less prevalent in this place,
and  in several of the ships  in this port at the
time, yet no notice is taken of the probability
of infection having been conveyed on board the
ships of war which were so terribly ravaged by
it; and  there does not appear that any attempt
to prevent its introduction  was made  at any
time. Indeed,  on these occasions, as well as
on  most others, the  adoption  or non-adoption
of measures of prevention rests with the com-
mander  of the vessel, or with the surgeon, un-
der the  sanction of the  former ; and where nei-
ther the one nor the other believes in infection,
no  restraints  are imposed.   It would  appear
from the official  reports of the high  medical
functionaries above  named, that  they did not
believe  in infection.  It is well known that Dr.
Bancroft has written voluminously, but it may
not  be  equally well known that he has not
written  either candidly or truthfully, in disproof
of infection.   By the  official reports  on the
ships of war  at  Port  Royal,  just alluded to,
neither  he nor his coadjutors have done them-
selves much credit.  They have most entirely
and most  signally  damned the cause  they
wished, at  least professed,  to  support.  Dr.
Bancroft furnishes, " proprio Marte," the most
damaging proofs, the most conclusive evidence
that could be  adduced against that very doc-
trine which he attempted to establish by means
of two thick octavo volumes of misrepresenta-
tions and special pleadings.  Dr. Wilson would
have deserved  the thanks of all candid minds
for the  publication  of  a report which entirely
destroys the most vicious doctrine—the most
destructive in its consequences to the commu-
nity—that has blinded the understandings of
weak men,  had he not at the same time at-
tempted to rear a structure equally injurious,
and even more unstable and  absurd than the
one which he  has  so  completely overturned.
But let.me advert more particularly to the case
of the  unfortunate  ships of war  which called
forth the reports of the above great West In-
dia authorities.
   129.  It should be premised that the infection
of this pestilence had lurked for several years,
or  even longer, in  the most  frequented sea-
ports of the West Indies, as  Port  Royal, the
Havana, Vera  Cruz, &c. ; and as the  inhabi-
tants, especially those who have resided long in
these places, have been once attacked, and are
no longer liable to be attacked again, it follows
that comparatively few are predisposed to the
affection,  excepting strangers or young per-
sons ; the arrival of a number of the former,
particularly of persons from Europe, being fol-
lowed, while the infection remains in the place,
by an increased prevalence  of the distemper.
Hence  the  arrival  of  ships  from  Europe—
whether ships of war, transports, or traders—
and of troops from a different  climate, is often
very soon followed by an outbreak of this pes-
tilence  among them,  more  especially  if no
■s Infectious Nature Demonstrated.     189

 measures are taken, as too generally has been
 the case, to prevent the introduction of the in-
 fection, or to sequestrate those first attacked.
 The Iphigenia ship of war, while in Port Royal
 harbour, became infected with  this  pestilence.
 At the desire of the  admiral, Drs.  Bancroft,
 Adolphus, and Macnamara proceeded to exam-
 ine her, and reported her clean, dry, and sound
 in every respect.  They admit that the malady
 prevailing in this ship was this pestilence ; and
 that it could "only be produced by an external
 cause," as no cause could be detected by them
 in the vessel  herself;  but what this external
 cause might  have been they appear to have
 been at a loss to imagine, for they  summarily
 dismiss the idea of infection, without, however,
 adducing any evidence  or argument  against
 either the introduction or diffusion of the dis-
 temper by this cause.   While  thus  drivelling
 respecting the existence of " an external cause"
 —this suspected entity or non-entity—the fol-
 lowing statement is made by this sage commis-
 sion :  " We abstain, at this time, from offering
 any opinion as to the probable cause of the disor-
 der [and this pestilence is only a disorder in Dr.
 Bancroft's estimation, the reporter of the com-
 mission] in the  Iphigenia ; though we think it
 right to state that we have not hitherto found
 evidence sufficient to authorize the belief that
 her anchorages in  the harbours  of Curacoa, off
 Puerto Cabello, or Port-au-Prince, within the
 last five months, at all contributed to produce
 the  fever."   Now what is  here aimed at 1
 They assert there was  no  internal  cause or
 source of mischief;  that hence there  must
 have been an external  one ; but that this ex-
 ternal one was not derived from the harbours
 just mentioned : they, therefore, would seem to
 infer that it  existed, or was  derived, from the
 port where this ship was now lying.  But Dr.
 Adolphus comes to this conclusion, in a separ-
 ate  document.  " I consider the fever (in the
 Iphigenia) to have been produced by increased
 temperature and  other atmospheric causes ;"
 and here he stops without a single word being
 added.  This, therefore, we  must consider as
 his  " external cause."   Dr.  Macnamara next
 enlightens us with his "external cause," also
 in a separate document of most palpable ab-
 surdity.   Here it is : " It is difficult to account
 for the generation of disease in a ship so well
 regulated, and in  such a state  of high disci-
 pline as the  Iphigenia ;  and I  am most posi-
 tively and decidedly of  opinion that the dis-
 ease, which has already committed such rava-
 ges on board that  ship, is to  be solely  attribu-
 ted to a particularly vitiated state of the atmo-
 sphere, the influence of which  has been expe-
 rienced along the whole of the American coast,
 from the  northern bank of the  Orinoco to
 Boston in New-England, and in the adjacent
 islands."   How precisely this vitiation of the
 air,  this arch assumption, is limited !   What
 countless crews of ships must have suffered,
 what interminable  wretchedness on  shipboard,
 and on coast-board also, must have  been pro-
 duced by a " particularly vitiated" air, extend-
 ing from the  Orinoco to Boston, inclusive of
 the West Indies, &c.  How few could possibly
 have escaped destruction, seeing that the air
 which all within these extended bounds must
 have breathed was, in the " positive and decided
 opinion" of Dr. Macnamara, in "a particularly 
190    PESTILENCE, HAEMAGASTRIC—Its  Infectious Nature Demonstrated.
vitiated state !"   What a loss science has sus-
tained in having had the particular vitiation in
question, so decidedly and yet so precisely ex-
tended, left entirely unexplained, and its nature
unascertained !   But this deficiency may have
been subsequently supplied, and the document
supplying it may be buried in the rich reposi-
tories  of the  Medical Board  and  Somerset
House.  The reader has now got the opinion
of the majority  of the commission  as  to the
mysterious  " external cause" of  this fever.
What Dr. Bancroft's  opinion is does not ap-
pear.   Probably his experience as to his former
opinions make him  more reserved on this oc-
casion, and he comes into the field  fortified by
the caution  of an old soldier.
  130. The crews of ships of war, transports
or traders, are rarely the subjects  of fever in
the West Indies, unless they are  exposed to
the infection  of this pestilence in  the ports
where it is prevailing at the  time, or have the
infection  introduced among them from  these
ports  or  from  infected  vessels.   They are
rarely in  that country exposed  to the malaria
proceeding  from marshes or lagoons, unless
when watering, or  when allowed to remain on
shore, and  then they  readily are attacked by
remittent fever, especially  if they have  slept
within the sphere of these sources of disease.
The pestilential fever now under consideration
has appeared on board many  vessels whose
crews have not been exposed to these sources,
and not a few of these have been ships of war
which were certainly not so exposed.  Never-
theless,  attempts have  been made, although
most fruitlessly, to show that the causes of the
distemper have existed  in  the ships them-
selves ; either the ballast, or the bilge-water,
or the wood itself of which these vessels  were
built, having been imputed as the cause, with-
out the least endeavour to prove any thing ac-
tually noxious  proceeding from  any one  of
these sources, or to demonstrate the genera-
tion  of any gas from them, whereby the  air
could be vitiated.  Ships of  war are now, and
have long been, provided with iron ballast and
tanks, so that the chief source to which the
non-infectionists imputed the distemper did not
exist in  them ;  and yet  we find  that  many
ships of war have had their crews nearly alto-
gether carried off by it; and although  the  in-
troduction of infection might have been pre-
sumed, owing to the remarkable probability of
such an occurrence, these vessels either being
at the very time in infected ports, or very recent-
ly having left such ports, or having communica-
ted with infected vessels, yet no satisfactory
inquiry was ever instituted by the surgeons of
these vessels  to determine the question as to
the propagation of the  malady  from these
sources ; the only inquiry that was made being
that respecting the conditions of these vessels
as to cleanliness and  discipline.  The  proba-
bility, or even the possibility, of infection was
not dreamed of; indeed, many of those to whom
the matter more especially appertained, would
neither see nor admit infection under any cir-
cumstances, neither the word nor the meaning
attached to it being comprised within the limits
of their belief.   Take, for instance, the follow-
ing :
  131. The distemper existed at Port Royal, in
Jamaica, both previously and subsequently  to
the arrival  of the Rattlesnake  ship of war
there, in July, 1824; this vessel  being clean,
sweet, well  ventilated.   Dr. Wilson, the sur-
geon of her, admits that he was himself the
first who was attacked ; and that he, as well as
the purser,  was  seized  "from exposure  to the
cause on shore."  Indeed, there can be no  doubt
of both of them having contracted the disease
on shore, for Dr. Wilson admits this in no less
than two places at p. 159 of his book, written
to prove the " ligneous  origin  of the distem-
per."  And there  is as little doubt of their hav-
ing introduced the infection on board.this ves-
sel, although he argues  against the existence
of infection, but without furnishing any proofs
of his position ; the efforts to infer the non-ex-
istence of this property obviously originating
either in a desire  to establish his own hypoth-
esis, or in the consciousness of having neglect-
ed measures to prevent the diffusion  of infec-
tion—a diffusion  fatal to a large proportion of
the crew.   The following are facts which can-
not be refuted.
   132. First: this pestilence prevailed at Port
Royal, more or less, for several years, about
this epoch,  namely, from 1819 to 1826 ; but the
doctrines of Bancroft and other non-infection-
ists were exerting a most noxious  influence
over the minds of medical officers in the pub-
lic services in the  West Indies.   Owing to this
circumstance, no  measures were taken,  with
few or no exceptions, among either the military
or the naval forces, to prevent, to limit, or even
to restrain the spread of infection.   The only
restraints which were attempted, and these but
few, were owing  to the  good  sense of com-
manding officers.  During this period the crewa
of many ships became infected with this pesti-
lence at Port Royal;  but the surgeons of these
ships, with  the exception of the surgeon of the
Scout sloop of war, were blinded against infec-
tion, and had some favourite hypothesis to sup-
port.
   133.  Secondly : the Rattlesnake having thus
arrived at Port Royal, where the distemper ex-
isted, communicated with  that port; the offi-
cers who first went on shore were the first at-
tacked by it; and  nearly the whole of the  crew
were afterward seized,  at first gradually, but
subsequently much more rapidly ; for the ship
having put  to sea under a false impression  as
to the cause of the malady, and  bad weather
having come on, and occasioned  the  shutting
of the gun-ports, &c, thereby preventing due
ventilation,  the distemper spread  with greatly
increased rapidity and fatality.  These are the
facts respecting this ship of war, and they can-
not be gainsayed by any special pleader.
  134. Thirdly : but in these fatal years, other
ships  of war arrived during the years 1824 and
1825 at Port Royal, and suffered in a similar
manner to the Rattlesnake.  The Isis ship of
war arrived at this port  in 1824,  and this dis-
temper appeared on board  of her in October.
She was ordered to the Gulf of Mexico, where
the prevalence of  north winds at this season
reduces the  temperature to about  65°, or  even
lower, and the disease subsided.  This ship re-
turned to Port Royal in the following  autumn,
and the  malady reappeared in her,  and was
very destructive.   In this year the Lively, Py-
lades, and Ferret  were half unmanned while
lying in this port;  and other ships wero simi- 
       PESTILENCE, HAEMAGASTRIC—I-

larly infected.   But the calamitous consequen-
ces of a general indisposition on the part of med-
ical officers to admit the existence of infection
were not limited  to the  naval service.  The
military medical officers, with the Coryphaeus
of non-infection then at their head, were equal-
ly blinded to every perception of the property
to the  non-admission of which the lives  of
thousands were sacrificed.  Stoney Hill, in Ja-
maica,  is situated 1300 feet above the  level of
the sea, and would be  healthy for troops if pre-
cautions against the introduction of infectious
fever were  duly instituted.   The  seventy-sev-
enth regiment arrived in Jamaica in 1825, and
was stationed here.  This pestilence appeared
among them, and, no satisfactory means of pre-
venting its spread having been  taken, it at-
tacked nearly all, and carried off a very large
proportion.  It should be, moreover, recollected
that the greatest  prevalence of the distemper
on shore  among  the  military, and among the
inhabitants of  Port Royal who were  not pro-
tected  by a previous attack (for this protection
and its influence should not be lost sight  of in
the argument),  was in the very year and sea-
son of its most destructive prevalence also in
ships arriving at this port.
   135  The surgeon of the Scout sloop-of-war
sent home  documents proving the contagious
nature of this distemper on board  of this ship ;
and Dr. J. Johnson, whose belief in this prop-
erty appears to  have been very limited, or con-
tingent, as he terms it, states that he " had seen
these documents,  and  can vouch for the highly
contagious character of the fever."  (Med. and
Chirurg. Rev., vol. ii.,  p. 12.)  Now,  if admit-
ted to have been contagious in the case of this
ship, and likewise in the case of the  Bann, as
demonstrated by Sir W. Burnett, the  able and
zealous head of the naval medical service, how
comes  the  same  identical malady to  be non-
contagious on board of other vessels placed in
similar circumstances to these, in which oth-
ers it has been  even more general and more fa-
tal 1   Surely, if in about a dozen ships of war
the same distemper appears after arriving at a
certain seaport where that distemper exists,
and  if it be  admitted by one from whom the
admission is almost extorted, that it was actu-
ally contagious in one of these ships, it could
not be less contagious on board  of the other
ships which had arrived at the same port, which
had been infected from the same source, and
in which it was even more fatal than in the
one to  which the contagion is conceded.  This
is a matter  which concerns the lives,  not only
of the crews of ships, but also of regiments, of
armies, and of the inhabitants  of populous cit-
ies and towns ;  and yet it has been allowed, up
to the present day, to be disposed of, and meas-
ures, or rather  worse than no  measures, have
been permitted  to be taken respecting it, in our
numerous colonies  and  dependencies—in our
fleets and in our armies—according to the vis-
ionary  notions of the totally inexperienced, and
of those altogether unacquainted with the na-
ture and cause of the pestilence in question ;
or, what is still  worse, to those who have form-
ed erroneous notions respecting its source and
properties.   What can be the  use of  accumu-
lated facts and of countless observations to
prove that which requires no farther  proof, if
they are  not  to furnish data from which cor-
s Infectious Nature Demonstrated.     191

rect inferences are to be drawn for the benefit
of the inexperienced, for the  direction  of the
wrong-headed, and for the advantage of the
general community, by those competent per-
sons it is  to be presumed to whom these facts
and observations have been officially furnished!
And possessing these data, should  it not be re-
quired that  such  inferences shall be drawn by
minds capable of weighing evidence and of de-
vising rational expedients of protection, that
these inferences might be made the  basis of
instructions for the institution of salutary meas-
ures for the guidance of the uninformed and
the unthinking, and  for the strict  observance
of the reckless and the vain theorizer, in order
that hundreds of thousands of human lives may
not be sacrificed to the Moloch of false doctrine,
as they have been during a long series of years.
   136. g.  Let the occurrences at Sierra Leone
in 1823 and  1829 be taken as a specimen of
the mode  of medical protection from pestilence
in a colony most liable to outbreaks of it, al-
though provided with a colonial surgeon, a dep-
uty inspector of hospitals, and with other med-
ical  officers.  This distemper has  appeared at
this place also in other years; but  the colonial
surgeons  and deputy inspectors have written
on the occurrences of these years, and books
and reports have been the results of their Sis-
yphian toils.   The governor of the colony, how-
ever, has thrown light upon  a subject  which
they  have confused and  mystified;  and has
shown, as respects  the epidemic of 1829, that
it was imported into the colony, and that it was
highly contagious  both there and among the
shipping.   (Narrat. of the Ashantee War, and
Present State  of Sierra Leone, &c.  By  Major
iiicKETrs, Governor.  8vo, Lond., 1830.)  The
medical writers on  those epidemics—for they
cannot be called authorities as regards this mal-
ady, unless they be viewed as such against the
doctrine which they toil so ineffectually to sup-
port—found that a distemper which they recog-
nized, after a time, as altogether different from
the endemic of the country, had come among
them ; but they were quite unprepared for the
occurrence, notwithstanding  the  records  and
recollections of former visitations. They ap-
pear  at first to have mistaken the malady for
the  endemic  of the country, and  when their
eyes were opened they were amazed and alarm-
ed, and they acted  as they have written, in a
state of imbecile confusion and bewilderment.
Their accounts are full of contradictions.  While
they  argue  against infection, they, in the un-
consciousness of helpless ignorance, furnish the
most conclusive evidence of the existence of
this property.  They admit that the persons at-
tacked first in the colony had visited a place in
the vicinity, two or three days previously, where
the pestilence was  then raging, yet they deny
the existence of infection, and issue notices to
prevent the  adoption  of precautions against
the spread of the distemper, at the very time
when such precautions ought to have been ta-
ken under their  directions.   They admit the
identity of the malady on shore with that on
board of several ships in the roadstead,  and of
both with the pestilential yellow fever, and yet
they contend that it was altogether non-infec-
tious in the former, and infectious in the latter!
Their admission  of this property  in the ships
was evidently extorted from them  by  undenia- 
192      PESTILENCE, HAEMAGASTRIC—Its Infectious Nature Demonstrated.
ble facts, and the firm  belief of every rational
and unprejudiced mind ; but no measures of
protection were proposed by them.
   137. The source of the distemper might have
been  readily  ascertained  in both these  epi-
demics, if the inquiry  had been instituted by
competent,  candid, and unprejudiced persons.
Indeed,  in  their unfortunate  endeavours to
mystify  the matter  they  sufficiently  indicate
the source,  although  without the precision and
force which might have been imparted to it by
positive evidence.  Still, the admissions of in-
fection which escape their powers  of conceal-
ment are, perhaps, the strongest proofs  of the
fact that could have been adduced.   The in-
fection having been introduced without having
been recognised or  suspected, until its  mis-
chievous effects had proceeded far, by those
whose duty it was to watch for, to detect, and
to  guard against it, their  secret yet manifest
desire was  to deny its existence, and to  sup-
press, misrepresent, and  distort  occurrences
and circumstances accordingly.  Although per-
sons belonging to the colony had visited places
adjoining where the pestilence was raging at
the time, had returned to the colony, and were
immediately afterward attacked and died, oth-
er cases of the disease following upon these
admitted to have been the first; and although
6hips, more especially slave-ships  with sickly
cargoes  of human beings, arrived at the colony
just before  and at the time of the outbreak of
these epidemics, some of the  writers  on the
subject contended that the distemper had arisen
from malaria  brought from  a  distance by the
winds, and others concluded that  it had trav-
elled from the interior of Africa to the coast—
a sufficient admission of infection ; while the
more observant of the residents believed in its
introduction through one or other of the chan-
nels just indicated,  or through  both.   There
can be  no  doubt, however, that the distemper
was conveyed in 1823 on board of the Bann ship
of war, then at Sierra Leone, where it was pre-
vailing  both  on shore and in the shipping, ei-
ther from  one of the slave-ships  detained  at
 Sierra Leone, or from a trading vessel at that
 place;  that the crews of  the Bann and of the
 San  Raphael, a tender to and accompanying
 the former ship, were generally attacked, a very
 large proportion having been carried off on the
 voyage  to the Island of Ascension, from Sierra
 Leone;  that the pestilence was introduced  by
 these ships into that island, where every one
 was seized, and many died of  it;  that the Dri-
 ver sloop of war arrived in perfect health at this
 island, where a very restricted communication
 took place between her  and  the Bann ; and
 that three persons  " were taken  ill with the
 prevailing  fever, two  of  whom  were  sent  on
 shore, and  one died  on board ; and the captain
 very properly put to sea  and  used every pre-
 caution ; and with these  three cases  the dis-
 ease ceased."  (Sir W. Burnett's Official Re-
 port of  Sickness, &c, in the Bann.)
    138.  While the pestilence was prevailing  at
 Sierra Leone in 1829, the Eden and Champion
 ships of war left that colony for Fernando Po,
 and immediately upon their departure it appear-
 ed and ravaged these vessels, all the medical
 officers, five in number, having been attacked,
 three having died.   When  the ships reached
 Fernando  Po they had  lost  about half their
crews.   At  this  latter place  communication
took place between the  crews of these  ships
and of the Sybille, the  Hecla, and Black Joke;
and the distemper appeared also in these ships,
and became most destructive. These facts can-
not be  disputed,  and  whatever attempts may
be made to explain them away by self-sufficient
cavillers, they will still remain remarkable  in-
dications to all common-sense persons  of that
very important property of the distemper upon
which every  means  of preventing and of  re-
stricting its propagation should be based; and
to the  neglect of which  so much misery has
been inflicted upon extensive communities, both
civil and military, up even to the present day.
During the continuance of this epidemic the
crews of several trading vessels were nearly
altogether swept away.  Every person on board
of two ships  was attacked, and only two sur-
vived.  This frightful mortality appears  to have
been  mainly attributable to erroneous  notions
entertained by the medical officers of the colo-
ny as to the cause of the distemper, and to the
neglect of every  precaution against it,  and  of
all means calculated to prevent  its extension.
Their minds  were preoccupied with one idea,
and  were incapable   of  conceiving another.
This single article of their faith and belief was
malaria;  it was  their evil genius which dis-
torted their vision, disordered their understand-
ing,  perverted their judgment,  and rendered
them altogether incapable of meeting the crisis
which their incapabilities had tended to devel-
op.   Malaria, according to them,  was in the
winds,  in  the waters, in the earth,  and in the
regions  under the earth; and yet  it did not,
they  believed, originate where it was so mis-
chievous, but was brought from  a distance  on
the winds, and even over the extensive bay into
which the Sierra Leone  River empties itself.
To this absurdity they joined a second, name-
ly, the  belief that a  distemper of a continued
and  rapid course, such as  they  observed and
described, could  proceed  only from a cause
always producing effects  of a  very different
character.*
  * While the foregoing pages were passing through thu
press, the author received the official returns to Parliament
respecting the disease which prevailed, in September, 1845,
on board the " Eclair," steamship of war, on her return to
this country from the coast of Africa.  The  conveyance of
this pestilence to the very shores of Great Britain—almost
to the portals of the metropolis—and the alarm of the pub-
lic mind consequent upon the circumstance, gave rise to the
correspondence and documents  on  the subject which have
been printed, and from these the following particulars uro
derived :
  The " Eclair" steamship left Plymouth on tne 2d of No-
vember, 1844, with a crew of 146 officers and men.  On the
20th of December she was at the River Gaboon, on the west
coast of Africa, and passed thence westward and northward
along the coast until she arrived at Sierra Leone on the 23d.
She there took in 40 Kroomen and liberated Africans, al-
lowed to assist the crew.  She departed from Sierra Leone
on the 28th of January, aud continued off Sheerboro, watch-
ing slave-traders, until the  4th of  February.  During this
time the vessel could not have safely approached nearer
than three miles to the shore, owing to the shelving natara
of the coast; but the boats were sent in, and the men land-
ed frequently, and slept on shore on two or three occasions.
Most of the men who had slept on shore were attacked with
feveT, which appeared to have been of a malignant  kind, M
nine or ten of those attacked died ; but two of the men who
were severally seized had not been out of the ship.   These
cases occurred during the months of April, May, and June,
and were  said to have been the endemic remittent of tho
climate; but no details of symptoms are given.  Whenthe
vessel returned to Sierra Leone, on  the 4th of July, the
crew was healthy ; but, from that time until her departure
on the 23d, the men were engaged in cleaning out  the hold 
             PESTILENCE, HAEMAGASTRIC-


   139.  h.  From what has been advanced above
it may be admitted without any assumption,

of the  " Albert" iron  steamship, and were allowed to go
on shore; and several of them slept on shore.  Of these, four
were attacked with fever on the 19th, 21st, 22d, and 23d ;
one was landed, but the other three were treated on board
and died.  No account of the symptoms are given.  But Sir
William Pym, who went  on  board on the arrival of the
" Eclair" in England, and examined the officers, states that
the first man who  died after leaving Sierra Leone on the
23d had black vomit,  and that the cases  which occurred
then and subsequently, as well as those which were still re-
maining, were actually this pestilence.   On this point it is
impossible for Sir William to have  been mistaken ; seeing
that his experience of this distemper in the West Indies
and in the south of Spain has been greater than that of any
other physician whatever; and, although no description or
details are given in the official papers now before the author,
yet quite sufficient is stated to show the nature of the dis-
temper.
   The " Albert" was  taken in tow by  the " Eclair," and
brought into the Gambia on the   10th  of August.  After
leaving Sierra Leone, three other men were attacked in the
end of July, and died ; these men had also slept on shore ;
aud a  merchant who embarked on  board the " Albert" at
Sierra Leone was also taken ill in  that  vessel, and died on
the 27th of July.   The first three of those attacked in Au-
gust were on board of the " Albert" when taken ill.  " Af-
terward the fever became  indiscriminate in its attacks."
The "Eclair" touched at Goree to  take in coals, but was
not allowed pratique.  She went on to  Bona Vista, one of
the Cape de Verd Islands, where she arrived on the 21st of
August, having had, from leaving  Sierra Leone, eighteen
men attacked by the distemper, and of these thirteen died,
most of them with  the black vomit.
   At Bnna  Vista the  disease continued to spread rapidly
among the crew, when,  permission having been obtained
from the Portuguese  governor, it was determined to land
the crew, sick and  well, and purify the vessel.  A fort was
appropriated for the accommodation of the seamen and sick,
and  the officers obtained lodgings in  the town.  Every
means were taken to purify the ship by washing and white-
washing, fumigation, &c.;  all the  Kroomen remaining on
board, with the exception  of six employed in attendance
upon the sick.  The disease, however, continued to prevail
among the officers and men on shore, thirty-one men having
died between the 21st of August and the  13th of September.
Under these circumstances a consultation was held by three
naval surgeons, and upon their report and recommendation
it was determined that the steamer and crew should proceed
to England.  The ship's company were  in consequence re-
embarked, and sailed  on  the 13th  of September;  Captain
Estcourt  having been taken ill the day  before leaving Bona
Vjsta,  and died on  the 16th.  At Bona Vista  the Assistant
Surgeon Haute, of the "Eclair," died, when Dr. M'Clu re,
a naval surgeon, passenger in the " Growler," and Mr. Cof-
FT, assistant surgeon  of the "Growler," volunteered their
services on board ; here, also, seven seamen volunteered from
the " Growler." Dr.  M'Clure died on the voyage to Ma-
deira,  and one of the volunteer seamen was taken ill of the
fever and recovered.  Upon the arrival of the steamer at
Madeira the authorities refused permission to communicate
with shore,  as had  been  previously done by the French at
Goree  ; but at this island Mr. Barnard, a naval surgeon,
volunteered his services, and was  received on board with
two seamen.  From the  day of her sailing from Madeira,
the 21st of September, up to  the  30th, seven deaths had
token  place from the fever, and eight  new cases had oc-
curred.
   On  the passage  from  Bona  Vista to England forty-one
were attacked, and twelve died.  In the short  time of the
vessel's remaining at the  Motherbank two men were seized
and died.  From the time of her being put in quarantine on
her arrival until the 31st  of October, nine new cases occur-
red, five of which were fatal.  The  pilot, who was taken on
board on the 1st of October to take her to Standgate Creek,
was taken ill on the 7th.  An officer was also seized on the
same day, and both officer and pilot died in three or four
days.   The surgeon was taken ill on the-4th of October, and
the assistant surgeon on the 5th ; the former died.  The ill-
ness of the two surgeons occasioned the sending two other
medical officers, on  the 5th, on board the " Eclair," and one
of them was attacked on  the 11th.   After this period but
slight illnesses occurred,  and the disease entirely ceased
soon afterward, owing  to the arrangements made under the
directions of the quarantine establishment, aided, most prob-
ably, by the low range of temperature at this season, and in
this climate.
  There appears to have existed in  the minds of the medi-
cal officers attached to this vessel a strong belief that the
distemper, which was so fatal, was merely the endemic re-
mittent of the African coast.  As such  they reported the
disease, and  hence were allowed, with great hospitality and
kindness, all the advantages which could accrue from visit-

     III                13
-Source  of  its Infectious  Nature.         193


  1st. That this pestilence is altogether different, in
  its causes, progress, and nature, from every form

  ing Bona Vista ; and yet, when they drew up their report
  advising the return of the vessel to England, the three med-
  ical  officers concur in characterizing the distemper as "a
  malignant fever," causing/' great mortality ;" and in stating
  that " many fresh  cases were  daily occurring;" and  they
  farther add, that " the extremely malignant character of the
  fever, which has resisted the  treatment usually found suc-
  cessful in the common endemic fever of the coast, its contin-
  uance since the removal of the ' Eclair' from the coast, &c,
  induce them to recommend the return of the vesrel to Eng-
  land ;" a resolution most proper in the circumstances ; but
  the very terms in which the  recommendation is  worded
  show a tacit consciousness that they had not the endemic
  remittent of the climate to deal with.  That the distemper
  was  genuine haemagastric pestilence, is shown by the  very
  few particulars furnished by the printed papers as to the
  appearances and symptoms of the distemper.  I state this
  from my experience of this  pestilence  and  of the endemic
  remittent of the coast of Africa.  Dr. Stewart, in his
  medical report of tne  few cases which came before him  after
  the 7th of October, when he joined the " Eclair," mentions
  " black vomit and slight yellowness of the  skin, which be-
  came of a deeper shade after  death.  In the second  case
  there was hiccough during the last fifteen hours of life, and
  with the hiccough a plugging, guggling sound, which con-
  veyed an assurance, that had it been possible to examine the
  stomach after death, coffee-ground fluid would have  been
  found in it.  There was a slight tinge of yellowness in that
  case, also, during the last hours of life ; and after death the
  body became very  yellow, while the neck was as dark as if
  the patient had been  strangled."   (P. 90.)
   That an infectious  fever had been introduced into this
  vessel, and that it spread by infection  to all who were at-
  tacked,  are proved by the history of its progress; by the
  extension of it to all but one of the medical officers who at-
  tended the sick, and the death of most  of them ; by the in-
  troduction and spread  of the pestilence to  the inhabitants
  of Bona Vista; by the infection of five of the Kroomen, or
  native Africans, who  are exempt  from  remittent fever, but
  not from this pestilence, although they are little subject to
  it;  and of the persons who went on  board  the vessel after
  her arrival in England ; and by the " fact of the sick attend-
  ants from the ' Worcester' getting fever  after returning to
  the 'Eclair.'"  (P. 90.)
   In farther proof of the above, it may be added, that of
  four officers of the " Growler" steamer sent to survey the
  purser's stores on  board the " Eclair," three  of them—the
  lieutenant, purser, and clerk—were attacked in consequence,
  and several of the crew ; " in all thirteen cases ; and two of
  the three last cases died at Woolwich with all the symptoms
  of the disease."  (P. 77.)
   It now remains  to notice what occurred at Bona Vista
  after the departure of the " Eclair;" and,  in doing this, it
  is necessary merely to furnish abstracts from the official re-
  ports of the British consul and of H.  M.'s commissary judge
  to Lord Aberdeen.  Consul Rendall states, that  the
  " Eclair" was  allowed pratique, and permitted to land her
  crew at Bona Vista on the representation of the medical of-
  ficers that the cases of fever which had occurred on board
  were the endemic remittent ; that black vomit had not been
  mentioned ;  that, seven days after the steamer had left, one
  of the white Portuguese soldiers who had been housed with
  the crew of the " Eclair" died in the fort (which had been
  given up to the crew) ; that on the  following day  another
  also died, and the remaining soldier in  the  fort (a coloured
  man) was reported sick ; that another coloured soldier, sent
  to assist his comrade, was also  taken ill; and that  the au-
  thorities therefore abandoned the fort and island, and caus-
  ed the two sic,k men to be brought into the town.  The dis-
  temper then began to spread, and the first fatal case in the
  town occurred in the house where the two coloured  soldiers
  from the fort had been brought and recovered from their
  sickness.  " Up to the first week of Decemberthe fever con-
  tinued to rage, and at that period it had found its way  into
  almost all the country villages, the deaths averaging seven
  or eight daily." " The English have suffered considerably,
  having lost one third of their number," and among them tho
 resident English  surgeon,  Mr. Kenny.   The symptoms
  were black vomit, pains in the head, back, and thighs, with
 suppression of urine, and sometimes haemorrhage.  The con-
 sul adds that the fever had proved contagious  to those who
 acted as nurses to  the sick ; this was  observed to be the
 case without exception.
   The commissary judge, Macaulay, in his letter to Lord
 Aberdeen, after remarking the usual healthy state of Bona
 Vista, and the introduction of a malignant fever  into it by
 the " Eclair," notices  the improper conduct of the medical
 officers who had reported the disease to be  merely the en-
 demic remittent of  the coast, while it was obviously a  ma-
 lignant and  fatal pestilence ; and remarks  that these offi-
 cers, not having " previously served on  the African station,
 had mistaken the malady," declaring from first to last that 
194       PESTILENCE,  HAEMAGASTRIC—Source  of its Infectious Nature.
or grade of remittent fever; 2d. That it is infec-
tious in its  nature  among  the predisposed, and
more especially in a warm, humid, and  close at-
mosphere ; and, 3d. That it  attacks the human
frame only once, the exceptions to this being  even
fewer than in respect of any other infectious mal-
ady.
   [Professor Dickson lays down the following
propositions, as  containing  all that  is clearly
known in  relation to the generation  of yellow
fever:
   "  1st. This malady is  the  effect of a specific
and  peculiar cause.
   " 2d.  In certain localities,  this obscure cause
is permanent, and always  active ;  in  others it
exhibits only an  occasional  activity, by which
alone  its  presence can  be inferred.    In Vera
Cruz,  Havana, and Kingston it is perennially
endemic ;  it is occasionally so in New-Orleans,
Mobile, Savannah, and Charleston, which  last
city  seems to be placed upon  its extreme north-
ern limit of spontaneous production.
   " 3d.  Its relation to season and temperature
is equally well made out,  being efficient only
during the hot months of summer and autumn.
   "4th. Yellow fever is contagious;  in other
words, a case of yellow fever having  been gen-
erated in a favourable season  and locality, by its
unknown  and undetected  cause, becomes it-
self a generating centre  productive  of other
cases, or of  a morbid agent  capable of produ-
cing them.
   "5th. It is transmissible from any  one cen-
tre to  another, or from any one of its genera-
ting centres  to  a  healthy locality;  and  this
communication or extension  may take place in
two modes: either by conveyance  of a portion
of atmosphere, in which is  diffused  its unde-
fined specific cause,  as  in the hold  of a  foul
vessel, from  any  place where it prevails  epi-

it was nothing but the common  coast fever.   He farther
adds, that Mr. Mantell,  the  queen's advocate, who had
come from the Gambia to Bona Vista in the " Eclair," first
mentioned the occurrence of black vomit in one of those who
had died on  the passage from the  Gambia; but that the
medical officers would not admit that any importance should
be attached to this circumstance ; and he concludes his let-
ter with the same account as the  consul has given, of the
infection of the  soldiers from the crew of the " Eclair," and
of the population of Bona Vista from the former (see above).
The latest published accounts  state the number of deaths
in this island to be upward of 400,  and the distemper still
prevailing.
  I cannot refrain from directing attention to the evils which
have  resulted on numerous occasions, and even more fla-
grantly and  flagitiously than on this, from the confident
tone  so often assumed by  very young and quite inexperi-
enced medical officers of the non-infectious nature of the dis-
temper under consideration, and  from the circumstance of
their confounding it with  the  endemic remittent. These
false  notions are mischievous enough even when entertain-
ed by theorists and speculators after  popularity with money-
getting  traders, who view restrictions requisite to the pro-
tection of public health as invasions of and abstractions from
the amount of their private interests and gains; but  they
become ten-fold more  destructive when they are made at
the caprice or upon the hasty suggestion of an inexperi-
enced and reckless young  surgeon,  the basis of measures
involving the lives of thousands.  Why, in the name of all
that is honourable and humane, among the regular members
of our profession—and we believe,  as yet, none  but  such
can gain admission into our public services, although such
limitations may not be observed  in  palaces or courts—are
not definitive instructions furnished by the heads and boards
of the medical  departments of the  public services, which
may guide the inexperienced in devising precautions against
the extension of malignant and pestilential distempers when
they first appear in ships, garrisons, and armies.  The vo-
taries of medical science would, in their simplicity, believe
that such ought to be one  of the chief functions of those
boards; but, alas! this at least  does not appear to  have
hitherto been one of their offices.
demically; or by the introduction of a sick body
or any fomites imbued with its own contagion.
  " 6th.  As a general rule, the contagiousness
of yellow fever is limited by certain contin-
gencies.  This is Hosack's doctrine of contin-
gent  contagion;  but the same circumstances
limit  the  efficiency,  also, of the  generating
cause, as, indeed,  of all  the  alleged  causes of
yellow fever.  Thus, high temperature is neces-
sary  to  its production,  existence, and exten-
sion.   A depraved  atmosphere, whether koino
or idio-miasmatic, is generally, but not always,
essential to the spread  of the disease.   The
chief contingency on which  its extension pre-
vails, besides heat, is  density of population
Originating in any one spot,  it spreads thence
not only by conveyance, but  by infected  atmo-
sphere, widening its sphere of influence gradu-
ally on all sides,  until   it  takes in the whole
limit  of a dense or concentrated population,
but losing its force as  soon  as  it reaches  an
atmosphere free from concentrated animal ef-
fluvia."   (Essays  on Pathology,  &c, vol.  i.,
p. 340.)
  The  apparent  anomalies  observed  iB  con-
nexion  with the mysterious  spread  of yellow
fever may, as Professor  Wood remarks, be ex-
plained by one of two theories.   According to
one of them, a peculiar  product is  generated,
under certain circumstances, which  is capable
of acting as a ferment, when  it finds the proper
materials to act upon,  and of reproducing  it-
self, or a  substance identical with  it, out of
these materials, as yeast  is generated during
the vinous fermentation which it  has set in
motion.   The other theory supposes the cause
to be a living, organized, microscopic being,
either animal or vegetable,  which, produced
out of  pre-existing germs,  under  favourable
circumstances, is capable of propagating  itself
indefinitely when  these circumstances exist.
According to  either  of  these views, the fer-
ment or the developed germ may be conveyed
in ships, or even in the clothing of individuals,
from one spot to  another; and,  if it find the
proper material to act upon, or the proper food
to support it, with the temperature essential to
its activity, may spread  itself indefinitely, and,
though  perhaps originally little more than a
mere point,  may poison the  atmosphere of a
whole city.  Thus is explained the conveyance
of the disease from place to place, without the
necessity of appealing to the medium of conta-
gion.   That it  is  not more  frequently propa-
gated to  interior cities,  may be  owing to the
less likelihood of the conveyance of the poison
in the clothing of an individual than in the
confined air of ships, where it may possibly be
kept in  existence by the same power of propa-
gation.   In favour of the theory which ascribes
the disease to organic germs, is the fact that it
is endemic or original only in a comparatively
small portion  of those   regions  of the world
where all the  exterior  circumstances would
appear  equally to  favour its  production.  Or-
ganic germs have been planted by the Creator
in certain parts of the earth ; and that of the
cause of  yellow fever, supposing it  to be or-
ganic, may have been originally limited, by the
same fiat which produced it,  to the warm lati-
tudes of America.   That it has reached Phila-
delphia and  New-York,  upon this  continent,
and Gibraltar and Barcelona upon the old, rath- 
PESTILENCE, HAEMAGASTRIC—Source of its Infectious Nature.       195
er than the more distant  ports of the Medi-
terranean or the East Indies, may be owing to
the less mercantile communication of the lat-
ter with the places of its production, or simply
to their greater distance.  (Treat, on Pract. of
Med., vol. i., p. 306.) We believe that the spread
of yellow fever may be more satisfactorily ex-
plained on either of these theories than on that
of abstract contagion, as held by our author.]
  VII. Of  the Origin of this Pestilence.—
The next topics which may require a brief con-
sideration are those involved in the following
questions:  a. Can remittent fever, or fever pro-
ceeding from malaria under circumstances of
crowding,  insufficient  ventilation,  and a high
range of temperature, change its character, and
become this distemper 1—b. Can the accumu-
lation  of the sick of other diseases in a close,
hot, and humid air, give rise to this pestilence,
or generate its seminium 1—c.  Can the accu-
mulation of a number of persons in similar cir-
cumstances,  and more especially of a  large
number of negroes in the close hold of a slave-
ship within the tropics, so contaminate the air
as to occasion, or otherwise generate, the dis-
temper, the pestilence being thus produced  de
novo, whenever  any of the foregoing circum-
stances exist in a marked or decided manner?—
d. Does this malady ever arise de novo from the
decomposition  of accumulated animal excre-
tions or exuviae, or of dead animals in a warm,
humid, and still atmosphere ; or from exhala-
tions from foul or obstructed drains and sewers
during states of the air favourable to their con-
centration 1—e.  And, lastly, is this pestilence
propagated only by a  specific cause, like  to
smallpox or scarlet fever, that may be preserv-
ed for a  considerable time in fomites, during
circumstances unfavourable to its outbreak, but
may occasion it as soon as those circumstances
supervene which favour its operation,  viz., a
high temperature and  a humid and still atmo-
sphere 1
   140. A. Can remittent or periodic fevers pro-
ceeding from malaria so change their characters
and properties under circumstances of crowding,
 of insufficient ventilation, and  a high range of
temperature, as to become this  distemper, and to
assume infectious properties?—The  solution of
this question is  by  no means easy.   The evi-
dence bearing upon it is probably  insufficient
to prove the negative;  but most certainly we
have  no satisfactory proof of the affirmative.
The occasions certainly have not been few on
which a large number of persons affected with
remittent or other periodic fevers produced by
malaria, have been confined  in close apart-
ments, or otherwise placed in circumstances
favourable either to the evolution  of a new
character  in  these cases, or to the production
of a distemper with different  properties from
those  attending the pre-existent malady;  and
yet  I can find no satisfactory evidence of such
conversion of disease having occurred within
the  tropics,  or in more temperate climates,
during hot seasons.   I cannot  deny the possi-
bility of this conversion ;  but  I have not met
with it on two or three occasions  of this de-
scription which have fallen under my observa-
tion ;  and, although it has been contended for
by several very respectable authorities, still the
evidence in favour of it is not  conclusive.   In
order that the necessary elements of sound con-
clusions should be furnished respecting it, the
proofs of malaria and of its consequences, pe-
riodic fevers, should be adduced ; and evidence
of persons holding communication with  others
affected with those fevers in  a warm, humid,
and close air, becoming infected with this dis-
temper, no other source of infection existing,
ought to be furnished.  The existence of re-
mittent fever and its origin in  malaria, the ac-
tual conversion of the remittent fever into the
true haemagastric infectious pestilence, and the
circumstances connected with  this conversion,
should be  fully and unequivocally shown; or,
in other words, the assumption of the proper-
ties of the latter by the former, under the cir-
cumstances just specified,  and the propag'ation
of the assumed properties and converted mal-
ady, thus originating de novo, in a similar way
to other manifestations of this pestilence in an
epidemic form, ought  to be satisfactorily de-
monstrated.  I cannot, however, satisfy myself,
after the diligent attention I have devoted to
this topic, that these premises  are so establish-
ed as not to admit of doubt.  We do not find in
the eastern hemisphere, where remittent and
other periodic fevers are prevalent, and where
the occasions favourable to the conversion of
them into this pestilence are as likely to occur
as elsewhere, that such conversion has ever
taken place,, for there this  pestilence  is un-
known.   During the late Niger expedition, tho
occasions favourable to the conversion of tho
remittent fever into this pestilence must be ad-
mitted, and yet I know that this conversion—
that  this  pestilence, did not  result.  Similar
facts have fallen under my own observation.
  141. This  doctrine  of contingent  infection
owes its origin chiefly to the fact of remittent
fever in its worst forms  having been  so fre-
quently confounded with this pestilence, and to
the circumstance of the infectious nature of the
latter having been so fully demonstrated as to
preclude skepticism, while the belief in malaria
as the original cause was still adhered to.  But
the undoubted and now generally admitted fact,
that this pestilence attacks the same individual
only once, strongly militates against the  con-
version in question,  and against the contingent
origin of  infection, while  it strongly supports
the doctrine of a specific cause of the malady,
different from, and independent of the  causes
productive of periodic fevers.  That the con-
version of these non-infectious fevers, under
the favourable circumstances mentioned above
(y 140), into the haemagastric pestilence, which
is afterward propagated by infection, may be
possible, I will not attempt  to deny.  I, how-
ever, believe it to be very improbable.  I know
that my own observation and research havo
not furnished me with any evidence of its oc-
currence  that can  be implicitly relied upon ;
and hence that conclusive proofs of the fact are
still required.   Besides, most of the outbreaks
of this pestilence have commenced  by solitary
cases, without any instances of remittent fever
having then existed  in the locality or vicinity,
and without any communication having been
known between those first  attacked and  per-
sons labouring under remittent fevers.
  [It is doubtless true that the yellow fever at-
tacks an individual but once in  any of its en-
demial seats, provided he  remain there a con-
stant resident; but let him remove to a coldei 
196      PESTILENCE, HAEMAGASTRIC—Source of its Infectious Nature.
climate  and spend but a single winter, he will
again be liable to a re-attack on visiting a trop-
ical climate.  "There  is much dispute," says
Dr. Dickson, "whether a  Gibraltar or New-
York attack will save a man from a second in
Havana or Vera Cruz, or even in a subsequent
epidemic visitation after a long interval.  I be-
lieve the security in these latter cases less per-
fect, but I  cannot help regarding it as still very
notable, and fully proved."   This protection is
evidently,  then, owing to the influence of accli-
mation, and therefore does not have an exact
analogy to that observed in smallpox and mea-
sles.  It is  very doubtful  whether one attack
of yellow  fever in New-York or Boston would
render a person insusceptible to another attack
in the same locality.  All, then, that can be af-
firmed,  in  the existing state of our knowledge
on  this subject, is, that  long residence in a
warm and tropical  climate, and a previous at-
tack  of yellow fever, secure  the constitution
for the future.]
   142.  B. Can the  accumulation of the sick of
other diseases in a close, hot, and humid air give
rise to this pestilence, or generate its seminium?—
What I have  stated in answer to the  former
question also applies to this, and even with still
greater force.  Without, however, denying the
possibility of such  an  occurrence as  that in-
volved in  this question, I cannot find sufficient
proof of the fact.   Moreover, as this  distem-
per possesses certain specific properties analo-
gous to those of other infectious fevers, arising
also  from a specific cause—as it, like  scarlet
fever, measles, and smallpox,  presents regular
stages and  periods  ; attacks the  same person
only once, and spreads among the unprotected
by means of an effluvium from the bodies of
those already affected by it under circumstan-
ces favourable to the concentration and opera-
tion of that effluvium—so  it may  be inferred to
be no more the contingent result of the accu-
mulation  of the sick in a close, humid, and hot
air, than any one of the maladies just mentioned
as analogous to it; and we know that there is
no proof of any one of them having so origina-
ted, or having been caused by  emanations from
the sick of  diseases different  from itself.
   143.  C. Can the  crowding together of a num-
ber of persons in a close, hot,  and humid atmo-
sphere, and  more especially  in the close hold of a
 slave-ship within the tropics, so contaminate the
 air as to occasion, or rather  generate, this distem-
 per, and  thus produce  it, de novo, whenever the
 foregoing circumstances coexist in a marked de-
gree ?—That the contamination of the air, es-
 pecially when it is  humid,  warm, and close, ei-
 ther by other fevers or by other maladies, or by
 a number of persons  previously in health con-
 fined in it,  will take place, so  as to produce fe-
 vers of a malignant  character, more especial-
 ly that fever which I  have called Putro-Ady-
 namic (see  Fever,  y 484-496), I have shown
 when treating of that malady (§ 496;; but sat-
 isfactory proofs are wanting of this pestilence
 ever having originated in  this way.  Since my
 visit, however, to several  places in Africa, and
 knowing  the  very  limited space  in  which a
 large number of slaves are often confined, both
 on shore  and in slave-vessels, I entertained the
 idea that this pestilence  or  its seminium, or
 specific infection, had been generated  original-
 ly by  the  congregation of negroes in a close
atmosphere, or is generated de novo by this race
when placed in the circumstances now stated ;
and that, although it affects them in a compar-
atively slight manner, it is most  particularly
baneful to  the  natives  of cold  countries; as
smallpox is comparatively mild in the white
races,  while it  is most pestilential  and fatal
among the  negroes.  This opinion, entertained
since 1817,1 have endeavoured to ascertain the
truth of whenever I have  had an opportunity
of making  any inquiry  respecting it; but the
evidence is not sufficient  to establish this as
the  source of the  infection.  The following,
however, may favour the truth of this idea.   A
small vessel in  which I was a passenger was
anchored,  in May of  1817,  a  short  distance
from Sierra Leone;  and the ship's boat, with
four of the crew, was bringing me  on  board,
when  a  tornado suddenly overtaking us, we
took shelter on board of a ship recently brought
into the harbour full of slaves, and near which
we were at the time.   The  men belonging to
the boat took shelter down between decks.   I
remained under a small poop on  the quarter-
deck.  All these men in two or three days were
seized with this distemper, the vessel having
just put  to sea, and I escaped.   The sick men
were constantly kept on deck, free ventilation
was enforced,  and every  possible precaution
under the circumstances  was  used,  and no
more were attacked.
   144. The organization of the negro, and the
more  extensive functions of the skin of this
race as an excreting organ, give rise to a most
offensive  and foul state of the  atmosphere,
when  numbers  of this race are confined in  a
limited space, and particularly in a humid and
warm atmosphere.   Indeed,  nothing can be
imagined more  nauseous and depressing than
the  respiration of air so contaminated ;  and it
cannot be  disputed that the  concentrated and
virulent effluvium generated from this  source
poisons  the surrounding  and sometimes stag-
nant atmosphere ;  and it may farther  be ad-
mitted that it so affects  the organic nervous
system and the blood as to develop this pesti-'
lence, when all the circumstances requisite to
the production of this effect exist in due force.
The above fact, these  considerations, and va-
rious occurrences or outbreaks  of this distem-
per, after communications with slave-ships, that
have come to my knowledge, induce me to at-
tach some importance to this source  of the
evil, and to suggest that some endeavour should
be made to ascertain  the  amount of credit it
may deserve.   At the same time, I must admit
that some  of the arguments I have used against
the doctrines involved in  the foregoing ques-
tions may be urged against this.
   145. D. Does this pestilence ever arise, de no-
vo, from the decomposition of animal excretions or
exuvia, or  of other animal substances, in a  warm,
humid, and still  atmosphere ; or from exhalations
from foul  or obstructed drains and sewers during
states of the air favourable to their concentration 1—
The remarks already made also apply, in some
respects, to the present topic.   If the distem-
 per ever arises  from negroes crowded in  a con-
 fined space, as  suggested above, this question
 should be answered in the affirmative, inas-
 much as the accumulated cutaneous excretions
 in these cases are mainly concerned in causing
 it.  That the putrefaction of animal substances 
PESTILENCE, HAEMAGASTRIC—Source  of its  Infectious Nature.       197
  in a warm, humid,  and stagnant atmosphere
  will cause malignant fever, cannot be doubted ;
  the  only question  being, whether this  pesti-
  lence, or a form of fever such as I have de-
  scribed under the name of putro-adynamic (Fe-
  ver, $ 484^496), will be the result.  Circum-
  stances  have proved to me the production of
  this latter fever in these circumstances, and in
  forms  more or less malignant and rapidly fatal;
  but I have no proof of the pestilence now be-
  ing considered as having originated in this lat-
  ter source.  The same remark applies to the
  concentrated exhalations from foul drains and
  sewers.   I believe that these are quite  suffi-
  cient,  especially before they are much diluted
  by the atmosphere, to occasion the putro-ady-
  namic fever just referred to ;  but, after exam-
  ining into the attempts which have been  made
  to connect this pestilence with that cause, I be-
  lieve them to have been quite futile, and  by no
  means  supported by even the slightest evi-
  dence.   In many warm regions and climates,
  more especially in eastern countries, as shown
  in several  parts of this work, emanations from
  the excretions, the  exuviae, and the  dead bod-
  ies of  animals, combine, with the  exhalations
  from a humid or marshy soil, to give rise to a
  low or putro-adynamic fever, which may pre-
  sent, with more  or less malignancy, evident
  remissions, more particularly when the terres-
  trial exhalations are the most influential in
  causing it, as  shown in  the  article Fever (v
  435, 484), still this fever will not acquire an in-
  fectious character with a moderate attention to
  ventilation and the  avoidance of crowding of
 the sick.  When, however,  emanations  from
 the decomposition of animal matters, and  from
 drains and sewers, are concentrated in a warm
 and humid air, and  predominate  over  those
 from vegetable matter or from a marshy soil,
 the resulting fever will assume more or less of
 the continued  type and putro-adynamic char-
 acters,  and become infectious in circumstances
 favourable  to the  manifestation of  this proper-
 ty.  Still the  fever hereby produced (and fully
 described in the article Fever, $ 434, el  seq.),
 is not the pestilence now under consideration ;
 and I cannot find any evidence that this pesti-
 lence has ever really originated in this source.
   146.  In thus disputing the origination of the
 true  pestilential yellow or haemagastric fever
 in several sources to which it  has been  very
 loosely  imputed, it may be stated that my skep-
 ticism is caused by the entire want of evidence
 of the truth of such occurrences,  and by the
 very general assumption, without any proof, of
 these as the sources of the distemper.  I have
 no favourite doctrine or cause of my own to
 support, and no theory to subvert, merely be-
 cause it is different  from the one  in which I
 believe.   I am  most  anxious to know the truth
 wherever the truth  is obscured or difficult of
 access; but I lean the most to that doctrine
 which is most truthful, which rests on the most
convincing evidence, and which, as  being itself
truth, is the safest to follow, and is, moreover,
the most advantageous to adopt as regards the
welfare  of the general community.
  147. E. Is this pestilence, like to smallpox and
rear let fever, propagated only by a specific cause
that may be preserved in fomiles for a considera-
ble time, without causing it, during circumstances
unfavourable to its outbreak, but may occasion  it as
  soon as those circumstances supervene which fa-
  vour its operation, viz., a high temperature and a
  humid and still atmosphere ?—That the cause is
  specific cannot be doubted, inasmuch as the ef-
  fect—the distemper—is also specific or deter-
  minate, as the other specific maladies just allu-
  ded to*  It has been repeatedly observed that
  this cause has been preserved in the bed and
  body clothes  of those who have been affected
  by  the disease for a considerable time, either
  when these clothes have been shut up from the
  air, or when  they have remained during the
  cold months  unexposed or unused ; and that,
  when these fomites have been exposed among
  susceptible persons, and  during states  of the
  atmosphere favourable to infection, the disease
  has been reproduced. Thus, in several towns
  in the south of Spain, as shown by most of the
  authorities already quoted, the  distemper has
 gradually  ceased with the  accession of cold
  weather ;  but it has appeared again in the sum-
 mer, or as soon as the atmospheric temperature
 and humidity reached those  grades which are
 requisite to the production  of  infection.   If,
 therefore, it be admitted that the distemper is
 specific—is so determinate in character as nei-
 ther to lapse  into remittent  fever, on the one
 hand, nor to pass into plague or putro-adynamic
 fever on the other ;  and that the cause is also
 specific, and, like other specific causes, capable
 of being  preserved  for a  considerable  period
 without losing its poisonous properties and ca-
 pability of germinating and reproducing itself
 and  the distemper, we may farther infer, what-
 ever may have  been its remote origin, that it
 is not a frequent contingent production or re-
 sult  of the circumstances to which it has been
 imputed, and which  have just been passed in
 review.   If it  were a contingency merely of
 one  or more  of these circumstances, it must
 have occurred in other warm countries besides
 those in which  it has been  so  frequently ob-
 served.  It must, in this case, have  appeared
 both in the eastern hemisphere  and on the
 shores of the  Pacific, where it has never been
 met with.  It may, however, be  stated that,
 while this consideration  militates against the
 contingent production of  the specific  poison
 causing this pestilence in the circumstances
 against which I have argued above, it in some
 degree supports the opinion which I have sug-
 gested, as  to the not improbable  origin of the
 distemper in the concentrated emanations from
 the bodies  of a great number  of negroes con-
 fined in the close, humid; and hot holds of slave-
 ships ($ 143).   If this opinion as to the  proba-
 ble origin of the  infectious poison be not ad-
 mitted,  there is certainly none other deserving
 greater confidence, and we are left entirely in
 the dark as to  the earliest origination of the
 mischief, although the fact of the communica-
 bility and diffusion of that mischief cannot now
 be disputed, nor  the circumstances which fa-
 vour its communicability on the one hand, and
those which prevent or retard it on the other.
The  cause being obviously specific, from the
 very determinate and specific character of its
effects,  we have no greater reason to believe,
in the absence of conclusive proof of the fact
  [* The intermittent fever may be called a specific or de-
terminate disease, and its cause is also specific. It is not
necessary that the cause should be a specific animal virus
in order to make the disease a specific one.J 
198      PESTILENCE, ILEMAGASTRIC—Source op its  Infectious Nature.
 that this specific cause is contingently produced
 in the course of other maladies, or in the cir-
 cumstances  above considered,  than  that the
 specific causes of smallpox, scarlet fever, and
 of other pestilences, are also contingently pro-
 duced in similar circumstances.
  [These facts do not certainly demonstrate
 the doctrine of the contagiousness of the dis-
 ease, in the ordinary acceptation of the term ;
 on  the contrary, they are among those which
 led our countryman, Dr. Rush, to abandon the
 belief in  its  contagious character, which he had
 held during  the greater portion of his life.  In
 his,last writings on this subject (Med. Inquiries,
 vol. iv., p. 144) he remarks, "That the yellow
 fever is not  contagious in its simple state, and
 that it spreads  exclusively by means of exhala-
 tions from putrid matters diffused in the air, is
 evident from the following considerations :  1st.
 It does not  spread by contagion in the West
 Indies.   This has been proved in the most sat-
 isfactory manner by Drs. Hillary, Huck, Hun-
 ter,  Hector, M'Lean,  Clark, Jackson, Bor-
 land,  Pinchard, and Scott.   Dr. Chisholm
 stands alone in maintaining a contrary opinion.
 2. The yellow  fever  does  not spread in the
 country when  carried thither  from the cities
 of the United States.   3. It does not spread in
 yellow fever hospitals when they are situated
 beyond the influence of the impure air in which
 it is generated.  4. It does not spread in cities
 from  any specific matter emitted from the bod-
 ies  of sick people.  5. It generally requires the
 co-operation of an exciting cause, with mias-
 mata, to produce it.  This is never the case
 with  diseases which are universally acknowl-
 edged to be contagious.  6. It is not propaga-
 ted by the  artificial  means which propagate
 contagious diseases, as inoculation, swallowing
 the matter  of  black vomit, &c.   To the  first
 four of these assertions  there are some seem-
 ing exceptions  in favour of the propagation of
 this  fever by contagion.  I  shall briefly men-
 tion them, and endeavour to explain them upon
 other principles.  The  circumstances  which
 seem to favour the communication of the yel-
 low fever from  one person to another by means
 of what  have been supposed to be contagions,
 are as follows : 1. A patient being  attended in
 a small,  filthy,  and close room.  The excre-
 tions  of the  body, when thus accumulated, un-
 dergo an additional putrefactive process, and
acquire the same properties as those putrid an-
imal matters which are known to produce ma-
lignant fevers.   I have  heard  of two or three
 instances in which a fever was produced by
these means in the country, remote from the
place  where it  originated, as well as from ev-
ery external source of putrid exhalation."  (In
what  respect does this  differ from Dr. Cop-
 land's doctrine of contagion 1)   "2. A person
sleeping in the  streets, or upon  a bed impreg-
nated with the  sweats or other  excretions, or
being exposed to  the smell of the foul linen or
other clothing of persons who had the yellow
 fever.  The  disease here, as in  the former case,
 is communicated  in the same way as from any
 other putrid  animal matters."  (Dr. Rush gives
several cases in illustration of this fact.)  "3.
The protraction of a yellow fever to such a pe-
 riod as to dispose it to assume the symptoms,
 and to generate the peculiar and highly vola-
 tilized exhalation from the  pores  of the skin
 which takes place in the jail fever."  (This dis-
 ease, Dr. Rush maintained, was decidedly con-
 tagious, and he speaks of time, i. e.t protracted
 duration, ' rendering fevers of all kinds now
 and then contagious, by excretion,' &c   In or-
 dinary cases he supposed the yellow fever was
 too transient to admit of the formation of this
 contagious  excretion, but might become so in
 rare instances.)  "4. Miasmata, whether from
 marshes or other external sources, acting upon
 a system previously impregnated with the ex-
 creted matters which produce  the jail  or ship
 fever.  5. A fifth instance in which contagion
 has been supposed to take place in yellow fever
 is, where the exhalation from the excretions
 of a patient in that disease acts as an exciting
 cause in persons previously impregnated  with
 the marsh or other external miasmata which
 produce  it.   The  activity of this  exhalation,
 even when  it is attended with no smell, is so
 great as  to induce sickness, headache, vertigo,
 and fainting "  (Cases in point are given.)  " In
 the months of July and August," says Dr. R.,
 " when miasmata are generally local, and  float
 chiefly near  to their hot-beds, the docks and
 holds of ships, persons who are affected by
 these miasmata, and  sicken in other parts of
 the city, never communicate the disease; but
 after the less prepared and heterogeneous filth
 of our whole city has been acted upon by an
 autumnal as well as summer sun, so as to emit
 pestilential  exhalations in all our streets and
 alleys, the fever is now  and then excited in the
 manner  that has been  mentioned by a single
 person in a whole family.   The common intcr-
 mittents of the Southern States are often ex-
 cited in the  same way, without being suspected
 of spreading by contagion.   Even the jail or
 hospital fever is vindicated by Dr. Hunter from
 the highly contagious nature which has been
 ascribed  to it upon the same principle.   He re-
 marks, in relation  to this fever  (typhus), ' In
 considering the extent and power of the conta-
 gion, I  am  not inclined  to believe that  this
 causes the fevers of all those who  are taken
 ill in one family after the first, as they are all
 along exposed to the same vitiated air which
 occasions the first fever. In like manner, when
 a poor woman visits some of her sick  neigh-
 bours, and is  taken ill  herself, and  afterward
 some of  her children, I would  not impute tbe
 disease to infection alone, she  and her  family
 having previously lived  in the same kind of vi-
 tiated air which originally produced the fever.
 If the cases in which the  infection meets with
 the poison already half formed be excepted, the
 disease in itself will be found to be much less
 infectious than has commonly b 'en supposed.'
 By  the  modes of communicating the yellow
 fever which have been admitted, the dysentery,
 and  all the  milder  forms of autumnal fevers,
 have  been occasionally propagated, and,  per-
 haps, oftener than the first-named disease, from
 their being more apt to run on to the typhus or
 chronic  state.   6. The  last instance of  sup-
 posed contagiousness  of the  yellow fever is
 said to arise from the effluvia of a putrid body
 that has  died of that disease.  The effluvia in
 this  case act either as the putrified excretions
just  mentioned under the first  head, or as an
 exciting  cause upon miasmata previously re-
 ceived into  the system.  A dead body,  in a
 state of  putrefaction  from any other disease, 
PESTILENCE, HaEMAGASTRIC—Sources of its Infectious Nature.       199
 would produce, under the same circumstances
 of season and predisposition, the same kind and
 degrees of fever.  The similarity of the fever
 induced by the means that have been enumer-
 ated, with the fever from which it was derived,
 has been supposed to favour the opinion of its
 being communicated by a specific contagion.
 But  let it be recollected that the yellow fever
 is, at the time of its being supposed to be thus
 received, the reigning epidemic, and that irri-
 tants of all kinds necessarily produce that dis-
 ease.  The morbid sweats which now and then
 produce  an  intermitting fever, and the alvine
 excretions which occasionally produce  a dys-
 entery, act only by exciting morbid actions  in
 the system, which conform in their symptoms
 to an immutable and universal  law of epidem-
 ics."  Dr. Rush then  assigns his reasons for
 believing that yellow fever is propagated by
 means of an impure atmosphere, at all  times
 and  in all places, which are chiefly the follow-
 ing :  " 1.  It appears only in those climates and
 seasons of the year  in which heat, acting upon
 moist animal and vegetable  matters, fills the
 air with their putrid exhalations.  2. It is un-
 known in places where a connexion is not per-
 ceptible  between it and  marshes, mill-ponds,
 docks, gutters, sinks, unventilated ships, and
 other sources of noxious air.  3. It is destroyed
 by means of long-continued and  heavy rains ;
 also  by frost, intense heat, and high winds."
 Dr. R. then proceeds to point out the advantages
 which are to result  from a belief in the non-
 contagiousness of yellow fever  (Med. Inq., vol.
 ii., p. 166), to which we beg to refer the reader.
  We have  thus, in accordance with a sense
 of duty toward our distinguished countryman,
 whose  writings  on this subject have  been
 strangely neglected  by our author, given a sy-
 nopsis of his leading views in  relation  to the
 nature and  mode of propagation of this fatal
 malady.   The reader  will perceive  that, not-
 withstanding the apparent difference of opinion
 between him and Dr. Copland, there is not,
 after all, that discrepancy which can justify the
 severity of language indulged in towards those
 who  seem to hold  different views on this im-
 portant subject, and that, if their terms were
 duly defined, and exceptions and explanations
 regarded, there would really, after all, be little
 cause for disputation.
  Prof. J. B. Beck, of New-York, has  written
 as ably against the contagiousness of yellow fe-
 ver as any other American author.  (See New-
 York Med. and Phys. Jour.)  We present but a
 single quotation.   "There are some  persons,"
 says Dr. B., "who have contended that yellow
 fever maybe contagious in one  kind of air, and
 not so in another.   All the testimony adduced
 from  the fever of 1822 is directly adverse to
 this position.  If we suppose the cause of yel-
 low fever to enter into chemical combination
 with the surrounding foul atmosphere, then  it
 would no  longer  be  the same disease.  If, on
 the other hand, the air serves merely as a me-
 dium  for transmitting the poison  to  a greater
 distance, then no reason can be assigned why,
 if you approach near enough to the sick body,
 contagion should not display itself as well in a
pure as in an impure atmosphere.   It has been
already shown that not merely in the pure air
of the country, but  even  in the most  impure
and unhealthy parts  of our city, patients sick
of the  yellow  fever in  1822  were uniformly
approached with perfect impunity.  The air,
therefore,  in the  infected  district must have
been more venomous than  the contagious poi-
son  itself  coming off directly from diseased
bodies ; that is, poison diluted in atmospheric
air must have  been more powerful than puro,
unmixed poison itself—a proposition absurd in
itself.  We infer, then, as the  air of the infect-
ed district was more  deleterious  than actual
contact with the sick, the poison existing in the
air must have been some  other than  effluvia
from the bodies of the  sick" (loc. cit.).
  We deem it unnecessary to enter at length
upon the discussion  of the contagiousness  or
non-contagiousness of thisWlisease.  Dr. Cop-
land has exhausted the arguments in favor of
the former doctrine, and it would require equal
space to set forth those connected with the
latter.   1.  We  hold it  to be a specific disease,
and  not a  high or malignant  grade of bilious
remittent,  as held by Rush  and others.  2.  It
is propagated  by an  infected atmosphere ; but
in what this infection  consists is  entirely un-
known.  3. It  is not communicated from one
individual to another in a pure air, in which re-
spect it differs from all other  admitted conta-
gious diseases. 4. It  does  not owe its origin
to those miasms which cause remittent and in-
termittent  fevers.   5.  The cause,  whatever it
may be, is  often  aided by a kind of epidemic
influence, the nature of which  is unknown, but
which gives efficiency  to the specific cause, al-
though it does  not originate the disease when
that cause  does not  exist.   6. There are cer-
tain  conditions and circumstances which act as
predispositions to the  disease, and there are
others which act as exciting causes ; but in all
cases the  individual must  be  exposed to the
peculiar specific cause.]
  148.  VIII. Nature  of this Distemper.—It
has been supposed that the plague of  Athens,
described by Thucydides and  noticed  by Plu-
tarch,  was identical  with this malady; and
certainly the   resemblance  between  them  is
strong  in  many  points.   Thucydides states
that it  prevailed in Lemnus and other places,
although not so extensively and fatally as  in
Athens, where  it afterward appeared;  that it
suddenly broke out in the port, the  Piraeus, and
extended over the  city;  that  when  it  had
reached the upper parts of the city it  had be-
come most fatal ; and that,  having ravaged
Athens, it was  conveyed to other places which
were most populous.  These  are  the  specific
statements of Thucydides, and indicate a simi-
lar importation  of an infectious malady and its
extension from the port over the  city, and to
places with which the intercourse was greatest,
to that  demonstrated on several occasions in
the  south of Spain during the last fifty years.
The  infectious  nature  of the Athenian  plague
is still more distinctly stated by Plutarch, who
remarks that the  distemper appeared in the
army with which Pericles besieged the sacred
city of Epidaurus, and  affected not only it, but
all those also  who had intercourse with  it.
(Plutarch,  Vita, &c.  8vo, Lond., 1729, vol.
i., p. 378 )
  149. Not only in their propagation, but also
in their  symptoms, may the resemblance be-
tween the Athenian and the haemagastric pes-
tilences  be  traced.  Thucydides  notices  the 
200           PESTILENCE, HAEMAGASTRIC—Pathological Inferences.
peculiar febrile heat, and the pale greenish yel-
low (xKupbv) and livid colour of the surface of
the body ; the singular affection of the parts of
generation ; the  excessive  sense of internal
heat; and the peculiar  amentia,  insanity, or
apathy attending the distemper.  The abun-
dant bilious evacuations  mentioned by him  may
have  been the black or dark-brown matters
characterizing the modern distemper, for it  can-
not be doubted that the black  stools produced
by altered blood were ascribed to black bile by
the ancients.  He farther notices the very  rare
occurrence of relapses ;  the fact of the disease
never having seized the same person a second
time; and the greater liability  of strangers,
and  of persons fwm the country visiting the
eity, to be attacked.
  150. Whatever may have been the original
source of this distemper, in  whatever way the
cause of it  may have been at first generated,
and however this cause may have been after-
ward preserved and propagated,  there can be
no doubt of the appearance of it in many places
and  on  many occasions, where  it  can  be ac-
counted for in no other mode than by referring
it to the operation of an infectious emanation
proceeding from a recently affected person, or
from clothes imbued with this emanation.   The
difficulty of obtaining information as to the first
persons attacked is always great, and  some-
times impossible, as respects not  only this dis-
temper, but all other infectious diseases ;  and
hence the early proofs of infection can rarely
be obtained even as regards any  of them.  In
respect  of the outbreak of this  pestilence in
America,  Africa,  and Europe, we know  that it
has  occurred  both  after and during states of
season and weather of the most  different and
even opposite kinds ; the only atmospheric re-
quisites to its appearance being high ranges of
temperature and of humidity.  It has occurred
in trie driest and in the most marshy situations ;
in dry as well as in rainy seasons;  after  pro-
longed droughts, and after excessive rains ; on
the surface of all soils, whether  rocky,  sandy,
gravelly, or clayey; and in  ports, towns,  gar-
risons, forts, and ships of all descriptions,  both
foul, clean, unhealthy, and healthy, and placed
in every  possible circumstance  that may be
conceived in respect of them.  It has appeared
in one or two isolated  persons  who had  not
previously breathed the foul air  of sick wards
or apartments ; nor visited the places in which
either the sick or  the  healthy had  been  con-
fined ; nor inhaled the effluvium  from  decom-
posing exuviae and animal substances; and thus,
by the exclusive process of reasoning, we have
left only that cause to which I have imputed it;
and  by means of which it  is as undoubtedly
propagated  and perpetuated as any other  mal-
ady whose infectious properties  are admitted.
  151. The terrestrial exhalations believed by
Dr. Fergusson and  others to  be emitted from
the fissures  of the  soil, caused  by  prolonged
drought, or from the dried-up beds of rivulets,
&c. ; the wooden  theory propounded by  Dr.
Wilson, and its combination with a limestone
influence; the malaria  carried by winds from
great distances, or issuing forth  in currents of
only a few  feet in  diameter;  the emanations
from bilge-water  and ballast;  and the  vegeta-
tive principle imagined to be thrown out from
rich absorbent and alluvial soils,  are the sever-
al sources which have been assigned ;  but are
merely illusions which  have played before the
minds of medical theorists, and which  are dis-
sipated by a more comprehensive glance of the
very different circumstances attending each out-
break of the pestilence.  The chief circumstan-
ces which remain without very material altera-
tion, in all the most destructive visitations of
the distemper, are certain ranges of heat and
humidity, a still atmosphere,  or an imperfect
renewal  of the air, and a more  or less dense
population; all which especially favour the prop-
agation of infection  of every  kind, and which
are indispensable to the extensive prevalence
of this distemper.
  152.  The pathological inferences  which may
be drawn from what has been advanced respect-
ing the causes,  the symptoms, and course, and
the consequences of the distemper, may be stated
as follows  : 1st. Of  the numerous causes and
sources which have been assigned to this pesti-
lence, there is not one which has  been ascer-
tained  to have existed in all, or even in the
majority  of, the  occurrences  of  it  since it be-
came in  modern times the subject of medical
interest,  with the exception of a specific infec-
tion, or poisonous animal emanation proceeding
from the sick, and directly, or by  fomites, af-
fecting those among the healthy who have not
previously  been  attacked, and who are other-
wise predisposed.  It should not  be overlooked
that the  majority of those who have reasoned
against the operation of this cause have either
wittingly or ignorantly overlooked the now well-
established fact of the immunity  from a second
attack, produced by the first,  and have attribu-
ted much importance to the escape of many of
those among whom an infected person has been
placed, without admitting the great probability
of the majority of those having been protected
by their having had the disease.   This partic-
ularly applies to the intertropical  parts of Amer-
ica, and  to many of those who have  written
upon the disease as it has there  appeared, and
who have even never inquired into the manner
in which this exemption  affects the diffusion
and  prevalence  of the  distemper, nor in any
way concerned themselves with this very im-
portant fact, although it so very materially af-
fects the results, and although they  present
themselves before the profession with the dog-
matism of an infallible inspiration.
  153.  Secondly, that the  effluvium proceeding
from the bodies of the affected being so remark-
ably offensive as to attract the notice  of every
observer, is itself a proof of the  infectious na-
ture of this distemper ; for when it is admitted
even in  single  and isolated cases, how much
more remarkable must this fetor become when
numbers are affected in a humid, warm, and
still atmosphere, and  in  a limited space, in
which  circumstances even the birds in the air
and the lower animals are also  infected.  Dr.
Imray, who has given a remarkably correct de-
scription of this pestilence as it appeared in the
island of Dominica in 1838, where  it could not
be expected to have been very prevalent among
old residents, owing to the exemption arising
from a previous attack, and where, indeed, he
states the number attacked to have been small,
with the  exception of the military, remarks that
the " odour of the cutaneous exhalations was oft-
en extremely disagreeable, as well to the patient 
              PESTILENCE,  HaEMAGASTI

himself as to his attendants," and that" the fetor
became more intolerable towards the  last stage of
the distemper."  Now I believe that every  one
whose experience of diseases attended by much
fetor  of the exhalations  from the skin  and
lungs [is extensive], will admit  that these  dis-
eases are more or less contagious or infectious,
especially in the  circumstances so frequently
alluded  to above, and where numbers are ex-
posed to this cause, or inhale  an  atmosphere
contaminated by these exhalations.   There can
be no doubt, however, that, where  those exha-
lations are much diluted by the  atmosphere in
an open situation, they will generally fail in
producing those effects which undoubtedly re-
sult from them in a close,  crowded, and humid
air, and where numbers of predisposed persons
are congregated.   The dissipation  of these ex-
halations by a rapid renewal of the air is the
chief cause of the limited extension of the dis-
temper to high and open situations, and to pla-
ces thinly  inhabited, and  is one of the chief
means of arresting the progress  of an epidemic,
facts proving what reason asserts, namely, that
on those occasions of the  outbreak of the  dis-
temper in close streets and barracks, the  re-
moval of the inhabitants  to  open and  airy
grounds and encampments, so that a free per-
flation is allowed under the tent-cloths, is al-
ways followed by a rapid subsidence and  total
disappearance of the malady.   A person  from
the country visits a town in  which the malady
is prevalent, and another from  a ship lands in
the same town, and both persons probably vis-
it the same place or house in which the disease
exists.   Both persons, if  unprotected by  any
circumstances, and equally predisposed, are in-
fected, but the infection will not become man-
ifest until two or three days subsequently.  The
one returns into  the country and  is attacked,
but, owing to  the circumstances favouring the
communication of the malady  being wanting
there—owing to  free  ventilation,  a high  and
airy  situation, and a sparse population,  with
numerous other favourable circumstances—the
distemper either extends no farther, or extends
merely to a few, even in  the  absence of any
other sanatory measures; while the sailor re-
turns to his ship, and in the ill-ventilated, and
perhaps over-crowded forecastle,  or between
decks, where  he is confined, he communicates
the malady to every  one who is not protected
by a previous attack.   Now these  occurrences
have  actually taken place, as now stated, times
out of number; and, moreover, the additional
fact has been often observed of a third person
having  come  from a  distant  town and  city,
been infected at the same place as the two oth-
ers,  and carried  the  infection  to such town
where he has sickened, and, owing to crowding,
ill-ventilation, and other circumstances favour-
ing infection, the malady spreads rapidly, al-
though it has proceeded no farther as respects
the first person here instanced.
  154. Thirdly, if we connect the circumstan-
ces attending the impression made by the ex-
citing cause of the distemper—by the effluvium
from the affected—if we consider the phenom-
ena which immediately result, those which are
subsequently developed, and the lesions which
are ultimately produced, we shall  have every
reason to conclude that this cause produces a
specific morbid impression upon the organic ner-
IC—Pathological Inferences.           201

vous system through the medium of the lungs;
that it changes the vital manifestations of this
system, and contaminates the  blood ; and that
this contamination farther affects the organic
and cerebro-spinal  nervous  systems,  which
again, in  their turn, react upon the vascular
system and blood, until the  vital tone and co-
hesion of the tissues  and capillaries are re-
markably impaired, and the vital crasis  of the
blood more or less dissipated.
   155. Fourthly, it cannot be doubted, by any
person who has seen both maladies, and who
is uninfluenced by partisan views, that this pes-
tilence is altogether distinct in its causes, its
progress and course, and in the lesions found
on  dissection, from more malignant states of
remittent fever.  The admission is made by
many of the non-infectionists themselves ; and
sufficient has  been adduced above  (§ 37, 122)
to prove this difference.   In those cases of the
pestilence  which proceed more rapidly  to the
extinction of life,  the  poisonous  emanation
which has infected the body produces but little
structural lesion in its fatal course, excepting
the changes in  the digestive  mucous surface
and in the vascular system, especially  in the
blood.  The viscera present no remarkable al-
teration  beyond  the defect  of vital cohesion
just mentioned, and the tendency to rapid de-
composition.  The  pale yellow appearance of
the  liver, -first  accurately  observed  by the
French physicians, who  described the distem-
per as it appeared  in Spain, and subsequently
noticed in the West Indies by Dr.  Imray and
others, is obviously occasioned by the loss of
blood from the digestive mucous surface.   The
loss of the vital cohesion of this surface and of
the capillaries supplying it, and the more or
less extensive detachment of the  epithelium,
with the other changes described above (§ 26,
et seq.), are consequences of the remarkable de-
pression of the organic nervous or vital energy,
and of the  changes produced in the blood by
the poisonous emanation causing the infection.
   156. Fifthly,  that the changes produced on
the blood are  not merely the ultimate effects of
the disease, but supervene, to a certain extent,
at a  more or  less early  stage, in consequence
either of the  morbid impression made  on the
organic nervous system by the exciting  cause,
or of the absorption of the cause into the blood
itself during the respiratory process, or of  a
combination of the two modes of operation, is
sufficiently  evident from the appearances of
the blood during the earlier periods  of the mal-
ady.  In  the cases where the vital depression
and changes  in the blood are the  greatest  at
these periods, blood-letting would be improper-
ly, and has been rarely, resorted  to ;  but  in
those  cases where vascular tone  and  action
have been less impaired, and  where the blood
has consequently presented the least amount
of change observed in this distemper, this fluid,
even  at  the time of its  escape  from the  vein,
has been more or less altered.  It  has  gener-
ally been much darker than  natural, and it has
separated very imperfectly into serum and cras-
samentum.  This change in the blood, remark-
ed and described by me many years ago, is far-
ther noticed by Dr. Imray in the epidemic ob-
served by him in the West Indies.  He states
that " the blood, as it flowed from the arm, pre-
sented a singularly mixed appearance, as if the 
202            PESTILENCE, HAEMAGASTRIC—Pathological Inferences.
vein had contained two differently coloured flu-
ids, the one bright red, the other almost black ;
and on examining the blood an hour or two af-
ter being withdrawn, the separation into serum
and crassamentum had taken place very imper-
fectly.   In the centre was observed a loose co-
agultim, easily  broken  down, the  surface of
which was streaked green and yellow, the se-
rum being in large quantity, and  intimately
mixed with the colouring matter of the blood.
These  changes in the vital fluid were  invaria-
bly noticed to a greater  or less extent in every
instance where blood-letting was had recourse
to, which  was always at the very outset of the
attack; and  as the disease advanced  to  the
last stage,  the blood was so altered  and broken
down as  to  escape from  the  capillary vessels
of all the mucous surfaces."   (P. 92.)
   157.  Sixthly, the  changes in the digestive
mucous surface  more  especially,  and in the
crasis and  constitution of the blood, favour the
escape of this fluid from this surface, and these
are necessarily followed, near the close of the
attack,  and  when  the  black  vomit and  anal
evacuations are very abundant, by an anaemial
state of the liver, giving rise to the  pale yellow
hue of it  so generally observed after death.
At an  advanced  stage of the  malady, more
especially, and even from a very early period,
the organic nervous or vital  power, by which
the  portal circulation is chiefly carried on, is
more or less impaired ;  and, consequently, the
abdominal organs and  digestive mucous sur-
face become congested  As  vital  power  and
the  crasis of the blood are farther  impaired
with the progress of the disease, the congestion
increases, and ultimately the digestive mucous
surface allows the altered blood to  exude  from
the weakened and overloaded capillaries ;  and
the  discharge from these  capillaries into the
digestive   canal  proceeds  with an increased
rapidity as the portal circulation becomes more
and more  impaired.  The loss  of  blood  from
this surface  at last leaves the  vessels of the
liver comparatively empty, and the organ pale,
notwithstanding  the dark appearance of the
blood at this period. The changes which are
thus early and  extensively  produced in the
vascular system  and gastric  organs,  and the
prominence of the symptoms referrible to them
during  the progress of the  distemper,  have
suggested the name hamagastric, which I  have
used to designate the distemper, and to distin-
guish it from those states  of remittent fever
which  are often attended by yellowishness of
the skin.
   158   Seventhly,  although  the digestive or-
gans and  vascular  system  betray the most
prominent affection during the progress of the
distemper, still the nervous system, and more
particularly the organic nervous system,  with
the organs chiefly supplied by it, are very re-
markably,  and most probably primarily affect-
ed.  The  morbid  impression  made upon  this
system, and the contamination of the blood,
whether they  be produced  in  succession or
contemporaneously, ultimately, at  least, react
on each other, until the functions of vital and
of excreting  organs, and the vital cohesion of
the several tissues, are impaired to an extent
incompatible with the continuance of life.  The
consequences  necessarily  flowing from  the
morbid impression made  by the cause of dis-
 temper upon the nervous systems are impair-
 ment of the functions of the lungs—the chan-
 nel through which this  impression  is made-
 diminished  secreting and assimilating actions
 of the liver ; and, consecutively, an almost to-
 tal suspension of the functions of this organ
 and of  the kidneys.   A marked  diminution,
 also, of the cutaneous  and intestinal exhala-
 tions and secretions is  present  from  an early
 period  of the attack.   The results of these
 changes, as respects the blood,  are the accu-
 mulation of effete and  injurious elements in
 this fluid, and the combination of them, as they
 are  partially eliminated  from secreting surfa-
 ces, into those  specific  infectious emanations
 which  propagate the pestilence.  When  the
 alterations  in the nervous  and  vascular sys-
 tems,  in the blood, and  in  the several tissues
 are  approaching  an  acme,  the  altered blood
 exudes from the relaxed capillaries and tissues,
 especially from  the digestive mucous surface;
 and when the passive haemorrhages which thus
 supervene are considerable, previous conges-
 tions are removed, and  the portal vessels  and
 larger veins are either left comparatively emp-
 ty, or contain a small  quantity of black fluid
 or semi-dissolved blood.  With the failure of
 organic nervous power, the due adaptation of
 vascular tone to the states  of vascular fulness
 on the one hand, or of vascular deficiency on
 the  other, is  lost, and the  progress to a fatal
 issue  is greatly accelerated, without  the con-
 servative influence of life being able to arrest
 the  advance.  But  when the passive hajmor-
 rhages in the last stage are considerable, the
 fatal result is rapidly accelerated, owing to the
 powers  of life being inadequate  to the adapta-
 tion of vascular tone and action to the amount
 of circulating fluid, and to the quality of  this
 fluid being such as  further depresses the al«
 ready depressed state of the nervous systems.
   159. Eighthly,  whether the progressive al-
 terations in the  blood actually arise as stated
 above (y 154), or are owing to the introduction
 into the circulation of the infectious molecules
 given off from the affected, and  inspired with
 the air in  which these molecules float, is a
 question which  does not admit of a positive
 answer in the present state of our knowledge.
 If we  adopt  the latter  alternative, it follows
 that the absorbed molecules, which infect the
 system, multiply themselves either in the blood
 or during the processes  of excretion ;  and that
 the  morbific leaven thus introduced gives rise
 to the progressive phenomena  of the disease
 in the process  of reproducing their kind,  and
 in the course of vital deterioration and vascu-
 lar contamination.
   160. The inferences which I  have  now at-
 tempted to draw from what appears established
 as to  the causes and nature of this pestilence
 must, at  least  in the  present  state  of  our
 knowledge, be made the basis of those meas-
 ures which should be adopted,  1st. For the pro-
 tection of the general community ; 2d. For the pre-
 vention of individual attacks in circumstances of
 imperfect general protection ;  and,  3d. For the re-
 covery of the affected.   As the measures for the
 attainment of the first and second of these ob-
 jects are nearly the same as regards the three
 kinds of pestilence discussed in  this article/ I
 shall  consider this  important topic in a sep-
| arate chapter, and with reference to  each of 
              PESTILENCE,  HaEMAGASTR

these pestilences.  (See Pestilences, General
and Individual Protection from.)
  161.  IX. Treatment.—There arc very few
distempers which  are less under  the  control
of treatment  than  that now under considera-
tion, or in which the protective influence of
life is less manifestly exerted.   Persons who
are the most robust, the previously healthy,
the young, and those in the vigour of life, are
generally the  most susceptible of infection, the
most violently attacked, and often  the  most
rapidly carried off.   Something, however, may
be attributed  to the dose of the infectious em-
anation, or poison, which has  impressed and
contaminated the frame ; and something, also,
may be owing to  the violence of reaction in
persons of a plethoric habit of body and strong
constitution.   In the first case,  the concentra-
tion and intensity of the cause may be so great
as to overwhelm even the most powerful, and
to annihilate  altogether that vital resistance
which is always opposed, in various  grades in
different persons, to the  influence  of injurious
agents ;  in the  latter case, excessive action,
while vital power is depressed, rapidly exhausts
itself, and accelerates, with remarkable rapid-
ity, those changes in the blood  which  so gen-
erally supervene upon high vascular action in
warm  climates or  in hot seasons, and  more
especially in  robust and plethoric  persons who
have recently migrated from a cold to a warm
country.    From this it  is manifest that the
treatment  which is advantageous to persons
circumstanced as  these  latter are, cannot be
equally, or even at all, beneficial to others who
are otherwise circumstanced, or to those who
have resided  long  in a  warm, or in  an un-
healthy climate ; and it is equally obvious that
medical means will be of service, or even detri-
mental to the person requiring them, according
to the judgment regulating the exhibition of
them appropriately to the morbid conditions
existing in each case individually, and in the
same case at the several stages of its course.
   162. The treatment, also, should  be modified,
or  even very different,  according to  the cir-
cumstances in which the patient is placed du-
ring its employment, for  the patient who is re-
moved  into  an open, well-aired,  and  healthy
locality before he  is attacked, will  bear, and
indeed require,  very different measures from
those required by persons who remain in the
close,  low, and infectious  air of a  crowded
hospital, or in the sick  bay of a  ship-of-war.
Hence the necessity of removing those who
are attacked  as much as possible from under
the influence of the contaminated air in situa-
tions where numbers are affected, and of pre-
venting the air surrounding them from  being
contaminated by as rapid a  renewal of it as
possible.   Thus, in cases of infection in low
and ill-ventilated houses and streets, removal
to  a well-ventilated hospital,  or even  tents
having a continued current of air passing under
the tent cloths, is  most beneficial, not merely
as  respects the chances of recovery, but also
in arresting the progress of infection, for the
contamination of the air surrounding  the pa-
tient is thereby prevented, at least to  that de-
gree which is hurtful to himself and  infectious
to others. In the  instance observed  by my-
self, of several sailors becoming infected by
communicating with a slave-ship, the sick were j
LIC—Treatment of its Grades.           203

 constantly kept on deck, sheltered only from
 the sun  by  means  of an  awning, open  all
 around, and the result was most favourable as
 regarded the infected, the distemper not ex-
 tending farther than  to  those men who had
 gone on board the slave-ship.
   163. Impressed with the necessity of apply-
 ing the means of cure with strict reference to
 the peculiarities  of  individual cases,  and of
 each stage of these cases, I shall not attempt
 to describe the treatment which is more espe-
 cially applicable to the disease as it occurs in
 different constitutions and temperaments, because
 I should thereby be led into  irksome repeti-
 tions, and very imperfectly accomplish the end
 in view.   Besides, different constitutions and
 temperaments  are not so readily  recognised,
 nor are they so precisely marked out, as to en-
 able practitioners of even  admitted  discern-
 ment  to  detect them during  the  tumultuous
 disorders  of function characterizing this dis-
 temper.  The  means which are  particularly
 suitable to grades of intensity, and to the several
 stages of the disease, may be stated with  more
 reasonable hopes of advantage to  the inexpe-
 rienced ;  still it should not be  overlooked that
 the malady  is very mutable in its character,
 and  that  an attack  which  may appear very
 slight, and by no means dangerous, during the
 second, third, or even the fourth day, may sud-
 denly change  its state, and become  remark-
 ably severe, or even rapidly  fatal.  Having
 particularized the several grades ($ 6, et seq.)
 and stages (v 21, et seq.) of this distemper, I
 shall first give a rapid sketch of the treatment
 which appears  to me the most appropriate to
 each  grade  and  stage, and afterward  notice
 those means individually which  have been or
 may be employed, and endeavour  to estimate
 the true value of each.
   164. i. Treatment as to Grade  or Form.—
 A.  In the Mildest Form ($ 6), our chief reli-
 ance should be placed on free  ventilation, and
 due promotion of the several secretions and
 excretions ;  measures equally applicable to all
 forms of the distemper.   The  bowels ought to
 be  early evacuated by means  of calomel with
 jalap  or rhubarb, or any other purgative, and
 afterward kept open by olive-oil taken by the
 mouth,  and administered freely in enemata.
 A tepid bath or the cold affusion  may  be  re-
 sorted to, if there be much heat of skin; and,
 after  the  surface has  been  carefully  dried,
 frictions of  the trunk and all the limbs with
 olive-oil will prove extremely beneficial, and
 favour a free perspiration.  This object will be
 farther promoted, after the  bowels have been
 freely evacuated, by the exhibition of the liquor
 ammoniae acetatis  and  the spiritus aetheris
 nitrici, in bland  diluents  or demulcents.  In
 the majority of cases of this grade, nothing
 more than the  above may be required ; light
 farinaceous  articles of food  and simple  emoll-
 ient diluents being allowed as the febrile action
 subsides.  If, however, the abdominal  excre-
 tions are not duly evacuated by these means,
 they should be repeated in increased doses ;
 the oil should be more freely administered, and
 the oleum terebinthinae, or common salt, may
 be added  to the  enemata, which  may  be  re-
 peated according to  circumstances.    If the
 malady should suddenly assume a severer form,
i the treatment  hereafter to  be described may 
204           PESTILENCE,  HAEMAGASTRIC—Treatment of its Stages.
be resorted to.   The physician should endeav-
our throughout  to inspire confidence in the
mind of the patient, and to dissipate despond-
ing ideas.
  165.  B  The Treatment  of the  more Se-
vere Form (§ 7) of this pestilence is generally
beset with more or less difficulty.   In many in-
stances a  recourse to the foregoing means may
be the  most judicious, at least until the  more
serious symptoms characterizing  this form su-
pervene ;  and they are the more likely to be of
service if  the bowels  are freely acted upon by
them, and  if the perspiration is copious and gen-
eral.   In these circumstances, a recourse to the
more heroic and perturbating means may be pro-
ductive of more mischief than benefit.  Where
vascular action appears high, blood-letting has
been advised by many, and many have been in-
duced  to employ it, and to repeat it even often-
er than once ;  the seductive  calm produced by
it for  a few hours  often alluring the reckless
and the inexperienced  to carry it  to an injuri-
ous amount.   But the calm is only momenta-
ry, and is generally followed by  reaction still
more violent than that preceding it, although
vital power and resistance are materially de-
pressed.   Unless in the circumstances hereaf-
ter to be noticed (y 167), and regulated as will
be mentioned,  this measure is of  doubtful effi-
cacy, and  in most instances should not be  re-
sorted  to.
  166.  If  the means now mentioned be follow-
ed by a subsidence of  the disease, attention  to
the several secretions and excretions, and  to
diet and regimen, will  insure recovery; but  if
the morbid actions assume an onward course—
if the  pulse become weak, compressible, une-
qual, irregular, or slow; and  more especially
if discoloration  of the skin about the  neck,
chest,  &c,  appear, either alone or with  in-
creased irritability of stomach, a most danger-
ous exhaustion of vital  power has now taken
place,  and powerful stimulants,  or  other  re-
storatives, as about to be advised for the third
stage of the malady, are urgently required.  To
these symptoms black  vomit and  hiccough are
soon added, if they be not removed by energet-
ic  means  ; and in  many instances such means
will fail in producing the desired effect.   Nev-
ertheless,  they should he employed perseve-
ringly, and be variously associated, according
to the changing features of the case.  Sulphate
of quinine, with camphor and capsicum, or with
the addition of opium, each dose being imme-
diately followed by a glass of  Champagne ;
friction of the  general surface with  olive-oil
and spirits of turpentine, or embrocations  of
these  kept constantly applied over the  epigas-
trium  and abdomen, by  means of flannel fre-
quently imbued with them ; enemata with olive-
oil, turpentine, and  asafcetida ; and even  more
powerful stimulants than the above, as brandy
with an equal proportion of water, ammonia,
or others  hereafter to be mentioned, are the
chief means on which  any reliance can  now be
placed. If black vomit  be imminent, or com-
mence, an occasional  dose of spirits of turpen-
tine with  olive-oil, and two or three grains of
capsicum  ; sulphate of quinine,  with sulphate
of zinc and opium ; or the acetate of lead, with
camphor and opium ;  the acetate  of lead, with
creasote,  acetic acid,  and tincture of opium,
brandy in  small quantity, but given frequently
with arrow-root, sago,  &c,  and the enemata
already advised, may, even in this almost hope-
less state, be followed by recovery in some in-
stances.   In  all cases  a careful watching for
the successive changes  taking place in the ad-
vanced course  of the malady, and a recourse
to means which are appropriate to  them, with
good  nursing,  are  among the most essential
requisites
   167. C. The Treatment of the Third Form
(y 9) is not very different from  that just con-
sidered.   Blood-letting, if at all resorted to,
should be employed only at the commencement
of vascular reaction, and be confined to the
young, plethoric, and robust.  It ought  not to
be carried so far as to produce at any time full
syncope, for excessive  reaction is  the  more
likely to return when this effect  is produced by
it.  Even in this form, and in this class  of pa-
tients, it. is doubtful whether  or no general
blood-letting  is  of  service.   I  believe that it
will rarely prove beneficial in those cases which
remain during the treatment within the range
of the contaminated atmosphere surrounding
numbers  of persons  affected  by the pestilence,
or in low, humid, and ill-ventilated places.  An
early  recourse  to the tepid  bath, followed by
frictions  of the  surface with olive-oil; to pur-
gatives and cathartics with calomel, in full do-
ses, and promoted by enemata containing olive-
oil and turpentine ;  and  to the diaphoretics al-
ready  mentioned (*.  164), ought  not to be neg-
lected.  When the vascular excitement is about
to lapse into exhaustion, the means already ad-
vised,  as well as those  about to be noticed (!)
173), are the most deserving of confidence
  168. D.  In the Fourth Form (y 11) of this
malady, blood-letting in any mode is most in-
jurious ;  and the means required for the third
stage (§ 172) are early required.  The early ex-
hibition of chologogue purgatives in full doses,
and the promotion of their action by means of
the enemata already mentioned, and by  olive
oil  taken internally, in  frequent doses;  the
warm  bath, followed by assiduous frictions of
the surface with olive-oil and turpentine; and
an occasional dose of spirits of turpentine (from
one to four drachms) with one or two drops of
creasote, and two or three grains of capsicum,
taken on the surface of milk, coffee, or any aro-
matic water,  aided by the more powerful stim-
ulants noticed above (y  166),  as the symptoms
may indicate the necessity of having recourse
to them, are the means most  likely to make
that impression upon the system which is re-
quired to subvert the morbid  action, to support
the conservative influence of life, and to restore
the secreting and excreting  functions.  When
yellowness of the skin,  black vomit, or passive
haemorrhage  supervene, the measures already
mentioned, and  others to be noticed in the se-
quel, may be adopted, although with faint hopes
of deriving advantage from them.
  169. ii.  Treatment  of the  Stages.—It is
unnecessary to remark  at any length upon the
means which  the pathological  states charac-
terizing these  stages may suggest.—.4. The
First  Period, or that of invasion  (y 21), is gen-
erally  so sudden in  its  accession, and passes
off so rapidly, as often to elude the observation
of the  physician.  In some cases, also, it is ex-
tremely slight, or the chills, rigours, or horrors
characterizing it are either so little complained 
PESTILENCE, HaEMAGASTRIC—Treatment of its Stages.            205
of by the patient, or so imperfectly manifested,
or even  so  entirely wanting, the disease ap-
proaching most insidiously with  most of the
symptoms of the second stage in a slight degree,
as almost to warrant a total disregard  of it  in
many instances.  When it  is  present, meas-
ures should be taken to  counteract the injuri-
ous impression produced on the frame by its
continuance, to restore  the equilibrium of the
circulation, and to procure freedom of secre-
tion and excretion.  The immediate removal
of the patient into an uncontaminated atmo-
sphere ; a warm bath with frictions of the sur-
face both in  the bath, and when removed from
it;  or warm baths  medicated with aromatic
and stimulating  substances,  and  followed  by
frictions  of  the surface with olive oil; warm
and chologogue purgatives ;  and warm  diapho-
retics and diluents, are the most appropriate to
this period.   But we cannot expect these to
cut short the disease, or prevent the accession
of the other stages.  All that we can hope for,
seeing that  this stage indicates the  actual in-
fection of the frame, is to render the  periods
succeeding it more mild, and more  amenable
to treatment, than they  might prove if it had
been left to  the unaided  efforts of nature ;  and
possibly  to prevent that  contamination of the
circulation which  takes place, and  advances
with the progress of the distemper.
  170. B. In the Second Stage (y 22) the treat-
ment  should always be  conducted with a per-
fect conviction of the  important truth  that,
however high arterial action or nervous excite-
ment  may appear,  and   however  robust  and
plethoric the patient may be, both the action
and the  excitement are unattended by vital
power or organic nervous energy or tone.  Vi-
tality  is overpowered or poisoned by the infec-
tion contaminating not merely the nervous and
vascular systems, hut the whole frame.  Hence
the very general failure of blood-letting even  in
those  cases  which  seemed most urgently to re-
quire  it.   For, owing to the relaxation of the
tissues, the  want of tone throughout the vas-
cular  system, and  the early contamination of
the blood, the vessels soon lose the  power of
accommodating themselves to any marked dim-
inution of the usual amount of their contents
With  this pathological state, the use of tonics
and restoratives is by no means incompatible;
and, as I have proved on numerous occasions,
the only way of subduing  excessive  action,
when thus associated with deficient  and sink-
ing power, is to administer the more  perma-
nent stimulants, or such tonics as are most ef-
ficacious in counteracting the loss of vital co-
hesion of the soft solids and of the crasis of
the blood, a loss more or less rapidly advancing
during the unfavourable progress of the dis.-
temper.   Instead, therefore,  of endeavouring,
as many have advised, to overcome the vascu-
lar  excitement characterizing this  stage  by
means of blood-leiting and depressing  agents,
I would recommend the  exhibition of camphor,
sulphate of quinine, ammonia, capsicum, decoc-
tion of cinchona, chlorate of potash, spirits of
turpentine, wine, brandy, &c, either singly or
in such combinations as  the states of the case
may require. During this stage  the blood  is
not only  deficient  in  fibrin,  but also in those
healthy requisiies resulting from complete as-
similation and free excretion of effete elements;
and the deficiency of fibrin, of healthy crasis,
as well as of normal purity, increases progres-
sively through this and the succeeding stage,
until these  several  morbid  conditions reach
their acme.   Now, by what means are these
changes most surely counteracted or arrested
in their  course ■?   If not by the above means,
we shall have much difficulty in finding others
more efficacious than they.  It will be in  vain
to attempt the cure of the malady, even in this
comparatively early stage, by any other means
than  such as  are  capable  of producing these
effects—of counteracting  or  arresting these
changes.  Can blood-letting possibly  accom-
plish  these ends T   It  may possibly indirectly
aid other measures to  this effect;  but this is
the utmost amount of its  agency as respects
the blood ; and it may save, in a few instances,
some important organ  from injury  during the
height of reaction.  With  this latter view it
is most frequently practiced ; but I much doubt
its  capability  of producing this  effect in  this
distemper, and am inclined to believe that this
solitary advantage is more than counterbalanced
by several unfavourable contingencies ; for the
increased loss  of power, consequent upon blood-
letting during  morbid states of the blood, is as
frequently followed by haemorrhagic or serous
effusions  or  exudations as  the  pre-existent
state of vascular fullness ;  for, after blood-let-
ting, the accommodation of  vascular tone to
the amount of the vascular contents is deran-
ged, and various consecutive changes take place
that might not otherwise have occurred.  In
some of the less violent states of vascular ex-
citement, when the pulse is less rapid, and less
expansive or tumultuous, where it is less open,
and presents more of tone  than is observed in
the more  violent and rapid states of vascular
excitement, the liquor ammoniae acetatis, with
potassae nitras, and spiritus aetheris nitrici, ta-
ken  either in  camphor  mixture, or in  the de-
coction or infusion of cinchona, will often prove
of manifest service, especially after the bowels
have been freely evacuated, and the functions
of the skin restored by  the tepid bath, and fric-
tions with olive oil.
   171. In this period the urgent thirst usually
present should be alleviated by  spruce  beer,
soda  water, or by water  rendered  pleasantly
acid with vinegar, raspberry vinegar, lime-juice,
&c.   Of these I prefer either of the kinds of
spruce ;  but the selection should partly be gui-
ded by the nature of the medicines prescribed,
and the quantity taken at each time should be
small, as large draughts, especially of cold flu-
ids, are very soon afterward followed by vom-
iting.  Even  at this  stage  of the more severe
cases, and especially of the 3d and 4th forms
(y 9-11)  of the malady, restorative  and stimu-
lating beverages, taken often, but in a moderate
quantity  at a  time, are frequently of service,
and are the only drinks which should be allow-
ed.  Of these, Champagne or hock, with soda
water  or Seltzer water, or with milk; small
quantities of  brandy in spruce beer;  and, in
other circumstances, Seltzer water with milk, or
milk with lime water, are to be preferred.  In
general, it is preferable to allow a considerable
portion of the  fixed air to escape before the flu-
ids containing them are taken, as this air dis-
tends the stomach, occasioning a reaction of its
coats, followed by the rejection of the distend- 
206           PESTILENCE, HaEMAGASTRIC— Treatment of its Stages.
ing body, in the form either of painful eructa- j
tions or of vomiting.
  172.  C. The Treatment of the Third Stage
($ 23) has been partly anticipated (v 168, 171).
In the favourable cases of the distemper, the
vascular excitement glides into a calm, attend-
ed by a return of the secretions, and by a gen-
eral and genial warm  perspiration;  and the
third stage, or that of vital depression  or ex-
haustion, can hardly be said to have appeared.
But, unfortunately, in the more violent attacks,
and when  the vascular excitement of the sec-
ond stage  has been excessive or violent, vital
power  is so depressed or overwhelmed as to
be unable  to make the  usual  resistance, or it
sinks in the struggle.  When such sinking or
exhaustion appears, whether suddenly or more
gradually, the energies of life require to be sup-
ported  by means which  may  be rationally in-
ferred  to be commensurate with the  existing
depression.   It will be seen, from what  I have
stated  above (y 170, 171), that I would  advise
the depression characterizing  this  stage to be
anticipated by a somewhat earlier recourse to
stimulants  than has been advised by some wri-
ters ; for I am confident, from my limited ex-
perience in this distemper, and from a more fa-
miliar  acquaintance  with  the  vascular excite-
ment attending the earlier stages of other ma-
lignant fevers, that  a judicious recourse to
those  remedies  may be had  much earlier in
these diseases than has usually been  advised.
This fear  of stimulants and  restoratives has
arisen  from the rapid, tumultuous, and expan-
sive state of the pulse; the restlessness, ner-
vous excitement, and harsh heat of skin, so gen-
erally  present, so  frequently  misinterpreted,
and so injuriously  treated  by evacuants and
other lowering remedies; the remarkable loss
of  power  accompanying  this  state,  and the
morbid condition of the blood—circumstances
strongly militating  against  such treatment—
being entirely overlooked, or,  if taken into ac-
count,  being inaccurately estimated.
  173. Anticipating,  therefore,  with more or
less decision or activity the accession of vital
depression in this  stage, by commencing the
exhibition  of stimulants before the  stage of
excitement or reaction has  altogether ceased,
these  medicines should  be  still more strenu-
ously prescribed after this stage has actually
supervened.  In the fourth form of the malady,
where vital reaction or excitement is  very im-
perfectly developed, the treatment appropriate
to this period should be employed without hes-
itation or delay.  In several  instances  of the
distemper which came under my care in Africa,
I had exhausted the  various combinations of
camphor with nitrate of potass ; of ammonia,
ether,  and  aromatic  spirits;  and of cinchona,
serpentaria, and capsicum, in the treatment of
this stage, without deriving  that benefit from
them which I had  expected.   I then had  re-
course to  the following: to warm clothes im-
bued with  spirits of turpentine  and kept con-
stantly applied to the epigastrium, abdomen,
and insides of the  thighs; to brandy with an
equal quantity of warm water, or  in sago, ar-
row-root, or in spruce or ginger beer, &c.; to
enemata with  oil,  spirits  of turpentine, and
camphor, or asafoetida ; to camphor with cap-
sicum, either in the form of pills or bolus with
opium, or rubbed up with olive oil and taken on
i the surface of some aromatic water, or spirits
 and water; to Madeira and other wines, either
 alone or with soda  water and ammonia ; and,
 when haemorrhages and black vomit  either
 were threatened or  had appeared, to spirits of
 turpentine in various forms and combinations,
 and the results were certainly most beneficial,
 several  cases having recovered that  presented
 some of the worst  symptoms of this stage of
 the malady.   The quantity of wine or of spirits
 taken in some of these cases was most remark-
 able, and generally  with no other effect than
 that of allaying the  sickness and vomiting, and
 calming the restlessness, tremour, and delirium.
 It  was  often  found necessary to the securing
 of a successful issue, in these cases, to repeat
 the stimulus frequently, and to continue the
 treatment  for several days.  It was  remarked
 that thirst, heat at  stomach, and anxiety were
 more certainly removed  by these stimulants
 than by milder fluids, or by simple  diluents.   I
 have  mentioned these means,  having experi-
 enced their good effect; but it is very probable
 that the addition of creasote to  some of them,
 as to the  camphor, capsicum, and opium, and
 that the farther addition of the  acetate of lead
 to the creasote and to  these would have in-
 creased the benefit  derived from them.
    [As yellow fever assumes different types in
 different years  and  different latitudes, so, also,
 it  requires modifications in the modes of treat-
 ment.   Dr. Imray has alluded to this circum-
 stance with respect to the disease  as it pre-
 vails in the islands  of Martinique and Domin-
 ica, which are  both mountainous,  and have a
 similar climate  and  temperature, and  yet in the
 one, while blood-letting proved a most efficient
 and successful remedy, in the  other it proved
 equally  destructive, and had  to  be entirely
 abandoned.   The   same  remarkable circum-
 stance  has been alluded to by Dr.  Nott, of
 Mobile, who witnessed  five epidemics of yel-
 low fever in  that city  in different years (1837,
 1839,1842, 1843, 1845), each of which present-
 ed some predominant  peculiarity of  type, and
 all demanded some  modification of treatment.
 As a general rule, it is now admitted  by Amer-
 ican practitioners  that yellow fever is not a
 disease which  demands  active depletion, and
 that the lancet is to be used with great pru-
 dence and caution,  and only in the first stage
 of the disease.   " If you determine to resort to
 it," says Dr. Dickson, "placeyour patient half
 erect, make a large orifice, and draw from the
 vein at  once a sufficient amount to make a for-
 cible impression on the system.   You will thus
 fulfil your purpose of the reduction of vascular
 excitement with the least absolute diminution
 of the original powers of action and resistance
 of the constitution."  Dr. D., however, admits
 that, in  the treatment of the ordinary inflamma-
 tory form  of the disease, the first and principal
 indication is, to  reduce vascular excitement,
 which is to be done by the  most prompt and
 efficient means compatible with the well-being
 of the patient.   " A few hours," says this ex-
 perienced observer, " at the very  commence-
 ment of the attack, comprises all the time al-
 lowed us for the  hopeful application of our
 remedies, as we have to contend with scarcely
 any disease in  which the vital  powers are so
 soon  crushed and  overwhelmed beyond the
 capacity for resistance.  The force of morbid 
PESTILENCE,  HaEMAGASTRIC—The Means of Cure.
207
determination, too, is chiefly directed upon an
organ at once of the utmost importance and of
the greatest delicacy—the  stomach—whose
sympathies involve peculiarly the tone and en-
ergy of the whole system."  And yet Dr. D.
thinks that the lancet is by no means an essen-
tial or even general remedy in yellow fever.
As a substitute, he prefers the cold bath, which,
he states, is equally effectual in subduing mor-
bid excitement and controlling irritation, with-
out any positive  expenditure of,  or subtraction
from, the vital  forces.  Cold water is to be
freely poured over the patient—seated in a con-
venient vessel—in  a large  stream, until the
heat of skin, thirst, headache, pain  and  irrita-
bility of stomach, &c, are abated ; and  this
process is to be repeated as often as these mor-
bid symptoms return.  It  is  very probable that
the cold, wet sheet would answer the same indi-
cations.   Emetics are to be wholly proscribed.
Mild  purgatives, as of calomel, followed by
oil or sulphate  of magnesia, are  considered
indispensable  by many, as the bowels are for
the most part torpid.  All bulky or nauseating
formulae will be instantly  rejected.  Dr. Dick-
son relies,  in a majority of cases, upon  the
mercurial treatment, without the use of diaph
 oretics,  persisting  in  free  doses  of calomel,
 until the patient has become better,  or ptya-
 lism brought on    " It is a matter of great im-
 portance," he observes, " that this shall be ac-
 complished speedily, in order to arrest the de-
 structive and rapid progress of this  terribly
 malignant disease.   Many and various are the
 measures proposed, with  a view to hasten the
 excitement of the mercurial action in the sys-
 tem.  Some rely on opium, as checking its pur-
 gative effect ; some regard  alkalies as specifi-
 cally adjuvant.   I am convinced that we shall
 succeed best by a judicious attention to the
 general symptoms.  By the cold bath and the
 cathartic, affusions  upon  the vertex,  and cups
 or mustard poultices upon the epigastrium, we
 relieve morbid local determination, and dimin-
 ish diffused  excitement; relaxing cutaneous
 constriction, deriving to  the extensive surface
 of the intestines, whose vessels, congested and
 engorged, are unloaded by  soliciting  free  mu-
 cous  discharges."  The  prostration and col-
 lapse are to be met by quinine,  or the infusion
 of cinchona with an aromatic, and a little al-
 kali, as soda or potash ;  also by camphor and
 opium in properly regulated doses.   Haemor-
 rhage from the bowels is said  to be best  con-
 trolled  by nitrate  of silver  given  in doses
 of one fourth to half a grain ;  also by enema-
 ta.  Where there is an  oozing of blood from
 the gums, pledgets, dipped  in a strong solution
 of it, should be held in the mouth.   Stimulants,
 as recommended by Dr.  Copland, have gener-
 ally proved entirely inert in this stage of the
 malady.   Capsicum, in  combination with opi-
 um, is undoubtedly one of the  best.   The spt.
 terebinth, will irritate the stomach, increasing
 the gastric distress, without accomplishing any
 useful object.   In  the last stage, most writers
 agree in the propriety of giving alcoholic stim-
 ulants freely, especially rum, or brandy in com-
 bination with milk, arrow-root, sago, rice gruel,
 &c.
    Much attention has been recently paid to the
 effect  of large  doses  of quinine  in the treat-
 ment of yellow fever, not administered during
a remission, but in the very incipient stage of
the disease, before any local lesions have oc-
curred.   Our army surgeons at Vera Cruz, we
understand, have recently employed this rem-
edy with great success in this disease, in large
doses, as thirty, forty, and even  sixty grains,
with the effect of producing a rapid  subsidence
of the violent symptoms, and speedy convales-
cence.]
   174. iii. Remarks  on various Methods and
Means of Cure.—A. Blond-letting.—It is gen-
erally found that the usual mode of treating fe-
vers,  occurring to persons who have recently
migrated to places within the tropics, sanguin-
eous depletions—a mode generally found bene-
ficial, and even necessary in young  and robust
Europeans—is not only inefficacious, but often
highly injurious, even in those persons  when
attacked by this  pestilence.  The  experience
of Dr. Imray as to this very important topic is
so  accordant with my own, and  with  that of
the most discriminating and  judicious physi-
cians, that I shall adduce it here  in almost his
own words.  Although a few instances, he re-
marks, of recovery take place  after blood-let-
ting, yet the effect  seems  rather an  accelera-
tion of  the  fatal event.  Where, from the on-
set, the pulse is feeble, and the prostration of
strength extreme, the abstraction  of blood is
clearly  contra-indicated;  " but,  on the  other
hand, when the  patient is young and robust,
the pulse strong, the skin burning hot, and gas-
tric irritation constant, it at first sight seems
evident that a  prompt and decisive use of the
lancet is urgently  demanded; and  yet, when
depletion is carried  to its fullest  extent, the
only good effects produced are but a temporary
alleviation of the symptoms."   When the blood
is  allowed  to  flow until  faintness or actual
syncope take place, the patient afterward ex-
presses  himself greatly relieved ;  the violent
 headache, pains in the back and lower extremi-
 ties  are removed, and the skin becomes cool
 and moist.  This respite, unhappily, lasts but
 a very short time,  giving place, after one or
 two hours, to a renewal of all the symptoms,
 perhaps in an aggravated form.  If blood-let-
 ting be again practiced, the same result follows
 as from the first bleeding, "and to whatever ex-
 tent  it may be carried or however often repeat-
 ed, no permanent impression is made upon the
 disease ; but the stage of collapse is hastened,
 and  the strength becomes much impaired by
 the loss of blood, rapid sinking being the con-
 sequence" (p. 85).   It will generally be found
 more beneficial in cases of local congestion or
 prominent affection of an important organ, es-
 pecially where moderate blood-letting is indica-
 ted,  to  have recourse to local  depletions, by
 cupping below the shoulder-blades, or by leech-
 es behind the  ears, or in other situations, and
 to an  amount which will be indicated  by the
 circumstances  of the case,  than to resort to
 large bleedings from a vein.
    175.  B. Mercurials, more particularly calomel,
 have been much employed  in this  distemper
 since they were so  strenuously recommended
 for it by Dr. Chisholm ; but in this, as well as
 in all other malignant diseases, confidence  in
 them, either alone or chiefly,  will  be followed
 by disappointment.  In the West Indies and
 America, in the south of Spain, and in Africa,
 calomel has been given by many physicians for 
208             PESTILENCE, HaEMAGASTRIC—The Means or Cure.
the cure of this pestilence, in  large and fre-
quently-repeated doses, with the view of bring-
ing the  system under its influence as speedily
as possible ; but the difficulty of effecting this
object was generally in the ratio of the severity
of the malady.   It is stated by Dr. Imray, that
"the more  malignant the  symptoms the less
probability there was of the  calomel exerting
its specific action ;  but even where this object
was attained, the  patient could never  be pro-
nounced absolutely  safe, inasmuch  as  cases
terminated fatally when calomel had been giv-
en in large quantities, and the system was de-
cidedly  under its  influence;" and that,  when
the desired object of salivation was  produced
by  enormous doses  of  calomel,  " recovery,
if it did  take  place, was much  protracted,
and intolerable sufferings inflicted on  the pa-
tient.  In the more malignant  cases, the only
approach to salivation was swelling  and sore-
ness of the gums,  tongue, and throat, with a
decided increase of the tendency to haemor-
rhage from the mucous surfaces."   There can
be no doubt of the accuracy  of these remarks
as regards  a recourse to  frequent  and  large
doses of calomel when given alone;  but  when
full  doses  of  this  medicine are  prescribed
early in the disease with purgatives  or cathar-
tics, or when  they are continued after free
evacuations of the bowels, in conjunction with
large doses of camphor,  capsicum, and opium,
a much more beneficial  result  is produced by
them.   I have had many opportunities  of test-
ing the effect  of  large quantities of calomel
given alone in several  malignant  distempers,
and  have  observed the general failure of the
practice ;  but when the calomel was  conjoined
with equally large doses of camphor, capsicum,
and opium, and employed, thus combined, early
in the disease,  the  result has been very differ-
ent, more  especially when these remedies have
been aided by the application of the warm epi-
thems and frictions of the surface, and by the
enemata already recommended (y 166); recov-
ery having very frequently taken place in most
unfavourable cases and  circumstances, and
often without salivation having been  produced
Much, certainly, was to be ascribed to the med-
icines conjoined with the calomel and to the
rest of the treatment; but something certainly
was also owing to this latter substance.  I be-
lieve, however, that the  effects of these  con-
joined  means are much more  beneficial than
may be  inferred from their individual opera-
tion, not only in removing the irritability of
the stomach and internal congestions, but also
in restoring the secretions and excretions, and
in calming the perturbation of the nervous and
vascular systems.   The  quantities  of those
substances which  I have prescribed, and the
intervals between the doses, have varied much
with the character and nature of the attack;
but I have given from 5 to 20  grains of calo-
mel, with  3 to  15 of camphor, 2 to 5 of capsi-
cum, and from one third of a grain to one grain
of pure  opium every four or six hours; and in
some instances, where it was not necessary to
give the former  of these substances  so fre-
quently, I have prescribed even a larger dose
of the opium.
   176  C.  Purgatives are required in  all the
forms of this pestilence, and more  especially
early in the attack, not  merely for the evacu-
ation of accumulated morbid secretions and ex-
cretions, but  also  for  the  promotion of  the
functions of the liver and intestines, and  the
selection of them is generally a matter of some
moment.  A full dose of calomel may be given
with jalap  or  the  compound  extract of colo-
cynth,  and  half a  drop  or drop of croton  oil,
and be followed by the infusion of senna, with
a neutral salt and an aromatic tincture, and
shortly afterward  by the oleaginous enemata
already advised (y 164,  166)   These will be
less apt to offend  the stomach if one or two
drops of creasote be added to each dose.  The
quantity of calomel may vary from 5 to 20
grains, and may be taken with the  other ingre-
dients  in the form of bolus  or of pills.  After
the free action of these, the frequent recourse
to sweet oil, in the  earlier stages, and of this
oil with spirits of  turpentine in the last stage,
as noted above (y 166, 173), aided by enemata,
will generally procure a sufficient evacuation
of the  bowels, more especially' if calomel be
given with camphor, capsicum, and  opium, as
already mentioned (y 175).
  177.  D. The irritability of stomach, so con-
stantly attending the disease, is not only a dis-
tressing  symptom of itself, but is one inter-
fering  remarkably with the exhibition of medi-
cines,  and  preventing their  retention by the
stomach and passage into the intestines.  In
order to allay this state, various means  have
been devised.   Blisters, bleeding, opium, effer-
vescing medicines, &c, were those most com-
monly  had  recourse to when I visited inter-
tropical countries in  1817 and 1818  ; but I soon
perceived their general  inefficacy.  Bleeding
often aggravated,  although it frequently miti-
gated for an hour or two, this symptom.   Blis-
ters  produced only  a  very  temporary effect.
Effervescing draughts occasioned a more rapid
and complete  evacuation of the stomach, and
often a_painful reaction  of this organ upon the
distention produced  by  the  fixed air.  Opium
often produced no sensible effect when given
alone,  or with fluids, it being generally thrown
off; I therefore gave it with full doses of calo-
mel and capsicum, and found great benefit de-
rived  from it.  The beneficial influence of
these upon the state of the stomach was much
promoted by the application of turpentine epi-
thems  over the epigastrium and abdomen.   In
the first and  second stages of the distemper
these means will often prove most serviceable;
and very probably the addition of creasote will
farther promote their efficacy, not merely  in
these stages,  but also in the third stage, when
the antiseptic and anti-emetic properties of
this substance are  so remarkably required.   In
this last stage, it is remarkable that the vomit-
ings  are more completely allayed by a most
nauseous medicine, viz., by the spirits of tur-
pentine, than by any sedative or narcotic, es-
pecially when  taken  on  the surface of milk or
some aromatic water, &c.  The irritability of
stomach in the slighter cases is often removed
by means of almond emulsion, or of sweet oil
with calcined magnesia and small doses of tinc-
ture of opium, taken after short intervals, es-
pecially when  these  are aided by  the turpen-
tine epithems on the abdomen and purgative
enemata (y 166).
  ITS  E. Tonics, stimulants, and antiseptics are
severally more or less serviceable  in this dis- 
PESTILENCE, HaEMAGASTRIC—The Means  of Cure.             209
temper, but I believe that they are rarely pre-
scribed in sufficient quantity to make a due im-
pression on the system in its existing  state of
vital depression.—a. Formerly cinchona, in va-
rious forms, was employed, but was either in-
ert, or not retained on the stomach unless con-
joined with camphor, or ammonia, or capsicum.
I have given it in substance,  in large doses,
and in these combinations in as much as half
a pint of Madeira, in malignant remittent fever,
with great benefit; but in this distemper it is
neither so frequently retained by the stomach,
nor so beneficial when retained.  The sulphate
of quinine is now substituted with great ad-
vantage in the former disease ; but it has been
found much less serviceable in the pestilential
distemper.   Dr. Imray states  that, while the
stage of excitement lasted, no opportunity was
afforded  of  exhibiting quinine, and when this
stage subsided, and that of collapse came on,
it was completely inert, even  in  the  largest
doses ; and he adds that it was also equally in-
efficacious  in arresting the malady if  given at
the commencement of those cases which were
accompanied  with extreme vital  depression.
There can  be no doubt of its general inefficacy
in the  last stage, and even early in the fourth
form (v  11) of the distemper;  for, in these
states  of vital exhaustion, it is either imper-
fectly, or not  at all, dissolved  in the stomach,
even when  retained; and even granting that
it is dissolved, the degree of depression is so
great as  not to be roused by it alone.  Hence
the bark in substance, taken in wine, with am-
monia,  capsicum, &c, as mentioned above,
would be preferable, if it were retained by the
stomach.   I would advise that quinine should
be given earlier in the disease than it usually
has  been, if given at all.  The existence  of
vascular reaction ought not to delay its, exhi-
bition, which should be directed in full doses,
and  generally conjoined with  camphor, capsi-
cum, and opium or creasote, or both, according
to circumstances ; for it  should  be recollected
that, however tumultuous and excessive vas-
cular action may seem,  vital power is so de-
ficient as to render tonics and stimulants indis-
pensable to the reduction of such excess.
   179. b. Mention has been  made (y  173) of
those stimulants which I  have employed in this
distemper.  In one case, to the notes  of which
I have referred, I find that somewhat more than
two bottles of brandy were taken within twenty-
four hours in the treatment of the period of
exhaustion, besides some Madeira, the patient
having rallied and ultimately recovered.  Dr.
Imray states that few stimulants were found
to answer  so well as Champagne.   " If any
irritability  of stomach remained, a greater or
less quantity of this wine, sometimes as much
as half a tumblerful,  was given every hour or
half hour, alternated with farinaceous food con-
taining  brandy;  and in some  instances the
quantity of  stimuli taken, with merely  the ef-
fect of warding off impending fatal sinking, was
truly surprising."  The circumstance most to
be dreaded,  and, indeed, to be  prevented by an
earlier recourse to stimuli  than is usually ad-
vised, is exhaustion of the vital power of the
stomach, so as to be  past being influenced by
this class of medicines.   If, however,  the cold,
clammy feel of the body and the sinking of the
pulse have come on before stimulants are ad-
     III            14
ministered ;  and if the pulse rise in strength,
and if a glow of returning warmth be diffused
over the surface, the best hope may be enter-
tained of the patient's recovery, notwithstand-
ing the late period at which they have been ex-
hibited ; but the strictest care will be required
for several days to prevent symptoms of sink-
ing from supervening.  Brandy, Madeira, hock,
&c, taken in  soda  water,  generally with the
addition of the sub-carbonate of soda, or car-
bonate of ammonia, or in spruce beer, Seltzer
water, &c, or the former in arrow-root, sago,
&e., are generally of service in the more severe
states of the malady, and when the stage of ex-
citement is about to pass into exhaustion.
   180. c. Of medicinal stimulants, camphor, am-
monia, capsicum, &c, are most deserving con-
fidence in this malady, especially when conjoin-
ed with opium and aromatics, or with the prep-
arations  of  cinchona.  Spirit of turpentine is,
however, the most generally applicable, as re-
spects both the state and stage of the  distem-
per and the  modes of administering it; and it
is even more  certainly beneficial when given
during the stage of excitement, especially con-
joined with  other oils, so as to  act freely on
the bowels, and administered in enemata, as
noticed above (y 166,173).   When the stage of
exhaustion is approaching, or has supervened,
and indications of passive  haemorrhages   or
black vomit  appear, it then should be prescribed
in smaller and more frequently repeated doses,
with small quantities of tinctura opii, capsicum,
or other aromatics, and administered largely in
enemata,  with camphor,  asafcetida, &c,  or
with tinctura  camphorae composita.  Much  of
the advantages derived from this substance re-
sult in this  as well as in other malignant dis-
eases from the mode of prescribing it, accord-
ing to the varying states of morbid  action ; and
the modes most appropriate to these states are
to be learned only from attentive observation
of its effects in various circumstances.   It will
be more easily retained by the stomach when
vital depression is very remarkable, if a drop
or two of creasote, or «tf cajeput oil, or of tinc-
tura capsica, be added to each dose.
   181. d. The  use  of antiseptics  in this and
other malignant diseases was more generally
adopted  by  the older  than  by recent  writers.
The humoral  pathologists  recognised  the vir-
tues of those  substances which  possessed an-
tiseptic properties ;  but  with the  adoption  of
the doctrine of Hoffman and Cullen, the pos-
sibility of antiseptics proving serviceable was
disputed and even denied, because they believ-
ed that benefit from these substances  was in-
consistent with their  doctrine.  Thus an im-
portant class of medicines for the most danger-
ous states of disease was sacrificed to a theory,
and the results of sound and close observation
were despised, because they could not reconcile
them with their limited views.   Many of the
substances which act as stimulants act also as
antiseptics,  and serve  to prevent the tendency
to a dissolution of the  vital cohesion of the tis-
sues, and of the crasis of the blood, character-
izing the malady, and manifesting itself even be-
fore life is extinct.  The preparations of cin-
chona, camphor, the chlorides, the chlorate of pot-
ass, the terebinthinate  substances, creasote, aro-
matics, &c, severally exert not only a stimula-
ting influence on the vitality of the frame, but 
210
PESTILENCE, HaEMAGASTRIC—The Means of Cure.
also an antiseptic effect not merely on the di-
gestive  mucous surface,  but also upon the
whole body, by imbibition and absorption into
the circulating fluids, if the exhibition of them
has not been delayed until the powers  of life
are sunk too low to be impressed by physical
agents.   The cause of the failure of most of
these agents in pestilential and malignant dis-
tempers is  often to be attributed  either to the
late period  of the malady in which they are pre-
scribed, or  the inadequate doses in which they
are given.
  182. F. With the chemical pathology of West
Indian fevers, Dr. Stevens introduced a differ-
ent practice in  their treatment from what had
hitherto been adopted ; but, as might have been
expected by those who have studied  the laws
of living bodies, in connexion with those dis-
played by  inert matter, the  practice  has not
justified the praise lavished on it by its author.
The chemical doctri nes of Liebig, with reference
to physiology and pathology, have tended to im-
part much greater importance to a purely chem-
ical treatment of disease than might otherwise
belong to it; still, chemical agents, as aids  to
the due development of  the controlling influ-
ence of life, ought not to be overlooked, hut
should be  rationally employed, under the gui-
dance of observation and experience.  The im-
portant truths,  that  the  chemistry of  living
bodies is not the chemistry of inert matter ;
that the  vitality of the body develops a  vital
chemistry of its own, and controls the chemical
actions of material elements to its  own ends ;
that it is only the deficiency  or loss of vitality
that allows purely chemical actions to be man-
ifested, while the due ascendency of this prin-
ciple  converts them  from  their natural and
purely chemical tendencies,  and directs them
to  its own  purposes; and  that due  energy
should be  imparted to this principle when we
wish to develop those chemical changes which
are strictly vital, and which  are indispensable
to the continuance  of animal existence—ought
never to be lost sight of in our speculations on
the treatment of malignant and pestilential dis-
tempers, and should be made the basis of our
indications of cure.
   183. Dr. Stevens justly stated that the colour
of the blood was changed in the more malig-
nant cases of fever ; but he was not equally
correct as  to the loss of the saline ingredients
of the blood, nor even as to the cause of the
loss of the  colour of this fluid.  The still more
important loss of the fibrin of the blood had not
its  proper place assigned  to it in his apprecia-
tion of the  changes evinced by  the circulation.
Believing that the alteration of the blood arose
from the loss of the saline ingredients, he pre-
scribed the neutral non-purgative  salts, viz.,
the chlorate and nitrate of potass and the carbo-
nate of soda, at short intervals and in moderate
doses, and confided in them entirely.  There
can be no doubt of changes in the blood occur-
ring in the course of the disease; but these
changes are not of a purely chemical nature ;
for, even admitting that a partial deficiency of
the saline  ingredients of  the blood is actually
present, it is evident that this deficiency arises
rather from a want of an  accustomed supply of
these ingredients during the course of the dis-
ease than from any increased loss or  waste of
them, as shown in another place.  They are
strictly a part only of those changes which de-
pend  upon the state of vital influence, or  of
organic nervous power in  the several viscera;
the deficiency of fibrin  being even  greater and
more remarkable than that of the saline ingre-
dients.   The treatment  of Dr.  Stevens, as
well  as  his  pathology, was  too  exclusively
chemical to be consistent with actual morbid
conditions.   He saw a portion, and that but a
small portion, of the mischief;  yet that little
was large enough, in his eyes, to intercept the
view of  much more important truths.   The
puny progeny of his mind was rapidly nurtured
by his imagination into premature and gigantic
growth, but like all objects attaining  large di-
mensions prematurely, it wanted the vitality
necessary to endurance.  While he unwarrant-
ably magnified changes which he considered to
be chemical, he mistook their origin, and en-
tirely overlooked those which are vital, which
depend  upon  the  state  of vital endowment.
He did not even appear to recognise any alter-
ation that  was vital.  What was  most prom-
inent and unmistakable  was  altogether hid
from him.  The highly diseased condition of
the blood was sufficiently obvious ; but it was
also  equally  obvious that  the  alteration  was
much more vital than chemical.  Dr. Stevens's
theory, failing in support from observations and
experience, has fallen " like an inverted cone."
Dr. Imray  thus states the results of the treat-
ment which  was based upon  it: " Unhappily,
the salutary  change said to be effected by the
action of the neutral  non-purgative  salts did
not take place,  as may be inferred from the ma-
lignant symptoms continuing unabated.  Not-
withstanding the exhibition of these salts in
large doses, and the administration of the car-
bonate of  soda, muriate  of soda, chloride of
soda, nitrate of potass, &c, variously  com-
bined, yet  in no instance in which they were
prescribed could it be  said that they  produced
any marked effects, either in preventing malig-
nant symptoms, or in removing them after they
had made their appearance."
   184. The inefficiency of this treatment has
partly been owing to the  erroneous views en-
tertained by its author respecting it, and to the
circumstance of  its being confided  in solely,
to the neglect of other  and  more  important
remedies.  If certain  of these salts had been
employed as adjuvants of other means in states
and combinations  appropriate  to existing mor-
bid  conditions, I  believe,  from my experience
of  them in other malignant distempers,  that
more benefit would have been derived, espe-
cially if they had been prescribed before the
vital powers  were too far reduced, and before
the consequent changes had proceeded too far
to be influenced by them.   The chlorate of pot-
ass was  recommended many years ago hy Dr.
Garnett and others ; and for more than thirty
years I have employed it  in the low adynamic
states of fever, more  especially in malignant
scarlet fever, with carbonate of soda and hydro-
chloric ether,  in the decoction of  cinchona or
the  infusion  of valerian ; combinations which,
with some modifications or additions, might be
prescribed with advantage in this pestilence, if
not delayed until a too advanced period.
   185. G.  The external means which offer the
most advantages are, during the first or cold
stage, or that of horror and invasion, the warm 
PESTILENCE,  HaEMAGASTRIC.
211
bath, followed by frictions of the surface with
warm olive oil, and sinapisms or turpentine em-
brocations  over  the  epigastrium.  When the
period of excitement  and vascular reaction has
supervened, the hair  should be removed from
the head, and cold applications, or the cold af-
fusion, be prescribed,  and repeated or continued
according to  circumstances.   The tepid bath,
or cold sponging of the whole surface, is gen-
erally as beneficial as it is grateful to the pa-
tient in this stage ; and when either the  one or
the other is followed by frictions of sweet oil,
a copious and general perspiration usually su-
pervenes, and proves critical,  especially when
aided by the  warm sudorifics, particularly the
liquor ammoniae  acetatis, spiritus ammoniae
aromaticus, and the  aether hydrochloricus, or
spiritus aetheris nitrici, as advised above (y 164).
In the last  stage, and even early in the  fourth
form of the distemper, the external applications
should be of a different kind from those  requi-
red in the second stage.  Warm and rubefacient
substances are now  required, the same means
as are advised in another part of this  article
being also the most appropriate in these states
of the distemper.  (See Pestilence, Choleric,
y 179, 180.)
  186. H. During convalescence the utmost care
is requisite to prevent a relapse, especially into
that state of  dangerous exhaustion or depres-
sion marking the third stage and the fourth form
of the malady ; a relapse being the more to be
dreaded the earlier the period of convalescence,
and the more liable to occur when the patient
has been rescued from sinking by recourse to
powerful stimulants  and restoratives;  for in
these cases the too  early  suspension of these
remedies allows the  distemper to resume that
course which  had been arrested only for a short
time by their  aid ;  for if they be altogether or
even partially relinquished before the secretions
and excretions are restored, and the condition
of the blood very materially improved, the dis-
ease returns,  the morbid actions characterizing
it being only  suspended for a  while under the
influence of the agents which had been admin-
istered.   When  convalescence is  farther ad-
vanced, the distemper having  altogether ceas-
ed, recovery generally takes place more or less
rapidly without any  disposition to relapse, un-
less errors of diet, excesses, or most injurious
exposure to noxious  influences have occurred ;
and even in these cases it is doubtful whether
or not the  consecutive disease is the same as
that from which the patient had recovered ; for
it must be obvious that a  patient convalescent
from this distemper cannot be exempt from the
operation of malaria, or of other causes of dis-
ease, but, on  the contrary, more likely to be af-
fected when exposed  to them, owing to existing
debility and impaired resistance of vital  power
to injurious agents. During convalescence from
this as well as from other pestilential maladies,
very nearly the same  measures may be adopted
as have been advised in  another  place, with
such modifications as the circumstances of par-
ticular cases  may suggest.  (See Pestilence,
Choleric, y 215-217.)
               [APPENDIX.]
  For the following valuable notes on the yel-
low fever at Vera Cruz, &c, we are indebted
to the kindness of P. S. Townsend, M.D., the
able author of the work on this disease, so oft-
en quoted, and the  well-known translator of
Velpeau's Operative Surgery.—(Ed.)

Yellow Fever and other Diseases  of the
  American  Troops, Sailors, and Marines
  at Vera Cruz, New-Orleans,  Lafayette,
  Mobile, Tampico  (?), &c, 1847.—Prevail-
  ing Diseases of the American Army on the
  table-lands of Mexico, as  at  Jalapa, Pe-
  ROTE, PUEBLA,  MaTAMORAS, CaMARGO, MoN-
  terey,  &c.
  During  this present summer of 1847 there
have rapidly  occurred in  the Gulf of Mexico
some of the  most instructive  lessons on the
subject of the origin and communicable, trans-
portable or importable, and contagious and in-
fectious nature, and specific sui generis charac-
ter of yellow fever (as contrasted with  other
diseases), that  are to be met with in the his-
tory of this disease.   These facts have result-
ed from the present  war of the United  States
with Mexico, and the extensive and sudden ac-
cumulation, within the tropics, of bodies of
troops, and sailors, and marines, almost exclu-
sively, or  at  least two thirds of them, unaccli-
mated, robust northern men,  and employed on
various expeditions  against the Mexican sea-
ports and interior towns.  During the past
spring some 15,000 to 20,000 volunteer troops
and  regulars, mostly from our northern and
western States (Illinois, Indiana, Ohio,  Missis-
sippi, Kentucky, Tennessee, Pennsylvania, and
New-York), together with a naval  fleet of one
74, several frigates and steam-frigates,  sloops
of war, brigs, gun-boats, and small steamers,
manned by four  thousand seamen and ma-
rines, assembled before Vera Cruz.  The volun-
teers and  regulars were brought thither chiefly
by the way of New-Orleans, in a short run of
a few days, in United States  steam-transports
and other craft, as ships, brigs, &c, and some
from ports in the middle and northern states.
The transports alone that carried the troops, first
to Tampico, but chiefly to the island of Lobos,
near Vera Cruz, and soon  after to the anchor-
age of Anton Lizardo, within five  to ten  miles
of Vera Cruz, where our naval armament were
moored, amounted to near 150  or 200 vessels,
chiefly of  large dimension, and a considerable
number of which were steamers.  The entire
coast of the Gulf of Mexico, from the mouth
of the Mississippi River to Vera Cruz (lat. N.
19°), was,  for the first time in history, alive
with  crowded expeditions, chiefly of northern
men, and all natives of high latitudes or extra-
tropical countries.*   All this occurred  for the
most part  in the beginning of March, and  about
the middle of that month Major  Gen.  Scott
landed from our squadron, in the space of a few
hours, some   15,000 of these raw northern
troops, including a large battalion  of marines-
upon the  strip or margin of gravel, sand, and
sand hills, which here, for miles  and  miles,
forms  the  coast  of  Mexico,  in the midst of
which arid spot, perfectly destitute of all marsh-
es, lagoons, or malaria, Vera Cruz  is situated.
During all these embarcations, transportations,
and  debarcations, whether at  Tampico, just

  * Though  four fifths of the soldiers and sailors were
Americans from latitudes  north of 34°  N., the other fifth
were almost  exclusively Irish, with a few Germans. 
212                        PESTILENCE, HaEMAGASTRIC.
without the tropics, or at Lobos or Vera Cruz,
both in about 19° N. lat., scarcely a single sol-
dier, or sailor, or officer died of any disease or
fever whatever, though all were of robust con-
stitutions, well fed and well clad, many of them
(as the volunteers) wealthy farmers, and all un-
habituated to a tropical climate, and  most  of
them thus brought, by the aid of steam chiefly,
suddenly into the neighbourhood of Vera Cruz,
within a month after leaving  their  northern
homes.  In all this time not one died of yellow
fever, although the temperature during March
and April was, for the greater part of the time,
ranging above 80° F.   More  than  this,  the
troops before and during  the bombardment of
Vera Cruz, and at the time of the surrender of
that town and of the  Castle of San  Juan  de
Ulloa,  and  afterward, lay for a month in their
encampments of tents on the sand-beach with-
out the city,  a few only being quartered within
the walls of the city and castle for  garrison
duty.  After this, the army proceeded on  its
march on the great public road, through dense
forests and shrubbery, called chaparrals, con-
stantly ascending rapidly above the level of the
sea, capturing on their route Cerro Gordo, the
city of Jalapa, Castle of Perote, and, finally, the
city of Puebla, on the vast table-land or plain
of the Valley of Mexico,  which plain is itself
100 to 200 miles in diameter, and upon an av-
erage of 7000 to 8000 feet above the level  of
the sea, besides being surrounded by an  amphi-
theatre of mountains which, many  of them,
are 8000 feet still higher above that plateau.
  The army have here since (i. e., up  to our
writing, September, 1847) enjoyed almost un-
interrupted  health, finding   themselves in a
pure, brilliant, elastic atmosphere of diminished
density, and  which, though  it  may be said in
that rarefied condition to be tropical, and is geo-
graphically within the tropics, possesses, how-
ever, a uniform mildness of temperature which
belongs to extra-tropical regions, but  of much
more salubrity than upon extra-tropical paral-
lels of similar temperature.  The only diseases
that have prevailed here have been incidental
to  exposure to the rank vegetation  on  the
march, irregularities, and excesses in diet and
liquor, exposure to night  air, and indulgence in
the mixed tropical and northern fruits, always
accessible in these places ; and  hence  the diar-
rhoeas, dysenteries, and intermittents, and some
remittents ;  but no yellow fever or vomito.
  Previous to the army leaving the coast, and
while being concentrated during February and
March at Vera Cruz and the neighbourhood, the
entire  Gulf of Mexico in this portion of it was
almost daily swept  by those refreshing, and
even in this season often unpleasantly cool and
fierce  breezes called  " northers," or heavy
blows  from  the  north, often, as occurred this
summer, augmenting  to  destructive tornadoes
to the shipping at anchor or near the coast, but
serving as most thorough purifiers and ventila-
tors against  the possibility of any lurking con-
tagion or infection.
  Hence, while these continued, viz., up to the
beginning of May, the full-blooded, sanguineous
northerner, with his rich  animal blood, wholly
escaped the de novo production of vomito in his
system ;  for  the  other  element, inter-tropical
heat, was nullified in its operation by the cold
winds named.  The city of Vera Cruz, though
naturally  a dry, clean, well-laid-out  place  of
some 7000 inhabitants, is surrounded with high
walls which completely exclude all ventilation.
The reflected and reduplicated irradiations  of
heat, untempered  by the  northern blasts, pla-
cing Vera  Cruz in a condition  similar to the
shut-up harbour of Havana, with  its  immense
battlement of the Moro Castle and Cavana op-
posite (200 feet high and  a mile long), making
it a perfect oven, now made the Mexican sea-
port also begin to  feel the force of this  suffo-
cating atmosphere.  The disease, of course, be-
gan to appear sporadically, or in isolated spon-
taneous cases, successively among the com-
bustible materials  there fresh for its reception,
viz., among the few northern troops left (after
the departure of the great  body of the army)
to garrison the city, in which  garrison duty
were included the  various  northerners em-
ployed in the quartermaster's department, or as
teamsters  or sutlers, &c.  To this concentra-
tion of healed human effluvia was doubtless su-
peradded the offensive putrid exhalations from
bodies crushed beneath the falling buildings,
walls, &c, and which must have amounted to
a considerable number, as several hundred of
the Mexicans were killed  in this way through
the bursting of the vast number of heavy, de-
structive shells sent by our  artillery and naval
batteries in the intrenchments during the bom-
bardment  which resulted  so gloriously to our
arms.  A greater portion of these smouldering
ruins  and  decaying bodies,  however,  were
speedily removed by the vigilance  of our com-
manding officers in garrison (Gen. Worth, Col.
Wilson, &c).
  Meanwhile, though the  disease, after being
once  generated, as I have mentioned, within
the heated atmosphere of  Vera Cruz, naturally
reproduced itself in others by its infectious or
contagious germs, it was, by a vigilant police,
ventilation, disinfection, and therapeutics, insti-
tuted under Dr. Barton (President of the Board
of Health of Vera Cruz), prevented from be-
coming epidemic.   And in the  famous Castle
of San Juan  de Ulloa, only a mile  distant, and
where there was  only a  small garrison, and
spacious shaded apartments, and  cleanliness,
and thorough ventilation and dilution with the
sea-breeze, not a solitary  case, we believe, of
the vomito occurred.  The fever soon  declined
also even in the city.  The reason why we shall
see.
  To exhibit, however, this most important
point of atmospheric dilution  in all prophylactic
or preventive  and purifying  measures, take
such facts  as these :  In consequence  of Gen.
Scott finding himself at Puebla, in  the interior,
greatly embarrassed by his communication be-
ing cut off with Vera Cruz, on the coast, ow-
ing to the large bodies of guerillas or rancheros
that  infested the road, it became necessary to
keep this route open or cleared by  correspond-
ingly  adequate  forces  of American  troops.
Bodies  of American  soldiery,  therefore—al-
most  every one raw recruits from  the north-
have  been constantly arriving at Vera Cruz all
the months of May, June, July, and August, and
have  successively  encampecl outside the city,
on  the extensive  beach  before  mentioned.
Here they have, almost all of them, remained
encamped  in their tents for near a month, as
force  after force was successively  marched up 
PESTILENCE, HaEMAGASTRIC
213
to Jalapa and the interior.  Thus the forces of
Generals Pillow, Cadwallader, Pearce, &c,
each from  1500 to 3000 men, with large trains
of ammunition and provisions.   And yet, while
encamped  in their  tents on the beach at this
hottest  season,  where  the  " northers" had
ceased to  blow,  scarcely a solitary soldier of
the whole of these troops has perished of vom-
ito !  The  under  parts of the tents being open
to free currents of air constantly, and the tents
themselves being judiciously separated, and so
located as to favour this thorough ventilation and
dilution  with the external  atmosphere, during
the  alternate land and sea breezes, night and
day,  and also the now (in the summer months)
constant range of the  thermometer,  night and
day,  at a very small distance  from 90° Fahr.
either way, are wholly sufficient causes for the
solution of this  problem.  It is, on  the other
hand, and  in corroboration of  what is here as-
serted, to  be remarked,  that the yellow fever
(from what has yet been disclosed) began now,
in the month of July, to make its appearance
also on  board of the squadron under Commo-
dore Perry, lying, as before,  more or less of
their time constantly at the anchorage of Anton
Lizardo, some five to  ten miles south of Vera
Cruz.   These cases occurred successively, and
chiefly on  board  the Mississippi steam-frigate ;
and we  explain its special occurrence here in
one or some, or  all of the following modes :  1.
Her ship's crew  consists of three to four hun-
dred, and  hence  below decks, ventilate as we
may, there must be  far more crowding, and
also, therefore, far greater concentration and
accumulation of human effluvia than  in the
smaller craft which have only small crews.   2-
Sailors generally (especially when off duty) are
more dissipated, and more ready to  indulge
than soldiers in  excesses of drink, fruits, &c,
exposure to  the hot sun  on shore, fatigue, &c.
3. Though the temperature of the atmosphere
on shore was now  at this  season too high (as
during the " northers" it was  too low) to  co-
operate with the rich blood of the  newly-ar-
rived northern man in the de novo production
of yellow  fever,  it was in the shipping less ele-
vated, viz., probably ranging below decks from
85 to 88°, and  at the same time converted into
a most  combustible medium or nidus  both for
the germination and for the re-propagation of
yellow fever. 4. Doubtless some of the disease
on board was introduced by communication of
the crew with the garrison and city of Vera Cruz.
  A curious episode, however,  occurred  in
the midst of  this exposure,  and during the
gallant  services of our naval  armaments; and
it proved  for  them  doubtless a  most  fortu-
nate one.   For,  by the activity of the commo-
dore and his officers, constant expeditions du-
ring these hot  months have been planned and
executed  to bring  to  submission  the various
other seaport  towns, mostly small  cities, on
the small  rivers that  open on this part of the
coast.
  Among  these,  and by far the most important
undertaken by Commodore Perry (Tampico and
Tuspan having fallen  early in the campaign),
was Tobasco,  in July.  Marines  and  sailors
were detached in large draughts from  all the
vessels  of the squadron, both from those left at
Anton Lizardo and from those that constituted
the expedition to the mouth of the Tobasco
River.   These forces, nearly 1200 in number,
were, on account of the current and shoals,
two days nearly in ascending some  150 to 200
miles, to the small town of Tobasco, though
towed  up in a masterly manner by the small
steamers of the squadron.   All the  accounts
represent this winding stream  and  its tributa-
ries  to  be margined with  the very heaviest
growth  of rank vegetation, which at the time
was  in  its highest state of luxuriance,  and
masses  of it macerating and decaying in the
humid  places along the banks.  The sailors,
in capturing the town of Tobasco, had first to
land and make fatiguing, rapid marches in the
hot and broiling sun, in the midst of exuberant
masses  of chaparral, and vines, and trees, and
underbrush, literally cutting  their way through
these entanglements.  They then returned to
Anton Lizardo, leaving only an inconsiderable
garrison, which in a few days being re-enforced
to nearly one third the original expedition,
thence proceeded on foot farther up the river,
encountering  in  their  tedious  and  difficult
march  the same  kind  of obstacles as before,
and  captured another small town, to which
also a force of small steamers  afterward went
up for the same purpose.
   Together with such expeditions and exposure
to the  most intense malaria  and  a hot  sun,
among  streams of fresh water clothed in sub-
merged vegetation, we should  remember that
our sailors and marines also had, a few weeks
previously, executed similar expeditions up sim-
ilar rivers, as to Alvarado, Tuspan, Laguna, &c,
under Tatnall, Mayo, Hunter, &c, directed
mostly in person by Commodore Perry.  It is
sufficient to know that the naval forces left  on
the Mexican coast, and thus operating in the
midst of the spring and summer months, were
thus constantly on the move, and  fearlessly
breasting, on this tropical shore, every kind of
hardship and danger ;  the  greatest  of which
was that of having been compelled, as already
remarked, to encounter the  deadly paludal ma-
laria of the mouths of the rivers.
   What was the  consequence 1   About  the
same time that the rigid police and cleanliness
of the squadron, while remaining at anchor at
Anton Lizardo, in  every respect the same dry,
healthy, and sandy shore and beach as at  Vera
Cruz, was, so to speak,  " staving off' the vom-
ito, or having only an occasional sporadic case
among the crews not on the expeditions named,
these last  began,  at the places they had cap-
tured, to yield to the influence of morbific causes,
which, though naturally less fatal, were far more
virulent than any element  of the vomito, so
far as regards, at least, their epidemic or atmo-
spheric extension.  This was  the malaria or
paludal  exhalations mentioned, of which more
than two hundred and fifty became sick almost
simultaneously, or in large numbers successive-
ly.  That they should have thus fallen sick to-
gether was to be expected as a matter of course,
where all were alike exposed to a general and
wide-spread  vegetable poison.  The 60 to 70
marines finally left in garrison  on the Tobasco
river were,  it is asserted, every one of them
taken down.  This was to be anticipated, from
their remaining several weeks  constantly in a
situation where they were compelled to breathe
in the  paludal poison  diffused so  abundantly
through the atmosphere.   All these invalids 
214
PESTILENCE, HaEMAGASTRIC.
were  now  successively brought down to the
anchorage at Anton Lizardo ;  and the utmost
astonishment was manifested by those unac-
customed to tropical climates and to vomito, in
perceiving that nearly every one of the above
cases of paludal remittents recovered, while
those at Vera Cruz, and the very few on board
the squadron that had been seized with vomito,
almost invariably died.   Such facts afforded but
poor consolation to the blind theorists who had
luxuriated in the scholastic absurdities of Rush-
ian dogmas, that the vomito is not a specific idio-
pathic disease, but identical with paludal or hepat-
ic disease, in other words, with bilious remittents.
What is more,  some of these very returned
men of the expeditions, enervated by these re-
mittents, now caught (by  infection, doubtless)
the vomito on board the Mississippi (little of it
as there was), and died of it!  Out of the com-
pany  of  marines just  named, and  who, from
their continued exposure at Tobasco for weeks,
naturally had the severest grade of remittent,
only six or seven, nevertheless, perished of it,
and of these probably two or three, or more,
may have been cases of vomito caught on her
arrival at the anchorage.  In the forepart of
August, in consequence of the great numbers
sick on board the Mississippi of remittents among
those who had been on the expeditions named,
Commodore Perry, who had previously shifted
his flag to  the sloop-of-war Germantown, de-
spatched the  frigate with the invalids, some
150 in number, to our naval station at Pensacola,
in Florida.  There they arrived in a few days,
and almost every one of them became rapidly
convalescent as soon as the frigate had put to
sea, and proceeded  north  before she reached
her destination.  So much for the purer, cooler
sea air in the tropics in its salutary influence
on the remittent type of disease.  Not so with
the vomito: the cases of this  last almost inva-
riably multiply at sea on leaving a hot port, as
Vera Cruz or Havana, at this season ; for there
is  necessarily  more or less  crowding below
decks, and the cooler oceanic temperature, by
its constricting effects on the  surface [see my
various  works on yellow fever],  favours the
retention and more  energetic action of yellow
fever poison.   The truth  of this is seen every
year.
   While the masses of troops, sailors, and ma-
rines have been assembling and operating, as
above described, on the tropical portions of the
coast of Mexico, at Tampico, where  we  have
also constantly had  a garrison  since early in
the spring, and where, also, a similar expedition
to that of Tobasco (viz , under Colonel De Rus-
sy) were similarly exposed to the  malaria  of
the River Panuco, remittents,  it is true, and di-
arrhoeas and dysenteries, as among all our troops
and garrisons, have been  prevailing (not, how-
er, mortally), while scarcely a case of the vom-
ito occurred !   Tampico is considerably without
the tropics,  and located in a  healthy position,
though far less so in respect  to paludal expo-
sure than Vera Cruz.
   Also the  other great arm of our service, viz.,
that under General Taylor, on the Rio Grande,
has been, during the above period of the present
spring and summer, receiving very considera-
ble re-enforcements, also  chiefly  of northern
men  (volunteers or regulars), and  mostly  by
the way of New-Orleans.  These  re-enforce-
ments landed all at or near the mouth  of the
Rio Grande, at Brasos,  Matamoras, &c., all of
which are in  about latitude 26°  north.   Here,
also, and at Camargo and Monterey, higher up,
more or less paludal fevers, diarrhoeas, and dys-
enteries occurred, and some, from neglect or im-
prudence, proved fatal;  but there was no mor-
tality, and, least of all, no vomito whatever.  The
higher up the Rio Grande the more intermit-
tents apparently occurred, and fewer cases of
remittent type.  So, in general, the juxta and
intra-tropical positions, from the greater heat
and greater intensity of malarious poison, and
the greater activity of the liver and secretion of
bile, furnish the most severe grades of remit-
tent or bilious remittent.  The malaria, as we
see above at Tobasco, acts then so powerfully
in its deadly poison, as  to occlude the reaction
of those elements that generate yellow fever,
which elements, however, where the  paludal
poison is wanting, as at Vera Cruz, &c, then
obtain the ascendancy.  The whole subject,
we repeat, is most  instructive, and most em-
phatically significant of the type of the two dis-
eases, and of their causes, symptoms, &c.
   Finally, the  vomito having now  been fairly
established at Vera Cruz from, as it were, im-
perious necessity, by forcing it into existence,
by the  large  numbers  from the north  landed
there, and latterly remaining under the most fa-
vourable circumstances, the disease thus ob-
tained a new and more  powerful auxiliary gen-
erating focus than it has at that city for many
years.
   New-Orleans, whose authorities have gener-
ally seemed to conclude that it would be more
disastrous for her great commerce with the trop-
ics to be sacrificed than to incur the risk of im-
ported yellow fever by a lax code of quarantine,
has thus acquired this year, through her patri-
otic co-operation in the Mexican war, not only
active and direct means of introducing the for-
eign tropical pestilence by a return from Vera
Cruz of the transports that carried troops and
provisions, but also her customary supply of
yellow fever infection  in the short transit of
her trading vessels from Havana, by which last-
named market  she is  usually furnished with
this pestilence.
   The  consequence has  been  that,  through
these  prolific sources,  the disease manifested
itself at New-Orleans a few weeks subsequent-
ly to the first cases of our countrymen that
were announced as its  victims at Vera Craz in
June and  July, or on  the  passage thence to
New-Orleans.   Meanwhile it was, as a matter
of yearly and familiar occurrence, being intro-
duced as usual at the wharves or levee at New-
Orleans by daily vessels from Havana, dec.  In
the beginning of July it was no longer possible
to blink the question, and since then its march
has been one of longer and longer strides, and
of a most frightful desolation, insomuch so that,
in the beginning of September, even the official
annunciation of deaths was acknowledged over
one  hundred  victims daily!   Gentlemen just
from thence declare it never was so fatal, and
they assert that the deaths daily are probably
much nearer 150 than  100.  This, too, it must
be borne in  mind, is in a population which at
this season, by the customary migration of the
richer classes to the north, is  reduced to some
40,000 or 50,000 souls!  At this rate our pres- 
PESTILENCE, HaEMAGASTRIC
!—Bibliography and Refere>*e3.           215
ent  population  in  New-York, of  450,000  to
500,000  inhabitants, should  lose by the vomito
about  500  to 600  souls  in every  twenty-four
hours!
  We learn from credible sources that, as usu-
al, the vomito has fallen with most severity on
the poor emigrants (Irish  and German  chiefly)
recently arrived within a few weeks from north-
ern Europe, and who die, many of them, from
pure neglect, and from having no means of es-
cape to  the country.  It is inconceivable that
the New-Orleans authorities should have culpa-
bly neglected to disperse their population bodily
into the country.  Even thinning out these emi-
grants in this manner would have done much ;
but the concentration of human effluvia has giv-
en a wild ferocity  to the epidemic character of
the pestilence.  Finally, the intensity of the ac-
cumulated virus has reached the native Creole
inhabitants, who  will still,  however,  indulge
the  delusion that,  in their latitude of 29° 30'
north, they can acquire  a tropical  immunity to
yellow fever  !   They, too, have fallen victims.
And, to  wind up the tragedy, for which, for the
sake of the country and the war in which we
are engaged, New-Orleans must, this  year  at
least, be forgiven,  the vomito has, after the dis-
ease had raged for some weeks at New-Orleans,
been, as might have  been anticipated,  carried
across the Mississippi River, from that capital to
the town or village of Lafayette opposite, and
there  proved alarmingly  fatal;  while, at the
same time, the disease has been fairly and clear-
ly introduced  also to a greater distance from
the same focus, viz., into Mobile.   So  succes-
sively other towns on the Mississippi, in com-
munication with New-Orleans, will successive-
ly become entangled in the chain of infection.
  Surely no one at this day will ever be so in-
fatuated as to say that there has been anything
in the atmosphere  at New-Orleans, or in any
part of the United  States, of an endemic or in-
digenous character, either as to river or wharf
mud, or  alluvium, that could have possibly war-
ranted the suspicion that so fatal  a pestilence
would this year have afflicted that devoted city.
It would be folly, after looking back at  the nat-
ural links that  connect the whole  of this sub-
ject together in the Gulf of Mexico, to  argue
with persons of this description.
  We will  make  one or two concluding re-
marks :  1. Its very fatality clearly demonstrates
the truth of all our positions ;  for it is the sub-
dued character of  the temperature by day, and
the  interregnum of cool nights that  succeed,
which furnish precisely that condition of things
which,  with  the crowding together  of north-
ern  and ever-unacclimated  subjects at hand
to feed upon, makes the disease imported into
New-Orleans, outside the tropics, so fatal there
at this moment, as compared with  its apparent
suspension (both de novo and epidemic) at Vera
Cruz, within  the tropics,  by excessive contin-
ued  heat.   2.  While this note has been  going
through  the press, we have had a striking ad-
ditional fact in support of the infectious or con-
tagious and transportable character of the yel-
low fever, in the actual importation of the disease
into Brasos, only three degrees outside of the
tropics,  in one or more infected transport ves-
sels from New-Orleans, in lat. 29° 20' N. ; to-
gether with the information that our military
authorities at Brasos interdicted the admission
of such infected shipping.   3.  One solitary case
only of the  vomito, and proving fatal,  has oc-
curred in  the Castle of San Juan  de Ulloa, in
Major Clarke of the army,  who doubtless took
the infection at Vera Cruz.  4. The prevailing
diarrhoeas and dysenteries in  the army, espe-
cially  the former, though  infinitely less fatal
than the yellow fever, have been attended with
an unusual number of deaths.
                      P. S.  Townsend,  M.D.
  New-York, September, 1847.]

  Biblioo. and Refer.—H. Warren, Treatise concerning
the Malignant  Fever of Barbadoes, 8vo.  Lond., 1740.—/.
/. de Gastelbondo, Tratado del  Motodo Curat, del Vomito
Negro,  12ino.  Madr., 1755.—/. P. Schotte, A Treatise on
the  Synochus  Atra  Biliosa; a Contagious Fever, which
raged at Senegal in 1778, <fcc, 8vo. Lond., 1782.—/. Mac-
kittrick, in Baldinger's  Syllog. Select. Opusc, vol. i., p.
87; et /. Moultrie, in Ibid., vol.  i., p. 163.—T. Romay, Dis-
sertacion sobre  la Fidbre Amarilla, 4to.  Habana, 1791.—
/. Deveze, Recherohes sur la Maladie Epidemique qui a
ravage Philadelphie en  1793, 8vo.  Phil., 1794.   (Non-in-
fectious.)— W. Currie, A Treatise on the  Synochus  Icte-
roides, or Yellow Fever, as it lately appeared  at Philadel-
phia, 8vo.  Philad., 1794.—M. Carey, A. short Account of
the Malignant Fever lately prevalent in Philadelphia, 8vo.
Philad., 1794.—B. Rush, Inquiry into the, late  Epidemic
Fever at Philadelphia, Svo.  Phil., 1793; and  An Account
of the Bilious Remittent  Fever as it appeared in the City of
Philadelphia in the year 1793, 8vo. Phil., 1794.   (In this
and his other works he  confounds Bilious, Remittent, and
Pestilential Fever with each other, and illogically contends
that what is true of the first and second is also true of the
third.)—/. Cathrall, A  Medical Sketch of the  Synochus
Maligna, 8vo.  Phil., 1794.—Anderson, in Duncan's Annals
of Medicine, &c, vol. v., p. 38 ; Drennan, in  Ibid., vol. v.,
p. 349.—Paterson, in Ibid., vol. v., p. 356.—/.  Holliday,
Tratado sobre la Fiebre Amarilla, 8vo. Habana, 1794.—/.
Patterson, Remarks  on  the  Opinions of Dr.  Rush on the
Yellow Fever, 8vo.  Lond., 1795.  (Infectious.)—/. Bryce,
Account of the Yellow Fever, with a successful Method of
Cure.   Edin., 1796.—/.  Clarke, A Treatise on the Yellow
Fever in Dominica in 1793-6, 8vo.  Lond., 1797.—/. Mas-
devall, Relacion de las Epidemias de Calenturas Putridasy
Malignas en  Catalana, 4to.  Madr., 1797.— S. Anderson, A.
Few  Facts and Observations on  the  Yellow  Fever, 8vo.
Lond., 1798.—C. F. Ameller, Descripcion de la Enfermedad
Epidemica en Cadiz, 4to.  Cadiz, 1800.—R. Armesto, Re-
flexiones sobre la Epidemia en Cadiz,  8vo.  Cadiz, 1800.—
W. Fowle, A Trentise on the different Fevers of  the West
Indies,  8vo.  Lond., 1800.—C. Chisholm, An Essay on the
Malignant Pestilential Fever introduced into the  West In-
dian  Islands from Bulam, in 1793 and 1794, 2 vols., 8vo.
Loud.,  1793, and 3d edit., 1801.—P. M. Gonzales, Diserta-
cion Medica sobre la Calentura que Regno en Cadiz, 8vo.
Madr.,  1801.—D. Grant, An Essay on the Yellow Fever,
8vo.  Lond., 1801.—/. N. Berthe, Precis Historique de la
Maladie dans l'Andalousie,  8vo.  Paris, 1802.  (Imported
and infectious.)—/. Dancer, Strictures on Dr. Grant's Es-
say on  Yellow  Fever, 8vo.  Lond., 1802.—N. P. Gilbert,
Memoire sur la Fievre Jaune, 8vo. Paris, 1803.—R.  Bay-
ley, An Account of the Epidemic Fever in the City of New-
York during the Summer and Autumn of 1795, 8vo.  New-
York, 1796.— T. Mifflin, Proofs  of the  Origin of Yellow Fe-
ver in Philadelphia, 8vo, 1797.—Facts and Observ. relating
to the Nature and Origin of the Pestilential Fever which
prevailed in this City in 1793, 1797, and 1798, by the College
of Phys. of Philadelphia, 8vo.   Philad., 1798.—W. Currie,
Memoirs of the Yellow Fever which prevailed in Philadel-
phia and other parts of the United States  in the Summer
and Autumn of 1798, with Facts  respecting the  Origin of
the Fever, <fcc, 8vo.   Philad., 1798.  (Imported and infec-
tious.)—B. Rush, Observat. on  the Origin of the Malig.,
Bilious, or Yellow Fever in Philad., &c., 8vo.   Philad.,
1799;  et A  Second Address, &c, containing additional
Proofs of the Domestic Origin of the Malignant, Bilious, or
Yellow  Fever, <fcc, &c, 8vo.  Philad., 1799.—C. Caldwellr
Medical and Physical Memoirs,  containing a Particular In-
quiry into the  Origin and Nature of  the  Pestilential Epi-
demics of the United States, 8vo.  Philad., 1801.—Address
to Philadelphia Medical  Society on the Analogies hetweea
Yellow  Fever  and true Plague, 8vo.  Philad.,  1801.—/I
Hardie, An Account of the malignant Fever lately prevalent
in New-York, 8vo. N. Y., 1799 ; and Account of the Malig..
Fever which prevailed in the City of New-York during the
Autumn of 1805.  New-York, 1805.—/. B. Leblond, Ob-
servat. snr la Fievre Jaune, et sur les Maladies des  Tro-
piquos,  8vo.   Paris,  1805.  (Infectious.)—S. H. Jackson,
Observations, &c, on the Epidemic Disease which lately
prevailed at Gibraltar, intended  to illustrate the Nature of
Contagious Fevers in general, 8vo. Lond., 1806.   (Infec-
tious.)—B. Progretto, Sull' Origine, Witura, e CaraUer* 
216
BIBLIOGRAPHY  AND REFERENCES.
della Peste dei Contagie, e della Fiebre Gialla, 8vo.  Lucca,
1804.   (Imported and  infectious.) — Dalmas, Recherches
Historiques et Medicales sur la Fievre Jaune, 8vo.  Paris,
1805.   (Imported and infectious.)—Palloni, Observat. Med-
icales sur la Fievre Jaune regnante en Livorne, 8vo.  Paris,
1800.   (Infectious.)—Puquet, Mem. sur les Fievres de Mau-
vais Caractere,  &c, 8vo.  Lyons, 1804.  (Infectious and
imported.)—T. Lafuente, De la Preservacion,  &c,  de la
Fiebre Amarilla, 8vo.  Madr., 1803.—L. Valentini, Traite
de la Fievre  Jaune, 8vo.  Paris, 1803.—/. .If.  Arejula,
Succincta Exposicion  de la Enfermedad  en Malaga, 4to.
Mai.,  1804; et Breve Descripcion de la Fiebre Amarilla de
Cadiz, 8vo.  Madr.,  1806.  (Introduced and  infectious.)—
W. Bait, Alenni ditagli sulla Febbre Gialla, 8vo.  Genoa,
1804.   (Imported and infectious.)—D'Oyarvide,  Delo Vom-
ito Negro, 8vo.  Habana, 1801.   (Imported and infectious.)
S. Henderson, On the Means of Preventing the Yellow Fe-
ver,  8vo.  Birm., 1808.—A.  M.  T.  Saveresy,  De Fievre
Jaune en General et Particulierement de celle qui a regne
a la Martinique  en 1803 et 1804, <fec, 8vo.   Nap., 1809.—
C. Chisholm,  A Letter to Dr.  Haygarth, exhibiting farther
Evidence of the Infectious Nature of the fatal Pestilential
Fever in Grenada in 1793-1796 ; and in the United States of
America from  1793 to 1805, 8vo.  Lond., 1809.—E. N. Ban-
croft, An Essay on the Disease  called Yellow Fever, with
Observat. on  Febrile Contagion, &c, 8vo.  London, 1811.
(Non-infectious.)—B. Mellado, Historia de la Epidemia en
Cadiz, el Anno de  1810, 8vo.  Cad., 1811— A.  Vilascca,
Noticia acerca de la Calentura Americana, 8vo.  Palma,
1811.—F. Flores, Sobray el Tifus Icterodes, 8vo.  Cadiz,
1813.   (Infectious and imported.)—F. Moreno Flores, En-
sayo sobre et Tifus Icterodes o Fiebre Amarilla, 4to.  Cadiz,
1813.   (Infectious and imported.)—C.  Powell, A Treatise
on the Endemic or Yellow Fever of Tropical Climates, 8vo.
Lond., 1814.   (Confounds endemic remittents with this pes-
tilence.)—E.  Doughty, Observations and  Inquiries on the
Yellow or Bulam Fever, 8vo.   Lond.,  1816.—A. Mor. de
Jonnes. Precis Historique surl'Irruption de la Fievre Jaune
a  la Martinique en  1801, 1802, 8vo.   Paris, 1816. (Infec-
tious.)—E. N. Bancroft, Sequel to an Essay on Yellow Fe-
ver, <fec, 8vo.   Lond.,  1817.—/.  Veitch, On the  Nature and
Treatment of the Yellow  Fever, 8vo.   Lond.,  1818.—V.
Bally,  Du Typhus  d'Amerique, ou  Fievre Jaune, 8vo.
Paris, 1814; et  Histoire Medicale de la Fievre Jauue  en
Espagne, 4to.   Paris, 1821.—IV". Pym, Observat. on  the
Bulam Fever which, has of late Years prevailed in the West
Indies,  on the Coast  of America, at Gibraltar, Cadiz, &c,
with  Facts  proving  it a highly contagious disease, 8vo.
Lond., 1815.—/. Fellowes, Reports of the Pestilential Dis-
order of Andalusia, which appeared at Cadiz in  the  Years
1800, 1804, 1810, and  1813 ; of that fatal Epidemic which
prevailed at Gibraltar in 1804, &c.,8vo.  Lond., 1815.  (In-
fectious.)—F. C. Caizergues, Memoire sur la Contagion de
la Fievre Jaune,  8vo.  Paris,  1817.   (Contagious.)—E.
Pariset et Mazet, Observations sur la Fievre Jaune, faites
a  Cadiz in 1819, folio.  Paris,  1820.  (.Contagious.)—G.
Burnie, Practical Remarks on  Yellow  Fever, 8vo.  Belf.,
1819.—N. Dickenson, Observat. on the Inflammat.  Epidemic
incidental to Strangers in the West Indies, commonly called
Yellow Fever, 8vo.  Lond., 1819.—M.  Pariset, Rap. lu a
l'Acad. Roy. de Med.  au nom de la Commission Chargee
d'Examiner les Documens de  M. Chervin, 4to. Paris, 1819.
—Report of the Committee of the Medical Society of New-
York on the Epidemic Fever which prevailed in  Buncker-
street,  in the Summer and Autumn of 1820, 8vo.  N. Y.,
1828.—M. Cavaniles, Memoria sobre la  Epidemia de Anda-
lusia de 1800, Hasta, 1819, 4to.  Cadiz, 1820.—M. Hurtado
de Mendoza, Nueva  Monografia de  la Calentura  Amarilla,
4to.  Huesca, 1820.—/. Devize, Traite de la Fievre Jaune,
8vo.  Paris,  1820.—A. de Maria, Memoria  sobre la Epi-
demia de Andalusia de 1800, Hasta, 1819, 4to.  Cadiz, 1820.
—A.  Moreau  de Jonnes, Monographie Historique et  Medi-
cale de la Fievre Jaune des Antilles et  Recherches sur les
Lois du Developement et de  la Propagation de cette  Mala-
die, 8vo.  Paris, 1820.—N. Gerardin, Memoires sur la Fie-
vre Jaune consideree  dans sa Rapports avec les  Gouvern-
mens, 8vo.  Paris, 1820.—/.  Sedillot, Notice sur la Fievre
Jaune, la Peste, et le  Typhus consideres comme non-con-
tagieux, Svo.   Paris, 1820.—F. M. Audouard, Lettre sur la
Contagion de  la Fievre  Jaune; reponse A /. Sedillot, 8vo.
Paris, 1820.—P. F. Keraudren, De la Fievre Jaune, Obser.
aux Antilles,  et sur les Vaisseaux du Roi consideres prin-
cip. sous la Rapport de sa Transmission, 8vo. Paris, 1823.
 (Contagious.)—W.  Fergusson,  in  Transac. of Med. and
 Chirurg. Soc.  of London, vol. ii., p. 180 ; vol. viii., p. 108.
—/.  D. A. Gilpin, in  Ibid., vol. v., p.  303.—A. Musgrave,
in Ibid., vol.  ix., p.  93.—/.  Fernandez, Ensayo  Analyrico
 Bobre la Natur. las Causas, &c, de las Calenturas Amaril-
 las, 4to.  Habana, 1821.—R. Jackson, Remarks on the Yel-
 low Fever of the South Coast of Spain,  since the year 1800,
 8vo.  Lond.,  1821.  (Non-infectious.)—T.  O'Halloran, A
 brief View of the Yellow Fever of Andalusia in 1820, 8vo.
 Lond., 1821.   (Non-infectious.)—J.  M. Salamanca, Obser-
 vaciones sobre el Contagio de la Fiebre Amarilla, 8vo.  Mal-
 aga,  1621.  (Imported and infectious.)—M.  F. M. Audou-
 ard, Relat. Histor. et Mfidicale de la Fievre  Jaune de Bar-
celona,  8vo.  Paris,  1822.  (Import, and infect.)—J. A.
Rochoux, Recherches sur la Fievre Jaune, Svo.  Paris.—
Larrey, Consid. sur la Fievre Jaune, 8vo.  Paris, 1822.—
P. S. Townsend,  An  Account of the Yellow Fever,  as it
prevailed in the City of New-York in 1822, 8vo, 1823.   (Im-
ported and  infectious.)—G. Blane, in Edin. Med. and Surg,
Journ., vol. iii., p. 385.—Nagle  and Wilson,  in Ibid., vol.
vii., p. 280.—Chisholm,  Ibid., vol. ix., p. 412.— W. Pym, in
Ibid., xi., p. 383; et vol. xii., p. 183.—Doughty, in  Ibid.,
vol.  xiii., p. 238.—Gilpin, in  Ibid., vol.  x., p. 41.—Fergus-
son, in Ibid., vol. xv., p. 427.— Smith, in Ibid., vol. xxxv., p.
12.—/. Imray, in Ibid., vol. lxiii., p. 78.—C. Chisholm, A
Manual of  the Climate and Dis. of Tropical Countries, Ac,
Svo.  Lond., 1822, p. 167.—/. R. Ferrari, On the Yellow
Fever of Xeres  in  1821, in Edin. Med. and  Surg. Journ.,
vol. xix., p. 368.   (Imported and infectious.)—Ozanam, Hist.
Med. de Epidemies, t. iv., p. 335.—E. Bally, Rapport, <fec,
sur  la F. J.  regnant au Port de Passages  in 1823,  8vo.
Paris, 1824.—V.  Bally, Rapport, <fec,  sur la F. J. qui a
regne au Port du Passage  en 1823, Svo.  Paris, 1824.—D.
Hosack, Essays on various Subjects of  Medical Science, 2
vols., 8vo.  New-York,  1824, vol. i., p. 253.  (Imported and
infectious.)—F.  E. Fodire, Le§ons sur les  Epidemies et
l'Hygiene Publique, &c, t. iv.,  p. 228.   (Imported and in-
fectious.)—Bally Francois et Pariset, Histoire Medicale de
la Fievre Jaune observee en Espagne et Particulierement
en Catalogue dans  l'Annee 1821, 8vo.   Paris, 1823.  (The
French Commission.  Most irrefragable proofs of importa-
tion and infection.)—T. O'Halloran, Remarks on the Yel-
low  Fever of the South and East Coasts of Spain,  8vo,
Lond.,  1823.  (Non-infect.)—Baldissonc,  Manifesto sulla
Febbre  di  Barcelona dell' Anno  1821, 8vo.   Gen., 1S24.—
W.  Burnett, Official Report on the Fever of H. M. S. Bann,
on the Coast of Africa,  8vo.  Lond., 1824.  (Infectious.)—
C. C. Matthai, Untersuchung iiber das Gelbe Fieber, 8vo.
Hannov., 1827.—I. Wilson, Memoirs of West Indian Fever,
Svo.  Lond.,  1827.  (Non-infectious.)—A.  J.  Ralph, in
Transac. of Med. and Chirurg. Society  of Edin., vol. ii., p.
49.—W. W. Fraser, A Letter to  the Earl of Chatham, Gov-
ernor of Gibraltar, relative to the Feverish Distempers of
that Garrison, 8vo.  Lond., 1^-26.  (Imported and infectious.)
—T. N. E. von Reider,  Abhandlung iiber das Gelbe Fieber,
8vo.  Wien.,  1828.— V. N. ab  Hildenbrand,  Institutiones
Practico-Medicse, &c, t. iv., p.  480.  (Infectious ; classes
this pestilence with the exanthematous fevers.)—A. Heastie,
Treatise on the Nature and Causes of the Yellow Fever,
Svo.  Lond., 1830.—/.  Hennen,  Sketches of the Med. To-
pography of the Mediterranean,  &c, 8vo.   Lond., 1830 ; of
the Gibraltar Epidemics, p. 91.—Gilkrest, Cyclop, of Pract.
Med., vol.  ii.—/.  A. Rochoux, Recherches sur les Differ-
entcs Maladies  qu'on appelle Fievre Jaune, 8vo.  Paris,
1828.—M.  D. Emery, Reflexion sur la  Fievre Jaune, 8vo.
Paris, 1828.—/. C. de Fermon, Revue Critique de quelques
Ecrits Publics sur la Fievre Jaune, 8vo.  Paris, 1829.—
Chervin, Examen des Nouvelles Opinions  de M. Lassis con-
cern, la Fievre Jaune.  Paris, 8vo, 1829 ;  et Examen Crit-
ique des Pretendues  preuves  de Contagion de la F. J. ob-
servee en Espagne, &c, 8vo.  Paris, 1828.  See, also, his
various papers reviewed in Edin. Medical  and Surg. Journ.,
vol. xxxv., p. 365.  (This zealous apostle of non-infection
confounds  remittent fever  with  this pestilence,  and either
suppresses or does not admit the  established fact of protec-
tion caused by a former attack  ; hence most  of his plead-
ings are baseless and irrelevant.)—Chervin, Louis, et Trous-
seau, Documens receuillis par  MM. envoyes a  Gibraltar
pour observer l'Epidemic de  1828, et par M. Barry,  <tc,
8vo, 2 tomes.  Paris, 1830.—/.  Boyle, The Epidemic  Yel-
low Fever in Sierra Leone in 1823 and  1829, in a Pract.
Medico-Histor. Account of the  Western Coast of Africa,
and of the  Fevers of Western Africa, &c, 8vo.  Lond, 1831,
(Furnishes proofs of the differences between this pestilence
and the endemic remittent of the climate ;  and while the au-
thor argues against infection, he actually furnishes proofs
against  his own doctrine.)—D.  Barry, On  the  Gibraltar
Epidemic ; in London Med. and Physical Journal, vol. lxv.,
p. 380 and 476 ; vol. lxvi., p. 91  and 475 ;  vol. lvii., p. 1-96
—P. Wilson, On Gibraltar Epidemic, Lancet, June, 1830,
p. 425.-3/.  Guyon, On the Origin of  the Gibraltar  Epi-
demic,  Journ. complem.  des Sc. Med., Sept.,  1830; and
Lond. Med. and  Phys. Journ., vol. lvi.,  p. 286.  (Imported
and infectious.)—H. Fraser, in Ibid., vol. lvi., p. 213,  314;
and Johnson's Med. and Chirurg. Review, Sept.. 1830.—Af.
E. A. Naumann, Handbuch der Medicinischen Klinik, b. iii.
Abth. i., p. 321.   (Classes this pestilence, theplague, chol-
eric pestilence, and exanthematic typhus  as  species of the
genus—contagious typhus.)—P.  C. A. Louis, Anatomical,
Pathological,  and Therapeutic Researches on the Yellow
Fever of Gibraltar,  &c, transl. by G. C. Shattuck, 8vo.
Boston, 1839.—Report of a Special Committee of the House
of Assembly of the State of New-York on the present Quar-
antine Laws, 8vo.  Albany, 1846.  This able report, kindly
forwarded by Dr. P. S.  Townsend, of New-York, reached
me  as this was passing  through  the press.  It contains the
evidence of the  most eminent physicians in that city, and
numerous  facts fully confirming the views entertained in
the preceding article.  It is most  satisfactory to have so 
PESTILENCE, SEPTIC OR GLANDULAR.
217
 Important and convincing a body of evidence as this report
 contains, so opportunely furnished, although too late to aid
 in my labours.
  [Am. Bib. and Refer.—P. S. Townsend, Account of the
 Introduction of the Yellow Fever into Peusacola and New-
 Orleans in 1822, New-York Med. and Phys. Jour., vol. ii.,
 p. 315 ; et An Account of the Yellow Fever as it prevailed
 in the City of New-York in the Summer and Autumn of
 1822, 8vo, p.  383.—A  History  of the Proceedings of the
 Board of Health of the City of New-York in the Summer
 and Fall  of 1822,  &c.  New-York,  1823, p. 270.—James
 Speed, On Yellow  Fever of North America, in  Med. Re-
 pository,  vol.  ix., p. 259.— William Baker, On the Origin
 and Cause of Yellow  Fever, and Means -of Prevention, in
 Med. Repository, vol. ix., p. 268.—/. Comstock, On Bilious
 or Yellow Fever, in New-York Med.  Rep., vol. x., p. 21.—
 H. Hill, On Yellow Fever in Havana, Med. Rep., vol. x.,
 p. 113.—Chatard, On Yellow Fever in  Baltimore in 1800,
 Med. Repository, vol. iv., p. 253.—Selden and Whitehead,
 On the Yellow Fever of  Norfolk, Va., 1800, Med. Rep.,
 vol. iv., p. 329.—Daniel Moore, On Yellow Fever of Balti-
 more, 1800, in Med. Rep., vol. iv., p. 351.—Charles Cald-
 well, An Address to the Phil. Med. Society, on the Analo-
 gies between Yellow Fever and true Plague, in Med. Rep.,
 vol. iv., p. 400; vol. i., N. S„ p. 143.—M. M'Dowell,  in
 Med. Repos., vol. ix., p. 366.—/. G. Scott, Examples  of the
 Origin of Yellow and Uncontagious Fevers in various parts
 of the State of New York, Med. Repository, vol. x., p. 240.
 —N. Webster, Address to the Citizens of the United States
 on  the Malignant  Fevers  of  their Country, N. S. Med.
 Repository, vol. i., p.  316.—R. M. Collins, A Dissertation
 on the Remote Cause of Fever, Transylvania Jour, of Med.
 for 1828,  p. 485.—Alex. Hosack, Jr., An Inaugural  Essay
 on Yellow Fever of 1795 in New-York.   New-York, 1797,
 8vo, p. 40.—Valentine Seaman, On Yellow Fever in  New-
 York,  New-York Med. Repository, vol. ix., p. 391; vol. i.,
 p. 303 ; et vol. iv., p. 248.—B. Ticknor, An Account of the
 Yellow Fever which prevailed at Thompson's Island, North
 Am. Med. and Surgical Journal, Nos. VI. and VII., 1827.—
 Charles Coffin, An Account of the Pestilential Fever which
 prevailed  in Newburyport, State of Mass., 1796,  Med. Re-
 pository,  vol.  i., p.  493.— Joseph Browne, Treatise on the
 Yellow Fever.   New-York,  8vo, p.  31, 1798. — Mifflin's
 Letters on Yellow  Fever, Med. Rep., vol. i., p. 391, 398.—
 John B. Davidge, A Treatise on the Yellow Fever.  Bait.,
 8vo,p. 65, 1798.—Phil. Acad, of Med., On Origin of Yellow
 Fever of 1797.  Phil., Svo, p. 49, 1798.—A. /. De Rosset,
 Account  of Pestilential Fever of Wilmington, 1796, Med.
 Repository, vol.  xi., p. 143.—W. Currie, Memoirs of Yellow
 Fever which appeared in Philadelphia  and other parts of
 the  United States  in  1793.   Philadelphia, 8vo, p. 145.—
 P. S. Physic, Letter  on Yellow Fever, Med. Repository,
 vol. xi., p. 327.—Ed. Miller, On Yellow Fever, Med. Rep.,
 vol. xi., p. 379.—i*aac Rand, On Yellow Fever in Boston,
 Med. Repository, vol. xi., p. 442.—Samuel Brown, A Trea-
 tise on Yellow Fever.   Boston, Svo, p. 42, 1800.—W. Har-
 ris, Fever, with Black Vomit, in the  middle part of Penn.,
 Med. Rep., vol. iv., p. 75.—L. Hallock, An Account of a
 Malignant Disease which appeared on board of the United
 States Frigate Gen. Greene, Med. Repository, vol. iv.,p. 1.
 —E. T.  Waring, Account  of  Same, Med. Repos., vol. iv.,
 p. 234.—David Ramsay, Facts concerning Yellow Fever in
 Charleston, S. C, Med. Repository, vol. iv., p. 217 ; vol. xi.,
 p. 233.—John Vaughan, in Med. Repository, vol, iv., p. 233.
 —Joseph Bayley, Facts  and  Observations relating to  the
 Yellow Fever which  prevailed at the Quarantine Estab-
 lishment  at Staten Island,  New-York, during the Autumn
 of 1821, New-York Med. and Phys. Journ., vol. i., p. 12.—
 Report on the Yellow  Fever which prevailed in New-York
 in 1822, New-York Med. and  Phys. Journ., vol. i., p. 422.
 —Daniel D. Walters, Diary of the Occurrences of the first
 Month of the Yellow Fever which prevailed in the City of
 New-York in  1822, with  Facts and Observations relative to
 the Nature and Character of the Disease,  New-York Med.
 and Phys. Journ., vol.  i., p. 469.—John B. Beck, A Report
 to the New-York Board of Health concerning the Nature
 and Origin of the Malignant Fever in Middletown, Conn.,
 1820, New-York Med. and Phys. Journ., vol. i„ p. 158.—
 Fevers : their Diagnosis, Pathology, and Treatment j Pre-
pared and Edited, with large Additions  from the Essays on
Fever in Tweedie's  Library of Practical Medicine, by Mere-
dith Clymer, M.D.,  <fec.  Phil., 1846, 8vo, p. 605.—George
B. Wood, A Treatise on the  Practice of Medicine, in 2 vols.,
8vo, p. 798.—Robley Dunglison, The Practice of Medicine,
a Treatise on  Special Pathology and Therapeutics, 2d Ed.
 Philad.,2-vols., Svo, 1844.—Samuel Henry Dickson, Essays
on  Pathology and  Therapeutics,  &c, in 2 vols., 8vo.
 Charleston, S. C, 1845.— John W. Monette, Observations
 on the Yellow Fever  of Natchez and of  the Southwest.
 Louisville. Ky., 8vo, p. 155; et Western  Med. and Phys.
Journal, 1825.—S. Barrington, Account of Yellow Fever as
it appeared on board the United States sloop-of- war Hornet
in 1828, United States schooner Grampus in 1829, and
United  States sloop-of-war  Peacock in  1830, Am. Journal
Med. Sci., vol. xii.,  p. 307.— E.  B. Hams, On Yellow Fe-
ver  at New-Orleans in 1833, in Am. Jour. Med. Sci., vol.
xiv., p. 41.—E. H. Barton, Account of Yellow  Fever at
New Orleans in 1833, in Am. Journ. Med. Sci., vol. xv., p.
30.— John Harrison, On Cadaveric Lesions in Yellow Fever,
in New-Orleans Med. and Surgical Journal, 1845-6.—C. C.
Dupre, On the Yellow Fever at Key West, East Florida,
in Am. Journal Med. Sci., vol. ii., N. S., p. 380.—Thomas
Stewardson, in Amer. Journal Med. Sci., vol. iii., p. 91.—
Richard D. Arnold, Two Cases of Black Vomit,  with  Ob-
servations, in Am. Journ. Med. Sci., vol. iv., p. 316.  (Dr.
A. makes  the peculiar distinctive characteristic of Yellow
Fever to be a  total absence of biliary secretion and excre-
tion.)—Account of Yellow Fever in Charleston, 1838, Am.
Journal Med. Sci., vol. xxiii., p. 263.—Thomas Y. Simons,
A Report  on the History and Causes of the Stranger's or
Yellow  Fever  of Charleston.  Charleston,  8vo, p. 23.—
Robertson, Garvin, and Eve, Report on  Yellow  Fever in
Augusta, 1839, 8vo, p. 30.—Ashbel Smith, An Account of
the Yellow Fever at  Galveston in 1839, with Cases, &c,
12mo, p. 78.  Galveston, 1839.—B. B. Strobel, An Essay
on the Subject of Yellow Fever, intended to prove its trans-
missibility.  Charleston, 1840, 8vo, p. 224.— John D. Gil-
lespie, Report on Yellow Fever at Brooklyn in 1809, in Am.
Med. and  Phil. Register, vol.  i., p. 106.—William Currie,
Facts and  Arguments in favour of the foreign Origin  and
contagious N ature of the Pestilential or Malignant Yellow
Fever, in a  Letter to  Dr. Hosack, in Am. Med.  and Phil.
Register, vol. i., p. 181.—John R. B. Rodgers, Account of
Yellow Fever in Brooklyn in 1809, in New-York  Med.  and
Phil. Jour, and Rev., et New-York Med. and Phil.  Reg.,
vol. i., p. 253.—Richard Channing Moore, Facts relative to
the contagious Nature of Yellow Fever in Brooklyn in 1809,
in New-York Med. and Phil. Reg., vol. xi., p. 22.—D. Hos-
ack, Review of Ed. Miller on Yellow Fever in Brooklyn in
1809, in New-York Med. and Phil. Reg., vol. ii., p. 91-164,
270.—History of the Yellow Fever at Perth Amboy in 1811,
Am. Med.  and Phil.  Reg., vol. iii., p. 102. (Drawn up by
Drs. Hosack, Bayley, and Douglass.)—John Stewart,  An
Account of  Yellow  Fever at Granada,  West Indies, in
1793-4-5, in Am. Med. and Phil. Reg., vol. iii., p. 183.—D.
Hosack, On the Yellow Fever of Huntington, L. I., in Am.
Med. and Phil. Reg., vol. iii., p. 191.—John M'Knight, On
Yellow Fever of New-York of 1798, in Am. Med.  and Phil.
Reg., vol.  iii., p. 293.—James Seagrove, On Yellow Fever
of St. Mary's, Georgia, 1808, in Am. Med. and Phil.  Reg.,
vol. iii., p. 417.—John Mitchill, An Account of the Yellow
Fever in Virginia in 1737, 1741, 1742, in Amer.  Med. and
Phil. Reg., vol.  iv.,  p.  181, 383.—P. Bowen, Account of
Yellow Fever in  Providence, R. I., 1805,  in Am.  Med. and
Phil. Reg., vol. iv., p. 331, 341.—C. Calden, On Yellow Fe-
ver of Virginia, in Amer. Med. and Phil. Reg., vol. iv., p.
378.—/. C. Warrin, On Yellow Fever in Boston,  in Amer.
Med. and  Phil. Reg., vol. iv., p.  557. — B. Dowler, Re-
searches, Historical, Topographical, and Critical, on Yellow
Fever,  New-Orleans Med. and Surg. Jour., vol. iii., p. 165.
—E. D. Fenner, Account of Yellow Fever in New-Orleans
in 1846, New-Orleans Med. and Surg. Journal, vol. iii., p.
445.— W. P. Hort, Report of Board of Health of  New-Or-
leans for 1846, New-Orleans Med. and Surg. Jour., vol.  iii.,
p. 467.—John W.  Francis, Report of a Special Committee
of the House of Assembly of the State of New-York on  the
Quarantine  Laws, 1846, p. 148.—A. V. Vache, in Ibid., p.
68.—T. Harris, in Ibid., p. 111.—P. S. Townsend, in  Ilrid.,
p. 115.— W. Sweetser, in Ibid., p.  153.—/. R. Manley, i.,
Ibid., p. 163.—Hort, in Ibid., p. 167.—D. M. Reese, in  Ibid.,
p. 211.—W. S.  W. Ruschenberger, in Ibid., p. 215.—VV. C.
Wallace, in Ibid.,  p. 207.—See, also, Bost. Med. and Surg.
Journal, passim.— W. P. Dewees, Practice of Medicine.—
Hosack, Lectures, and Ed. of Thomas's Practice,  <fec.]

PESTILENCE, SEPTIC—Synon.  Pestilentia
   Septica, Author.  Pestis  (from pasco,  pas-
  tum,  quod  depascatur artus ;  or from  pes-
  sum, quod pessum det).   Pestis Septica, Pes-
  tis glandulosa, P. Adeno septica (from ZrjTroi,
  putrefacio ;  SnnToc,  oijTrTiKbc,  septic,  putrid,
  liquescent, &c), Aoip.oc, Hipp., Galen.   Aoi-
  pudrjc  nvperoc,  Auct.  Graec.   Aoip.bc  enn-
  tikoc.   Pestilentia,   Oelsus,  Pliny,   Cicero.
  Pestis,  Auct. Var.    Pestis  Orientalis, Auct.
  Typhus Pestilentialis,  T. Gravissimus,  T. An-
  thracicus, T. Bubonicus, Febris  Pestilentialis,
  <5rc,  Auct.   Var.    Typhus  Pestis,  Young.
  Anthracia  Pestis, Good.   Exanthema  Pestis,
  Parr.   Loimopyra, Swediaur.   Pestis  Acutis-
  sima, P. Inqumaria, Peslilitas, Ephemera Pes-
  tilentialis,  E.  Mortifera,  Febris  Adeno-Ner-
  vosa, Pin el.   Peste, Pestilence,  Fievre pesti-
  lentielle, Fr.   Pest,  Plage, Peslfieber,  Pesti-
  lienz, Germ.   Pest, Pestilents,  Dan.  Swed.
  Peste, Pestilenza, Ital.  Plague, Pest, Pesti- 
218           PESTILENCE, SEPTIC  OR <

  lence, Levant Plague, Septic or Glandular Pes-
  tilence, &c
    Classif.—Same as Choleric and Haema-
       gastric Pestilences.
  1. Defin.—i. Nosological.—After chills, rig-
ours, or horrors, nausea and vomiting, with verti-
co, headache, or stupefaction, and fever ; sense of
heat or burning at the pracordia ; i apid, weak, ir-
regular, or intermitting pulse; and carbuncles,
buboes, spots, pustules, or petechia of various col-
ours distributed in different parts of the body.
  2.  ii. Pathological.—An  animal poison  or
miasm specifically affecting the  nervous and vas-
cular systems,  the circulating fluids, vessels, and
glands, and remarkably impairing, and very fre-
quently entirely subverting, vital resistance and
the cohesion of the tissues.
  3.  Annihilation of vital resistance and of the
tohesion of the  tissues characterizes more or
Jess all severe cases, of pestilence, and all ma-
lignant febrile  diseases.  The causes which oc-
casion them—specific animal poisons—exert  a
manifest septic  influence ;  manifest, at least,
in their results, however the powers of life, in
their resistance  to  the  noxious  causes which
have  invaded  them, may  give rise to  various
modes of reaction, or attempts at reaction, and
ultimately  either throw  off  the  destructive
agencies, or sink beneath them.   But the viru-
lence of the poison occasioning the plague, and
the septic or life-dissolving influence it exerts,
as evinced by the spots, by the carbuncles, by
the sphacelations of portions of the cutaneous,
adipose, and cellular  tissues, by the softening
of the internal viscera, and by the diffluent or
softened state of the lymphatic glands and sur-
rounding structures found  immediately after
death, are so remarkable, especially where this
pestilence is epidemic, that I have thought that
these malignant properties, as being the most
characteristic and the most generally present,
should furnish the specific designation of the
distemper.  I have, therefore, used the word
septic  in the  sense usually  attached to it, to
mark this tendency to vital dissolution and its
actual consequences in this  pestilence, as be-
ing, perhaps, the most appropriate, as marking
the chief disposition and  pathological condi-
tions—the remarkable malignancy of the fully-
developed distemper.  It may not be approved
by many, as not  indicating  the  states of ner-
vous power and  vascular action characterizing
the attempts made by the nervous and vascu-
lar systems under the influence  of life, to re-
sist the exterminating influence of the poison
which has infected them ; and I cannot say that
it quite pleases  myself; but I am anxious to
avoid, on this occasion,  as  I have hitherto
avoided, the introduction of new and foreign
terms into this work.  I shall, however, adopt
any one that  is  unquestionably better, if the
objectors will furnish it;  but the topic will be
discussed more  fully hereafter.
  4. There can  be no doubt  of this pestilence
having appeared at various epochs  as remote
as history has furnished the records, in several
countries bordering on the Mediterranean, and
especially in Egypt.  The sacred books of the
Old Testament, and the writings of Hippocra-
tes, AreTaEus, and Galen, furnish notices of
pestilences, which may be considered as more
applicable to  this  than  to any other  species.
Still they give no description sufficient to ena-
5LANDULAR—Description of.

 ble us to decide positively as to their identity
 with that now under consideration.   The ear-
 liest notice strictly applicable to this distemper
 to be found  in the writings of the ancients is
 that  by Rufus, preserved in  an inedited book
 of Oribasius,  and to which reference is made
 by M. Littre, in his edition of Hippocrates, and
 in his article on the  plague in the Dictionaire
 de Medicine.   Rufus describes  buboes  as  ap-
 pearing in  the neck, armpits, and thighs, and
 as being either with or without fever.   But the
 buboes  called pestilential,  he states, are  the
 most acute and the most dangerous.  Such as
 are  seen especially in Libya, Egypt, and  Syria ;
 and  of which Denvs,  surnamed Kyrtus, has
 made mention.  Dioscorides  and Posidonu's,
 he adds, have concerned themselves  chiefly
 with the pestilence which prevailed in Libya.
 They state that in  this  plague there were acute
 fever, pain,  and  tension of the whole body, de-
 lirium, and the  formation of buboes, which
 were hard and large, and which did not. go on
 to suppuration.   These  buboes appeared not
 only in the  usual  places, but also  in the hams
 and  bends of the  arms.  (Classicor.  Auct. e
 Vaticanis Codicibus Edit, curante A. Maio, 8vo.
 Romae, 1831, t. iv., p.  11.)
   5. No farther account need be taken of the
 brief notices  of  plague  which are scattered
 through the works  of the  ancients,  until  we
 come to the description  of the  fatal epidemic
 by Procopius  that depopulated the Roman em-
 pire  in the reign of Justinian.  An abstract of
 these notices will be  found  in Mr.  Adams's
 translation  of Paulus  -<Egineta (vol.  i., p.
 279).  The  pestilence which  prevailed in the
 reign of Justinian is also described byEvAGRi-
 us and .\gathias.   It resembles the plague of
 Avignon, described by  Guy de Chauliac.  Ac-
 cording to Procopius,  the usual precursors of
 an attack were  disturbed  dreams and various
 delirious fantasies;  but the  early symptoms
 were not well marked ;  for there  was neither
 increased heat nor discoloration of the skin, nor
 did the patient apprehend danger. Generally
 on the first  or second day, but in a few instan-
 ces somewhat later, buboes appeared not only
 in the groins, but  also in the armpits  and  be-
 low  the ears.   Some were affected with deep
 coma,  and others with wild  delirium.  Some
 died from sphacelus of the buboes,  which, when
 inspected by the  physicians after death, pre-
 sented the  appearance of an anthrax,  or car-
 buncle.  Some died at the commencement, and
 others after the lapse of several days.   In cer-
 tain cases  the  skin was  covered with black
 phlyctenae, of the size of a lentil, which were
 usually succeeded by sudden death.   Others
 were unexpectedly  cut  off by a discharge of
 blood.   To  women  in the puerperal  state it
 proved  particularly  fatal.   When the  buboes
 came to a proper suppuration,  they generally
 proved a favourable crisis ; but when they did
 not  suppurate, they were commonly followed
 by a wasting of the thigh.   One of the conse-
 quences of the  distemper was an affection of
 the organs of speech.   a\11 the usual  prognos-
 tics  proved fallacious ; and the effects of the
 common remedies were uncertain.   In some
 cases the bath proved  beneficial, and in others
 it had a contrary effect.  The amount of deaths
 in Constantinople, at one time, was  said, but
 probably  with  great  exaggeration,  to have 
GLANDULAR—Description of.           219
              PESTILENCE, SEPTIC OR C

ranged from five to ten thousand each day.
(De Bella Pers , 22, 23, and Adams's Comment.
on Paulus aEgineta, vol.  i.,  p. 281.)  This
plague appears to have very closely resembled
the plague of London in 1665, as described by
Dr. Hodges.  My limits will not  permit  any
notice of the descriptions  of the septic or
glandular pestilence  contained in the writings
of the Arabian physicians.   The reader, how-
ever, will find a brief abstract of these descrip-
tions, and of the treatment recommended by
these writers, in the volume by Mr. Adams just
referred to.
  6.  This  pestilence has  presented  various
grades of severity, malignancy, and prevalence,
according to the several accounts which have
been furnished by contemporary historians and
physicians, since the days of Avicenna  and
other Arabian writers; and  even within  our
own  memories,  since the commencement of
the present century,  it has evinced different
degrees of severity and prevalence, according
as it has appeared in a sporadic or endemic, or
in an epidemic form.  In the  countries of the
Levant, and particularly in Egypt, the distem-
per occurs sporadically or endemically, or rath-
er appears in isolated cases, without becoming
epidemic, unless after periods or epochs of in-
definite but of considerable duration.  In more
northerly climates it has occurred only as a de-
structive epidemic, and then often without  any
manifest dependence upon season,  time of the
year, or  weather,  although  a temperate  or
warm season has appeared to favour its malig-
nancy and prevalence.  During the Middle i^ges
numerous epidemical visitations  of this pesti-
lence occurred in Europe, A^frica, and Asia, not
merely in the countries surrounding the Medi-
terranean, but also in others more or less re-
mote from this sea.   The most destructive out-
break, however,  of this pestilence upon record
is that which occurred near the middle of the
fourteenth century.
  7. This pestilence, usually denominated the
Hack death  or black  plague, first appeared in
China in  1333, when it was  said to have de-
stroyed more than  one fourth of the  popula-
tion  ; and it thence proceeded gradually to the
western countries of Asia, to those surround-
ing  the  Caspian Sea ; to  Arabia,  Syria,  and
Egypt; and to the eastern and southern king-
doms of Europe. It reached Avignon in 1348,
gradually extending northward to France, Ger-
many, England,  Denmark, Russia, &c.  It in-
vaded Russia in 1350 ; and there, as well as in
other northern countries, it proved nearly as
destructive  as  in southern climates.  It ap-
peared first in the southern counties  of Eng-
land, and gradually proceeded northward ;  and
in this, as well as in other countries, was most
remarkably destructive in  the large, close, and
crowded cities and towns.   It did not altogeth-
er cease in some places, or it continued to re-
cur after intervals, until  1360 or 1361, when
it seems to have entirely disappeared.   Dr.
Hecker has collected from numerous sources
much information concerning this pestilence.
He states that it was an Oriental plague, marked
by boils and tumours of the  glands, such  as
break out in no  other febrile disease.   From
these boils or buboes, and from the black spots
and carbuncles indicatory  of a putrid decom-
position which appeared in the surface, it was
called, in the northern countries of Europe, the
black death; and in  Italy and other southern
countries, the great mortality, or great plague.
   8. According to Guy de Chauliac, the vic-
tims of this plague  were  frequently attacked
with an ardent fever attended by discharges of
blood, which proved  fatal in  three days.  Bu-
boes and boils  did not come  out at first, but a
carbuncular affection of the lungs often occa-
sioned the destruction of life before the exter-
nal symptoms were developed.  He adds, that
" the plague  thus raged  in Avignon for six or
eight weeks, and the pestilential breath of the
sick, who expectorated blood, caused a terrible
contagion far and near ; for  even the vicinity
of those who were affected was certain death ;
so that parents abandoned their infected chil-
dren, and all the ties of kindred were dissolved.
After this period, buboes in  the axilla  and in
the groin, and boils over the body, made their
appearance ;  but it was not until seven months
afterward that some  patients recovered with
buboes, as in  the  ordinary  milder form of
plague."  (Tract., ii., c. 5, p. 113.)  This pesti-
lence appeared in a similar manner in Egypt,
destroying quickly with  burning  heat  and ex-
pectoration of blood.
  9. Boccaccio makes no mention of the first
appearance of this pestilence in China, and of
its progress  westward, but remarks that " this
most terrible plague happened in  Florence in
1348 ; that it had broken out some years before
in the Levant, and that after passing from place
to place, and making  incredible havoc all the
way, it had now reached  the west."  It began
to show itself in the spring of the year, " in a
sad and wonderful manner ; and different from
what it had  been in the east,  where bleeding
at the nose was  the fatal prognostic; here
there appeared certain tumours in the groin or
in the  armpits, some  as  big as a small apple,
others as an  egg; and afterward  purple  spots
in most parts of the body ; in some cases large
and but  few in number, in  others  less and
more numerous ; both sorts the usual messen-
gers of death."  (Decameron, Giorn. i., Introd.)
   10. The same phenomena were remarked in
this pestilence  as  it occurred  in Germany,
France, Norway, and Russia, and the  most
prominent  among these  were  the  infallible
signs of the Oriental or glandular plague.   But
in different   countries certain symptoms ap-
peared more prominently than others, or per-
haps were more particularly noted by contem-
porary or subsequent  chroniclers.  In  France
many were struck as  if by lightning, and died
on the spot,  and this more frequently among
the young and strong than the  old;  and the
patients with buboes scarcely survived two or
three days.    In England the distemper was at-
tended, as at Avignon, with spitting of blood,
buboes, and  carbuncles.  In Norway  and Po-
land spitting  and vomiting of blood are  stated
to have occurred in addition to the characteris-
tic signs.  In Russia the distemper was said
to have commenced  with rigours, heat, and
darting pains, to have been attended by spitting
of blood, and  to have terminated fatally in two,
or, at most,  three days.  It was chiefly when
the spitting  of blood  had continued for  some
time that buboes and carbuncles appeared.
  11.  Dr.  Hecker remarks,  that  all  the de-
scriptions of this most remarkable pestilence 
220            PESTILENCE, SEPTIC OR
GLa\NDULAR—Description  of.
which have come down  to us contain, with a
few important exceptions, all the symptoms of
the true plague as observed  in  modern times.
No doubt can obtain on this  point.   The facts
are placed clearly before our eyes.  We must,
however, bear in mind that this distemper does
not always appear in  the  same form ; and that
while the essence of the poison which it produ-
ces, and which is separated so abundantly from
the body of the patient, remains unchanged, it
is proteiform in  its varieties, from the  almost
imperceptible  vesicle, unaccompanied  by  fe-
ver, which exists for some time before it ex-
tends its poison  inwardly, and then excites fe-
ver and  buboes, to the fatal form, in which car-
buncular or gangrenous  inflammations affect
the  most  important  viscera, as appeared to
have been the case in a large proportion of ca-
ses of this pestilence.
   12. The  haemorrhages  which  were so  fre-
quently remarked, in  various countries where
this pestilence prevailed,  and soon occasioned
death, were obviously the result of the vital
dissolution of the structures and of  the crasis
of the blood ;  the inflammations said to have
existed being a state of asthenic vascular con-
gestion  with sanguineous exudations,  or   in-
flammation of a gangrenous  nature,  owing to
the rapid loss of the vital  power of  the  capil-
laries.   That such was the case in a remarka-
ble degree, as respected the capillaries, the  tis-
sues, and the blood itself, was evinced by the
rapid discoloration, the purplish hue, and  the
loss of sensibility of the affected parts.  There
was a loss of vital  cohesion throughout  the
whole frame, those  tissues and  structures, as
the mucous, the cellular, the glandular, and the
parenchymatous, that possess the least density,
and the capillaries supplying them, most rapidly
and most completely undergoing this septic al-
teration.
   13. The plague, which  devastated  the Em-
pire of Morocco in 1799 and  1800, appears to
have been equally virulent with the above, but
much more circumscribed in its spread.   Mr.
Jackson, who  resided in  that country  during
its continuance, has described it as it came un-
der his own observation.  He states that Te-
rodant, the metropolis of a province, lost above
eight hundred each  day during  the  height of
the  pestilence;  the  city  of  Morocco lost  up-
ward of one thousand daily ;  and that old and
new Fez, about fifteen  hundred daily.  Young,
healthy,  and robust persons were for  the most
part attacked first, then women  and  children,
and lastly thin, sickly,  emaciated, and old peo-
ple.   The symptoms of this plague  varied in
different  persons with  age,  constitution, and
habit of  body.   " It attacked some with a sud-
den and violent shivering,  others  with a sudden
delirium, succeeded  by  unquenchable  thirst.
Cold water was  eagerly resorted to by the  un-
wary, and proved fatal to those who indulged
in its momentary relief.   Some  had  one, two,
or more  buboes, which formed and became as
large as a  walnut  in the course of a day;
others had a  similar  number of carbuncles;
others had both buboes and carbuncles, which
generally appeared in the  groin,  under the arm,
or near the breast.   Those who were affected
with  shivering,  having  no   bubo,  carbuncle,
spots, or any other external disfiguration, were
invariably carried off in less than twenty-four
hours, and  the body became quickly putrified, so
that it was  indispensably necessary to bury it a
few hours after dissolution."*  (P. 273.)
   14. The  plague of London in  1665,  or the
Great  Plague, of which,  according  to  Dr.
Hodges, upward of  100,000 persons  died, pre-
sented the  phenomena already noticed various-
ly  grouped.  This writer remarks  that  this
pestilence  puts  on  various or even  different
appearances, according to the constitution and
age of the  patient, the season of the year, the
modes of living, the  preceding and present dis-
tempers, and the virulence or degree of infec-
tion.  Dr. Hodges practiced in London during
the continuance of this  plague ; and,  notwith-
standing the admixture of  the prevailing patho-
logical notions of the day with his description
of  the symptoms,  has given a very instructive
account of them.   He first states uthe mani-
fest signs of infection," and afterward  describes
" the appearances after infection."   The manifest
signs of infection  he states to be horror, vom-
iting, dizziness, delirium, headache, and stupe-
faction.   The appearances after  infection are
fever, watching, palpitation of the heart, bleed-
ing at the nose, and  great  heat above the prae-
cordia, all which may occur in other pestilen-
ces, but in  this  they are  conjoined with those
which are peculiar to it, as pustules, commonly
called blains, buboes, carbuncles, spots, marks,
or tokens.  (Loimologia, p. 86, et seq.)
   15.  Septic   pestilence,  which  had  become
much  less  prevalent  for  several generations
after the  black plague  of the fourteenth cen-

  * The following brief notices of cases will illustrate the
characters and nature of the pestilence ; I. M.  A. fell sud-
denly down in the street, and was conveyed home.  Three
carbuncles and five buboes appeared the same day, in the
groin, under the joint of  the knee, in the armpits, and in-
side of the elbow, and he died three hours afterward.
  2. L. R. was suddenly smitten when following his avo-
cations, and fell down.  He described a sensation  similar
to that produced by running needles into the parts; and in
the situations  where this was felt carbuncles afterward ap-
peared.  He died the same day.
  3. Mr. Jackson's cook appeared in good health and spir-
its ; but in half an honr  afterward he came to the room
door with his  eyes starting from his head, and his bed-
clothes in his hands, saying, " Open the gate for me, for I
am smitten.''  The next morning he came to the gate half
dressed, saying that he was quite recovered.  Ho was not
admitted ; and accordingly returned to his apartments, and
expired the same evening, about twenty-four hours utter
his seizure ; and before daybreak his body was in such a
deplorable state that his feet were quite putrefied.  His
wife was afterward seized, but recovered.
  4. II. ben A. was smitten suddenly, and felt  at the time
as if two musket-balls had passed through his groins.  A
giddiness and delirium followed, and immediately after-
ward n green vomiting, and he fell senseless to the ground.
A short time  subsequently, buboes formed in the places
where he felt as if shot; and, on suppurating, disclaimed
a fetid black pus. A carbuncle in the bend of the arm was
full of a thin  ichor contained in an elevated vesicle, and
surrounded by a burning red areola.  He ultimately recov-
ered.
  Mr. Jackson remarks, that  those who had vomitings of
green or yellow bile, generally recovered after suffering in
various degrees; but that those who were affected with
giddiness or delirium, followed by vomiting of black bile,
invariably died after lingering one, two, or three days, their
bodies being covered with small black spots similar to grains
of gunpowder.  In this state, however, they possessed their
intellects until their dissolution.   He adds, that when the
constitution was unable to throw the poison to  the surface
in the form of buboes, carbuncles, boils, or blackish spots,
" the virulence seemed to have acted inwardly, or on vital
parts, and the  patient usually died in less than twenty-foul
hours;" and that, when the carbuncles or buboes had a
blackish circle round their basis, the case was invariably
fatal.  " Sometimes  the  whole  body was covered with
black spots like partridge-shot.  Such patients always fell
victims ; and  those who  felt the blow internally did not
survive more than a few hours."  (P. 238, 4.) 
PESTILENCE, SEPTIC  OR GLANDULAR—Svmptoms.              221
tury. again devastated many countries in the
sixteenth century, as shown in the writings of
Langius, Valleriola, Schenck, Joubert, Pal-
marius, Ingrassias, and others.   In the follow-
ing century, also, it prevailed in various coun-
tries of  Western Europe ; and, although limit-
ed chiefly to  large and  commercial  cities, it
was most destructive in those places ; as fully
shown by the writings of Diemerbroeck, Hod-
ges,  De Foe, and  many others.   During  the
last  century  this plague became  even more
generally epidemic than in the  17th, and inva-
ded most of the countries of Europe, some of
them far remote from those to which it was
commonly confined.  Of these pestilences, full
details are to be found in  the works  of Che-
not, Schraud, De Mortens, Minderer,  Sa-
moilowicz, Russel, and  others.
  16. I. Symptoms.—There  are  few  distem-
pers in which the symptoms are so diversified
as in the  pestilence now being  considered.
The severity  of the attack, resulting  from  the
intensity of the cause, or dose of  the poison,
relatively  to the susceptibility of the  patient;
the age; habit of body, and temperament of the
person attacked;  the severity or character of
the prevailing epidemic ; and the various  cir-
cumstances influencing the  patient at the time
of seizure  or during  the continuance of  the
malady, tend to modify the phenomena  in a
more or less remarkable  manner.   Diemer-
broeck  has given a very succinct view of the
symptoms of this pestilence, and of the diver-
sities they present, and which I shall here  ex-
hibit with but little alteration.  Fever, jactita-
tion, extreme anxiety, frequently a remarkable
internal heat, dull  or gravative pains in  the
head, rarely acute ; terror, horror, or delirium,
convulsive startings  of the tendons,  or slight
contractions of the limbs ; in some continual
watchfulness, in others an overwhelming som-
nolency ; a restless expression of countenance,
noises in  the ears, and in some deafness; a
dry,  but rarely a black tongue; great fetor of
the breath and of the perspiration ;  leipothy-
mia  or syncope; the pulse sometimes almost
natural  or full, but most frequently rapid,  fee-
ble,  unequal, or even intermittent,  in many
very small, rapid, equal, or irregular; a short
or dry cough, sometimes haemoptysis; thirst,
loss of appetite, pain at the epigastrium and car-
diac orifice of the stomach, nausea, vomitings,
hiccough;  crude  alvine evacuations, remark-
ably offensive, sometimes containing worms ;
occasionally an exhausting diarrhcea ; the urine
often almost natural, and depositing  a settle-
ment, in  many high-coloured  and scanty, in
others crude and turbid, in some sanguineolent,
and generally very different in the course of
the distemper, or even  in  the  course of the
day ;  sudden prostration of strength, and inca-
pability of motion from the commencement in
some, in others but little impairment  of power
until the moment of dissolution ;  the heat of
skin sometimes acrid and increased, sometimes
natural  or  even  reduced;  the  colour of the
countenance either pale or reddened, or some-
what livid, or even natural; purple, violet-col-
oured, black, or red spots on different parts of
the body, sometimes in small numbers, in oth-
ers in great numbers, and either large or small,
but always round, occasionally seen chiefly in
certain parts  of the  body, but confined to no
one  part  in  particular,  and often scattered
over the whole surface ;  tumours or buboes in
the groins, armpits,  neck, &c.;  carbuncles in
different parts of the.body, &c.   These symp-
toms are generally not all present in one case ;
but many  of them occur in one, and the rest in
others.  During the epidemic prevalence of
plague in various countries, the symptoms have
presented  several grades or states, most proba-
bly owing  to the causes just assigned.  These
grades or  states have been described by sever-
al writers of the last  century,  and their de-
scriptions  have been confirmed by those of the
present day.   I shall first notice these grades,
and afterward the several stages into which the
progress of the distemper may be divided.
   17. i. Grades or States.—Chicoyneau, Ve-
rug, Soulier, and others have  noticed five
grades or  states of this pestilence, and which
they have described nearly as  follows: First
Grade.—This,  the most intense form of plague,
is observed chiefly at the commencement and
during the early course of an  epidemic, and
consists of all those cases in which the symp-
toms are most severe, and are most  promptly
followed by death.  The patient is attacked by
irregular chills or rigours, or a feeling of gen-
eral cold,  a very small, soft, slow, or frequent,
unequal or irregular pulse ; by a heavy pain in
the head, with a stunning, vertiginous feeling ;
and by a stupid, muddled, or drunken appear-
ance.  The  countenance seems  fixed, or va-
cant and apathetic, or presents a look  of alarm
or  despair.  The  speech is slow, hesitating,
plaintive, or interrupted ; the tongue is white,
and afterward dry, re$ black, and rough; the
face is pale, or of a leaden hue, or cadaverous ;
the  contractions  of  the heart  are very fre-
quent ;  the spirits are  remarkably depressed;
faintness  or  syncope,  vomitings,  retchings,
great restlessness, distressing anxiety, &c, are
frequent,  and terminate existence.   Persons
thus attacked  often sink in the course  of a few
hours, sometimes almost suddenly, or in the
courjse  of a night; frequently within twenty-
four hours; and seldom survive longer than
thirty-six  or forty-eight hours ;  the powers of
life sinking lower and lower, without being able
to make any resistance.  Frequently tremours,
or slight convulsive movements, occur at inter-
vals ; but none of the external signs, tumours,
or eruptions,  characteristic of  the  pestilence
appear, the powers of life being insufficient to
throw them out on the surface.
   18. B. Second Grade.—This grade  generally
commences, as the foregoing,  with  chills or
rigors, and with a similar affection of the head ;
but these  symptoms are followed by some evi-
dence of vascular reaction.  The pulse  becomes
frequent, open, quick, expansive,  but remarka-
bly soft and compressible.  The  patient com-
plains of burning heat internally, while the ex-
ternal temperature is either natural or but lit-
tle augmented.  Thirst is unquenchable ; the
tongue  is white,  or  reddish brown, or  dusky
red ; speech is hurried, or impetuous, or stam-
mering ; the  eyes are  suffused, fixed, or wild,
and bright;  the  countenance  is reddish  or
slightly livid ; respiration is frequent, laboured,
or large and slow, but without cough  or pain;
nausea  is  common, with vomitings of bilious,
greenish, black, or bloody matters, similar mat-
ters being passed by the bowels, without ten- 
222              PESTILENCE,  SEPTIC 0]

sion or pain  the urine is sometimes natural,
sometimes turbid, or pale, at other times black
or sanguineolent; and the perspirations are of-
fensive, and instead of relieving, merely enfee-
ble the patient.  In some cases haemorrhages
from mucous  canals  take place, and produce
fatal depression.  Wandering  or phrenitic  de-
lirium is common ; and when the patient is ra-
tional, there are great depression and  appre-
hension  of immediate dissolution;  nothing
tending to rally his spirits, or to re-assure  his
confidence.  In this grade the  characteristic
signs always appear from the commencement,
or in the course of the distemper.  Painful tu-
mours or buboes occur in the groins or a little
below them, in the armpits,  or beneath the
ears or lower maxilla, or neck  ; as well as car-
buncles  chiefly in the  arms  and thighs, but
sometimes also in other parts ;  and frequently
pustules of a whitish, pale, or  livid, black, and
carbuncular appearance, or purple spots spread
over the surface of the body.  Recovery rare-
ly takes place from this state of the pestilence,
although death does not occur so quickly as in
the foregoing.   Nearly all those attacked seem
to be carried off by  a rapid sphacelation of the
parts chiefly affected,  extending even to the
thoracic and abdominal viscera.  It is singular
that this form  of the disease is met with prin-
cipally in the fat, robust, and plethoric ; and the
more these conditions are remarkable, the less
is the chance of recovery.
  19, C  The third form or class of cases com-
prises the two former;  for the writers on the
plague of Marseilles observed, during the whole
course of the pestilence, humerous cases which
presented in succession several symptoms ref-
erable to  both  the foregoing grades ; so that
most of  the signs  characterizing the second
were the precursors of those attending the first
form, which always indicated the rapid extinc-
tion of life.  In these the buboes receded ; and
if carbuncles had advanced, they rapidly  as-
sumed a more extended and gangrenous form.
  20. D.  The fourth state or class of cases con-
sists  of those  attacked with the same symp-
toms as are noticed in  the second grade ($ 18),
but these symptoms abate more or less  on  the
second or  third day,  either spontaneously or
from the effects of treatment,  and almost al-
ways owing to a considerable eruption  of bu-
boes and carbuncles which seem to have con-
centrated  the  morbid leaven,  and which, pro-
ceeding on  towards suppuration, in  this way
procure the recovery of the patient.
  21. E.  The fifth grade or class of cases com-
prises all those in which there  is no febrile or
other disorder, or but  very slight disturbance,
but which present  buboes .or carbuncles, or
both, that either go on to suppuration,  or  be-
come hard or chronic, or are more rarely re-
solved without occasioning any unfavourable re-
sult. Thus there were seen at Marseilles a num-
ber of persons of both sexes who went abroad,
lived as usual, and experienced but little or no
impairment of strength, and yet were affected
with  buboes and carbuncles,  or with one oi
other.
  22. a. M. Gosse, one of the most recent wri-
ters on  the plague, and who saw the disease
during its  prevalence  in Greece in  1827 and
1828, furnishes some interesting particulars as
to its history.   He remarks that the contagion
I GLANDULAR—Symptoms.

 produces a form of the distemper which, as re-
 spects the primary local symptoms, very close-
 ly resembles malignant pustule, or anthrax : this
 is the carbuncle.  First, there appears in  some
 part  of  the  skin, but especially on the limbs,
 the  arms  or neck, a small  brownish spot, like
 a flea bite, attended by an itching and smarting,
 and  afterward  by  a  burning heat.  This spot
 increases to the diameter of three or four lines,
 assumes a violet hue, and is covered by a flat-
 tened vesicle or phlyctena formed of the de-
 tached epidermis.   The base is hard, and swoll-
 en like that of a boil.  In a short time the cen-
 tral part assumes  a bluish  black  appearance,
 and the  margins, as they diverge from the cen-
 tre,  form concentric circles of a violet tinge,
 then a dark purple, a bright purple, &c, or they
 assume an erysipelatous appearance. The black
 centre extends rapidly, as well as the surround-
 ing areola.  When this carbuncular pustule has
 reached the extent of an inch and a half in di-
 ameter,  it generally  about  the third day con-
 tinues for a  short  time stationary.  In some
 rare  instances  vascular reaction is developed
 around the gangrenous centre, an  inflammato-
 ry circle is formed between the living and dead
 parts, suppuration takes place with symptomatic
 fever, and detaches the central slough, and the
 disease  terminates.  But much more frequent-
 ly inflammatory action is either not established
 around the gangrened part, or, if it exist, it  is in-
 sufficient to separate or throw off the slough ;
 absorption takes place, and the poisonous fluid
 of the part is absorbed, contaminating and in-
 flaming  the  lymphatic vessels and glands, so
 that  red lines may be traced from the carbun-
 cles to the glands through which these vessels
 pass, these glands rapidly becoming most  pain-
 ful and swollen.  When the patient is robust,
 and the  case  proceeds favourably, the glandu-
' lar enlargement increases rapidly, and the pains
 in the glands are acute and lancinating.  The
 buboes thus formed tend rapidly to suppuration,
 with moderate symptomatic fever; and if the
 patient  is guilty of  no  imprudence in diet or
 otherwise, and  if his vitality is  sustained, the
 suppuration  proceeds favourably.  While the
 buboes  are developed the  carbuncles extend,
 the  gangrenous portion or central slough tends
 to separate from the surrounding inflamed tis-
 sue,  suppuration is  established, and the cen-
 tral slough is detached, leaving a deep wound,
 which is often slowly healed.   In  some cases
 the  slough thus detached is very large.  When
 suppuration takes place in the buboes recovery
 generally follows ;  but if the patient be weak-
 ened by any cause, or be depressed by cold, by
 mental  anxiety, or disordered by indigestible
 food ; if a temporary swelling of the glands
 merely occurs,  the tumour disappearing with-
 out  passing on to inflammation or suppuration;
 if,  especially,  no buboe  follows a carbuncle
 which has not suppurated, the  constitutional
 symptoms assume  the  worst form, and  soon
 pass into dissolution.
   23. b. The other form of plague, according to
 M. Gosse, instead of presenting the local or
 external symptoms as the primary and promi-
 nent phenomena, manifests  intense affection of
 the  whole system from  the commencement.
 Chills or rigours, with acute frontal headache,
 noises in the ears, vertigo,  or a stunning sen-
 sation or confusion in the head, are first com- 
PESTILENCE, SEPTIC OR GLANDULAR—Symptoms.
223
plained of.   A sensation  resembling sea-sick-
ness is often felt, and these are generally fol-
lowed by all the worst symptoms mentioned
when describing the first and second grades of
the distemper ($ 17,  18).
  24. c. De Mortens describes the carbuncle of
the plague to be a gangrenous spot in the skin,
resembling that caused by a burn.   It consists
of a reddish  spot covered  by small vesicles,
which are pale, livid, or black, and surrounded
by an inflamed circle ; and passing quickly into
a black, hard  eschar.  The term anthrax,  he
states, is usually applied  to a sore resembling
the carbuncle, but is larger and more elevated.
It penetrates deeper, and  is surrounded by pain
and inflammation.    Carbuncles are found  on
the  neck, on the cheeks, the chest, the back,
and the extremities, sometimes even on the
buboes.   The anthrax  is seen chiefly on the
neck and back.  Carbuncles sometimes appear
without buboes;  frequently they accompany
these swellings of  the glands, or even  occur
later than they.  M. Aubert remarks that car-
buncles rarely appear alone, but are generally
followed or  preceded by buboes;  and that the
plague,  termed carbuncular, is not the more
dangerous, especially if the carbuncle is solita-
ry.   He adds that the largest carbuncle which
he has seen was on the middle of the back, and
was four inches in diameter ; the  cicatrization
of it was very slow.  He has met with as many
as eleven carbuncles in  the  same case ; and
with an  instance of a pregnant  female, who
died of the  plague, having a carbuncle  on the
breast.  She was delivered of an infant of sev-
en months during her illness, and it had a car-
buncle on its forehead.
  25. d. The petechia, which are seen in plague,
are stated by De Mjertens, Aubert, and others
to be a most unfavourable symptom, and to oc-
cur chiefly at an advanced period, or shortly
before  dissolution.  M. Aubert,  however,  re-
marks  that  he has seen recoveries after the
appearance  of petechiae.   They are always in
this  pestilence round, purplish, or black, vary-
ing from an  almost imperceptibly small  point
to the diameter of two lines ; and are found on
all parts of the external surface of the body as
well as on the internal surfaces.   Ecchymoses
more immediately precede death ; and proceed
from effusions of blood  of greater  or less  ex-
tent in the cellular  tissue and membranes, ow-
ing to loss of the vital cohesion of the  capilla-
ries and tissues, and of the crasis of the blood.
Hodges,  Morea,  and others mention  certain
eruptions, marks, or tokens, which are very dif-
ferent  from petechiae  or the  furuncular pus-
tules  now  described.  They are  small  tuber-
cles, somewhat resembling warts, callous, and
more  or less  deficient in sensibility; varying
in size from that of a  millet seed to that of
a bean.   They are probably merely a modifica-
tion  of the  early stage  of  carbuncles in  the
more unfavourable cases.
  26. e. Various  modifications of the symptoms
are observed during the prevalence of this pes-
tilence.  Hodges mentions cases of persons
who walked about, or presented the appear-
ance of health, and partook of their usual meals,
and yet had the most unfavourable signs of the
distemper in various parts of the surface, death
taking place in  a few hours.  Some became
delirious immediately after  being seized, and
wandered about until they fell down exhausted
and dying.  In the plague of Noja, it was ob-
served by Morea that when buboes appeared
in the neck, especially near the carotids, the
eye on the same side as that presenting the bu-
boes became inflamed, and ultimately destroyed.
Rensa states that he has seen persons so little
affected by  the disease  as  to walk about, to
eat and drink as usual, and to dress their own
buboes.  Those who have been already affected
by the pestilence generally escape  during sub-
sequent epidemics, or experience  in rare  in-
stances a modified attack, or merely pains in
the cicatrices of old sores and buboes.
  27. /. A secondary and modified attack of plague
is occasionally met with, although a person who
has been once  infected is generally secure
against a second  seizure.  M. Gosse  states
that in Turkey and Greece,-those who had been
already attacked, and who presented the cica-
trices of  buboes or carbuncles, were employed
in preference  to others  as attendants on the
sick;  and that, although  they took no precau-
tions, in waiting upon the  infected, slept and ate
near to them, handled their clothes and persons,
and interred them  after death—although ex-
posed to the influence of infection in its full in-
tensity, they generally escaped a second attack
of the distemper.   Many  of them, however, ex-
perienced pains in  the cicatrices of the old bu-
boes without any other ailment.  A few com-
plained during a subsequent epidemic of head-
ache or vertigo, or disorder of the stomach and
general debility.  Others had slight enlargement
of the glands  in addition to these symptoms,
and but very rarely new carbuncles  or sores ap-
peared.  M. Gosse mentions only one case in
which the second attack was  so severe as to
terminate fatally.  This person had been much
exposed  to the effluvium proceeding from the
fetid evacuations of the  sick,  upon  whom he
was an attendant.   He was soon after infected,
and died on the sixth day of the disease.
   28. ii.   Stages  or Periods.—Although this
distemper may consist of only one  stage in its
most aggravated cases,  that one  being  char-
acterized by rapid sinking of the powers of life,
as manifested by the nervous and vascular sys-
tems and internal organs, still it  much  more
frequently exhibits the  several  periods  into
which febrile, exanthematous, or other diseases,
attended by vascular reaction, have been usu-
ally divided.  These  periods have been vari-
ously divided; but they  may be described as
follows, and as they appear in  the  majority of
cases.
   29. A.  The period which elapses between the
first impression of the exciting cause and the
actual manifestation or irruption of the symp-
toms of  plague has been differently estimated
by different writers.  The duration of this  pe-
riod obviously depends upon the intensity of
the cause, relatively to the susceptibility of the
patient—upon the  dose of the  poison infecting
the individual.  During devastating epidemics,
when  it  may  be presumed that the infectious
agent or poison exists in its greatest intensity,
and when its activity is augmented by an in-
creased  susceptibility of infection  among the
great majority of the community, this agent
produces its effects with more or less rapidity.
In  some  instances where it may be presumed
that the morbid effluvia from the bodies of the 
224               PESTILENCE, SEPTIC OR GLANDULAR—Symptoms.
dead, or evacuations of the diseased, have been
more than usually abundant, the  effect upon
those very nearly exposed to them has been
most depressing,  and almost, instantly over-
whelming to the powers of life.  Many writers
have mentioned the  seizure of persons thus
circumstanced as suddenly as if they had been
struck by lightning, vital  exhaustion  proceed-
ing most rapidly, with a feeling of the utmost
internal anxiety and distress, and  terminating
in fatal sinking in an hour or two.   In these
cases,  and even in many of much longer dura-
tion, the malady admits not of any division into
stages or periods, these having, in fact, consist-
ed of only one  stage,  namely, that of progres-
sive exhaustion of the powers of life, following
immediately after the impression of the exciting
cause, and terminating fatally with great yet va-
riable rapidity.  In these, as there is no variation
in the course of the distemper, so there can be no
division of it into stages ;  and there is also no
latent period between the impression made by the
poisonous agent and the manifestation of its ef-
fects—no period for the incubation of the mor-
bid seminium, the fatal results of which are ren-
dered instantly apparent in such cases.
  30. In different circumstances, however,  and
in the  large majority  of instances, the distem-
per  requires  a longer or  shorter period from
the  time  at which its cause has infected  the
system before  its effects  are apparent.  This
period, which has been denominated that of in-
cubation, or the latest  stage of the malady, can-
not  be said to  exist in the circumstances just
mentioned ; and even in some of those which
are  now about  to be  considered, it is often of
so short duration as either to be entirely over-
looked, or to attract  but  slight attention.   In
these, as well as in other cases, when the pe-
riod between infection and the irruption of the
distemper is much longer, the patient is  not
generally in sound health during the interval.
Although no complaint may be made and but
little ailment is felt, still  more or less  of  ma-
laise, or lassitude, or slight disorder may be
detected; at last, after a period  varying from
a few hours  to several days, the actual mani-
festation of the distemper, inaccurately called
the  period of invasion by  many writers, takes
place,  and the malady proceeds in its usual
course.  It is fully ascertained that the morbid
phenomena may instantaneously follow the im-
pression made  by the  poisonous effluvium upon
the susceptible, when it is intense, relatively to
the  grade of susceptibility ;  and that they may
follow at periods more remote from such  im-
pression ; but the extreme duration of this pe-
riod has not been precisely ascertained.  Sev-
en,  eight, or nine days have been viewed by
many  as  the longest  period  during which  the
infectious emanation  operates  its effects, in a
silent or latent manner, in the frame of the re-
cipient before  it explodes in open disease.  It
is even possible that a longer period may some-
times  be required, especially when the distem-
per  is merely  endemic or sporadic, when  the
dose of  the infecting poison  is weak relatively
to the susceptibility  of the  recipient, or when
the  action of the poison is resisted by the con-
stitution and circumstances of the patient.  It
is also obvious that  in this, as well  as in all
other  infectious distempers,  as will be shown
more fully hereafter, persons whose  suscepti-
bility is by no means great may altogether es-
cape, although very much exposed to infection,
until some depressing agent or influence comes
in aid  and determines the operation of the ex-
citing or infecting cause, as  I have more par-
ticularly explained in the article Disease ($ 61).
  31.  B. The period of irruption or invasion usu-
ally appears with a  short chill or rigour, nau-
sea,  lassitude, vomiting, severe  pain of the
head  and  praecordia;  continued anxiety ; a
sense of internal heat referred to the stomach
and bowels;  vertigo, with a  staggering walk
and appearance of drunkenness.  The spirits
are depressed to a state of apathy; the fea-
tures are pale, collapsed, sometimes turgid or
bloated ;  the  tongue is coated  with a white
mucous crust; thirst is urgent and constant;
the skin dry and hot; and the pulse most va-
riable, usually quick, but at  one time weak,
small,  and irregular,  at another more  full and
equal.  The vertigo, headache, and drunken ap-
pearance  of the countenance soon pass into
delirium,  with  jactitation,  restlessness, and
tremour of the  limbs and tendons, often pass-
ing into profound lethargy.   Sometimes diffi-
culty of breathing, pain, and  oppression at the
chest; hoarseness and cough ; a sense of burn-
ing heat  at the praecordia,  and  occasionally
throughout the thorax ; and, in  some cases,
slight expectoration of blood, or more copious
haemoptysis, are present from the commence-
ment.  These symptoms are often increased by
the accession of vomiting, or of borborygmi, or
meteorismus, or diarrhcea.
  32. C. The  eruptive period may occur after a
few hours, or in the course  of the second or
third, or even the fourth day.  .\fter the rapid
aggravation of the foregoing  symptoms, sting-
ing and lancinating pains are felt in parts of
the surface, followed by the appearance of car-
buncles, in the manner already described ($ 22),
and generally, either subsequently or contempo-
raneously, by tumours of the  lymphatic glands,
or buboes  (y 22).   These are developed with
greater or less  rapidity, and with an increase
of all the constitutional symptoms, which pre-
sent a  more  marked malignancy as they con-
tinue.   The nervous systems of organic and
animal life evince extreme depression  and dis-
turbance, and the vascular system remarkable
loss of vital tone.   The delirium is either fu-
rious,  or resembles violent intoxication, or it
sinks into a stupid muttering or typhomania, or
into complete sopor.  The face is lurid, or of
an earthy or leaden hue ; the  eyes are watery,
suffused, and the lachrymal carunculae red and
congested ; the tongue  is dark, contracted, dry,
and  tremulous, sometimes almost black; the
voice is hoarse or altered ; the  speech rapid,
hesitating, interrupted,  or stammering; vomit-
ing is constant, irrepressible, attended by hic-
cough,  and the  matters ejected have a putrid
odour ; the perspiration is cold, viscid, and most
offensive, and the surrounding air is sickening
and  fetid.   The carbuncles  sphacelate;  the
buboes either subside or pass into an ichorous
ulceration; petechiae, vibices, or ecchymoses
appear; subsultus tendinum and convulsive
movements supervene; and the pulse becomes
soft,  weak, small,  irregular,  or  intermittent,
with  faintness,  sinking, deafness, and loss of
sensibility.   These symptoms, which are often
variously grouped, differ but  little from  those 
PESTILENCE, SEPTIC OR GLANDULAR—Appearances on Dissection.
225
of putro-adynamic  and true typhus fevers, ex-
cepting  m the appearance  of carbuncles  and
buboes.
  33.  D. The period of crisis  supervenes; but
the distemper may terminate fatally with the
symptoms of vital depression, and of dissolu-
tion of  the vital cohesion of the tissues just
mentioned, at any period from  the second to the
seventh day.   When it proceeds so rapidly as
to terminate  in  death  on the second or third
day, the stages of its course  are generally but
imperfectly marked, at least  according  to the
division of them adopted by Hildenbrand, and
followed by Naumann.  But when the attack is
less severe, and when it  is  prolonged  to the
sixth or seventh day, a favourable change fre-
quently occurs on the latter  day.  The pulse
is fuller, more equal, and stronger; a general,
warm,  and  copious  perspiration  breaks out;
the sloughs of the carbuncles begin to separate,
and the buboes assume a healthy suppuration.
The  alvine  and urinarv evacuations are also
improved, although a crisis is more rarely in-
dicated by them than by the  external surface
onQ sores
   34. E. The decrement or cessation of the dis-
temper is generally gradual and slow when the
attack has been severe, and when the carbun-
cles  and  buboes have been  large, open,  and
foul.  When  the disease has been milder the
svmptoms disappear more rapidly, a resolution
of the buboes taking place without suppuration
occurring; but in  all  cases where the buboes
go on to the production of a morbid matter, ei-
ther infiltrating the cellular tissue surrounding
the diseased glands,  or breaking  externally,  a
healthy  suppuration  is requisite  to  returning
health.  Hence  convalescence is more or  less
prolonged  by the severity and extent of the ex-
ternal sores,  as well as by the violence  of the
preceding constitutional  affection, by the  pro-
found alteration and depression of the powers
of life in  all  the vital  organs, and by the con-
ditions of the circulating fluids.
   35. F. The  duration of an attack  of  plague
varies from  an  hour or  two to six or seven
days  in fatal cases.   According to M. Morea,
death generally occurs  before  seven  days.
When  recovery takes place, the suppuration
and healing of the carbuncles and buboes great-
ly protract the distemper, at  least the early pe-
riod of convalescence from it.  In slighter at-
tacks, when no foul and open sores are formed,
recovery is much more rapid, and the duration
of the distemper is much shorter, but of an in-
definite duration, under nine or eleven days, no
precise  period having been remarked.
   36. II. jYppearances on Dissection.—M Ri-
gaud, lately physician to the  European Hos-
pital at Alexandria, states the following to have
been the results of his examination of the bod-
ies of sixty-eight subjects of the plague.  The
exterior of the body, when death has  ensued
rapidly and without any  medical aid, is bluish
and dark-violet, in large, irregular patches, es-
pecially about the head, the neck, and upper
extremities, the surface appearing as if  rubbed
over  with  mulberries.   This  discoloration,
which is  often absent when death has taken
place slowly, is accompanied  with  petechiae,
varying in size from  a flea-bite to  that of  a
vetch.  One  or more  carbuncles and  buboes
are found in the situations already specified ($
    HI.            15
22).   The usual cadaveric stiffness is present.
—a.  The membranes of the brain are injected
with  black  blood.   The  vessels  beneath the
arachnoid are greatly distended.  This  mem-
brane is, however, rarely thickened; it is most-
ly adherent, by a huffy and  granular transuda-
tion, to the  upper and inner parts of the hemi-
spheres of the brain.   Sanguineous effusions
are observed  in  some  cases ;  but more  fre-
quently the  cellular sub-arachnoid tissue is in-
filtrated with a serous fluid,  sometimes yellow,
or even purulent-looking.  The cineritious sub-
stance of the brain is of a  deeper colour than
natural; and the white substance, when sliced,
shows very  numerous  bloody points.   A little
limpid serum is  found in  the ventricles.  The
choroid plexuses  are of a reddish violet colour,
like the lees  of  wine.  The  brain  is  seldom
softened.  The membranes  and substance of
the spinal  chord  are  generally  in the same
state  as those of the brain.   The cephalo-spi-
nal fluid is in excessive quantity.
  37.  b. The lungs are generally found more or
less  altered, but  the lesions are often  conse-
quences  of  antecedent maladies.  They  are
often  rose-coloured on their exterior and ante-
rior surface, but  sometimes pale yellow, mar-
bled with blue;   these appearances are, how-
ever,  seen only when they are bloodless.   Pos-
teriorly they are always of  a deep violet, their
vessels being gorged with black and thick blood.
The pleura  is always  of a  dark red, with nu-
merous adhesions.  Effusions  of a yellowish
serum in considerable quantity are frequently
met with in  the pleural  cavities.   The pericar-
dium usually contains from half a pint to a pint
and upward of  serum.  The  heart seems in-
creased in volume, and its  superficial vessels
are congested and well defined.  Spots like pe-
techiae are observed over the left cavities. The
right  cavities, the auricles  especially, are  dis-
tended by black  blood, sometimes clotted, but
always gluey.  On the left side the cavities are
empty, with the  exception of a very little blood
in the ventricle.   The  substance of the heart
and  its inner membrane  are  unaltered.  The
arteries are always  empty; the veins  are, on
the contrary,  distended, and full of black clot-
ted blood, the jugulars more particularly.  While
the inner coat of the  arteries  presents  no al-
teration, that  of the  veins  is  spotted  largely
and irregularly, as if with ink.
   38. c. The pharynx and oesophagus are com-
monly natural;   and this has been the case
even  with the latter, when  appearances of in-
tense inflammation have existed in the cardiac
orifice of the stomach.  The  peritoneum is al-
ways of a pink or bright red tinge, and the ves-
sels  are seen beneath it largely gorged with
black blood.  The adipose tissue is injected
and reddened, sometimes darkish, like  lees of
wine.   The stomach is often distended by gas.
It frequently contains a quantity of a dark vis-
cid fluid, like a mixture of bile and putrid blood.
The mucous membrane varies  in colour from
pink and bright red to a brown, bluish, or lead-
en tinge, and  often to a bronze green.   Large
ecchymosed patches  and petechial  spots are
ajso observed in the internal surface.   The in-
ternal coats  are remarkably softened, and some-
times  ulcerated.   The intestines  present  the
same changes as the stomach, excepting the co-
lon, which is somewhat contracted. Lu.mbrici, 
226       PESTILENCE, SEPTIC OR GLANDULAR—Diagnosis and Prognosis.
and less frequently taeniae, are  found in many
cases.   The mesenteric glands are engorged and
blackish, and the whole gUndular system is more
or less altered.  The liver is almost always en-
larged, especially its large lobe, which presses
up the  diaphragm very much on tUe right lung.
Its vessels are engorged ; its substance some-
what softened, but not otherwise altered.  The
gall-bladder is  double,  or  nearly triple its usual
size, containing a  thick, greenish-black bile.
Petechial spots are seen beneath its peritoneal
covering.  The  spleen is much  augmented  in
volume, softened, friable, and pulpy.   The kid-
neys are engorged with  blood ;  the ureters are
arborescent, with a red hue  along their entire
course, or covered with black  spots, or even
wholly blackened, as if with charcoal or  ink.
The urinary bladder is commonly half contract-
ed, and its inner membrane presents the same
appearances as  those of the stomach and in-
testines.
  39. d. These changes were observed in Eu-
ropeans who had died in the hospital in Alexan-
dria, and who had been addicted to every kind
of excess ; but they differ but little  from those
found  by other physicians who have observed
the disease in various countries and epidemics.
Petechias have been remarked in all  the vis-
cera, especially in the mucous surface, where,
also, ecchymoses  and large dark spots have
been very common.  The carbuncles said  to
have been found by the older writers on this
pestilence in  the  abdominal and thoracic or-
gans have manifestly been  those large ecchy-
moses  or exudations of blood in the tissues,
more  accurately observed by recent  writers.
M. Lachaise, in his description of the changes
in the  bodies of those who died of the Egyptian
plague of 1835, states that the whole lymphatic
glandular system was diseased, internal as well
as external.   These glands were more or less
engorged, enlarged, often softened  and discol-
oured.   The spleen was always very much en-
larged, and so remarkably softened as not  to
admit  of being  handled.  In all cases when
black vomiting had occurred, the mucous sur-
face of the stomach was not only ecchymosed
and softened,  but also ulcerated, the ulcers be-
ing very small and  often numerous,  and appa-
rently  the consequences  of the ecchymoses,  or
small effusions of blood in and under the mu-
cous or villous membrane.  Red petechiae and
small rounded ecchymoses were also frequent
under  the serous surfaces.   He adds, that all
the parenchymatous organs were engorged with
fluid black blood, which had  frequently gone on
to decomposition, causing the presence of gas,
which  was often remarked.   M. Aubert states
that he observed the ganglia of the  great sym-
pathetic engorged with  blood,  and  presenting
numerous red points externally, and internally
the colour  of wine lees.  M. Lachaise men-
tions the frequency of red points in the nerves
arising from  extravasations of  blood in their
neunlema.
   40  e. All recent writers concur in  remarking
the very sensible alteration  of the blood in  this
pestilence even during the  life of the patient.
Blood  drawn from a vein, even early in the
distemper, does not separate into a coagulum
and serum, and there is  no fibrinous portion  or
buffy coat.  These elements remain mixed to-
gether, presenting the  consistence  of cream.
I During  venesection  the blood presents, as it
| flows, the same dark colour at the close as it
j did at the commencement of its abstraction j
I and  it often emits  a peculiar odour.  A^fter
[ standing, drops of oil often appear on the sur-
| face, and  the  whole mass speedily undergoes
 putrefaction. M. Bulard states that M. Rochet
 analyzed the blood in three cases.  The blood
 was taken from three young and plethoric men,
 and from  the third to the fifth day of the dis-
 temper.   In 100 parts  there were  only  six
 tenths of  fibrin, and it contained sulphuretted
 hydrogen gas.  It was always more dense than
 in health.   The venous trunks contained blood,
 presenting the same appearances and  chemical
 constituents as that taken away by venesection.
 The blood h these vessels was fluid and black;
 it appeared as dissolved, and often contained
 small oily dropa.
    41. III. Diagnosis.—Plague is often distin-
 guished with great difficulty from other malig-
 nant or low fevers on the first breaking out  of
 an epidemic, so that physicians who have been
 in the habit  of seeing plaguo patients have been
 deceived  in some  instances.  The difficulty
 however,  is only felt at the commencement  of
 an epidemic, and when neither carbuncles nor
 buboes  appear.   When  these are present  or
 even either the one or the other, then the'na-
 ture of the  distemper is made manifest.  Du-
 ring the prevalence of an epidemic  plague, a
 white chalky  tongue, a quick and rapid prJse,
 and headache, are sufficient proofs of an attack,
 although  neither carbuncles nor  buboes, no!
 even petechiae are present.  The septic or pu-
 trescent disposition, although greater in this
 pestilence than  in  others, is not  sufficient to
 distinguish  it in many cases, and especially
 early in the attack; but, when  the  affection
 of the glandular system becomes  apparent  ei-
 ther alone or  conjointly with the  other symp-
 toms of malignancy, or signs of a septic ten-
 dency, then no doubt of the nature of the dis-
 temper need be entertained.
    42. IV. Prognosis.—The  prognosis in this
 distemper has been  more fully stated  by Dibh-
 erbroeck than by any  other writer.  He  re-
 marks that  no dependence, in genera!, could be
 placed upon critical  changes occurring even in
 the  critical days ; when, however, they take
 place on  the sixth day, the  disease is always
 fatal; and he adds,  that those who are seized
 at new  and  full moon rarely recover.  A seiz-
 ure  after  a  fit of anger, after terror,  dread, or
 anxiety, and after  sensual excesses, is espe-
 cially to be  dreaded. The commencement  of
 the  distemper during warm, humid  weather,
 and a still  or calm state  of the air, in warm
 countries, or during the summer or autumn in
 colder climates, and in low, close, foul, and
 crowded localities, among a  population insuffi-
 ciently nourished, prone to excesses,  and neg-
 lectful of cleanliness, is generally followed  by
 a rapidly  diffused and fatal epidemic.   I shall
 treat of the prognosis uiih reference, in suc-
 cession, to the chief functions of the economy,
 according to the information  furnished by the
 most experienced writers.
    43. a. The circulating organs sometimes fail
 of furnishing  those  indications  of the  result
| which might be expected from them; but this
j may be  owing as much  to deficiencies in the
i observer as to the conditions of these organs. 
PESTILENCE,  SEPTIC  OR GLANDULAR--Prognosis.              227
Faintings, syncope, or marked impairment of
the heart's action, or palpitation at the time of
seizure, or soon afterward, are generally un-
favourable. An irregular, unequal, small, weak,
and very soft pulse during the course of the dis-
temper, and an intermittent, small, weak, and
creeping pulse at an advanced period, are gen-
erally fatal.  A rapid, quick, open,  and expan-
sive pulse  at the commencement, or early in
the attack, is also unfavourable.  An even, not
very frequent, or even an almost natural pulse,
cannot be relied upon as indicating a favoura-
ble result unless accompanied  by other favour-
able symptoms. Diemerbroeck remarks  that
a pulse nearly approaching the natural state is
deceitful, and that  an intermitting  pulse is al-
ways fatal.  The state of the blood, as shown
after venesection, or by the appearances of the
mucous and cutaneous surfaces, and considered
in connexion with the heart's action and pulse,
also indicates the amount of  danger, evidence
of serious change in this fluid leaving but slight
hopes of recovery.
   44.  b. The nervous systems, especially the or-
ganic nervous system, often furnish evidence of
the  ultimate result from the  beginning of  the
attack.  In some cases the cerebro-spinal  sys-
tem is not remarkably affected even during the
whole course of the malady;  the intellects  are
not disordered, and muscular power and action
are often so far retained as that the patient is
enabled to walk about until shortly before  dis-
solution ; and although the pulse may have dis-
appeared from the extremities, he can, in some
instances, change from one part of the chamber
to another.  When, however, the  powers of
the mind are impaired, depressed, or otherwise
disordered at the commencement, or when vi-
olent or low delirium  occur   early, and when
apathy, lethargy, stupor, or complete coma ap-
pear, the distemper generally terminates fatal-
ly.  Tremour of the  tongue and hands ; convul-
sive movements of the  extremities or other
parts ; contractions or startings of the tendons,
generally indicate dissolution, especially when
associated with delirium, stupor, or coma.
  45.  If all the functions which are actuated
by the organic nervous system be remarkably de-
pressed or otherwise disordered ; if the digest-
ive, the assimilative, the excreting,  and   the
circulating functions are either arrested or re-
markably impaired; if  the vital or chemical
conditions of the blood be visibly altered ;  and
if the vital cohesion or tone of the capillaries
and of the several tissues be manifestly dimin-
ished,  occasioning passive haemorrhages  and
discoloration?  of the  surface, recovery rarely
takes place, especially if these  changes are very
apparent.   Diemerbroeck  remarks  that  epi-
staxis is dangerous on a critical day, and fatal
on a non-critical day.  Other haemorrhages are
even still more dangerous.
  46.  c. The tongue  often  indicates the result
with much certainty.  When it becomes black,
or  very dry and contracted at the commence-
ment, an unfavourable issue may be expected ;
but when it preserves a natural appearance and
continues moist, or when it regains these ap-
pearances,  recovery may be anticipated.   Se-
vere affections of the throat, or pain  in this sit-
uation, even  although there  may  be  neither
dryness, nor  aphtha,  nor tumours,  or other
manifest cause, often announces a  fatal term-
ination.  Exudations of blood from the gums,
tongue, mouth, or throat, are equally unfavour-
able.
  47. d. If the symptoms referable to the stom-
ach and bowels  are  severe  at the  commence-
ment, and  especially if vomiting be  exhausting,
frequent, or continued ;  if the matters ejected
be  black or  unnatural;  and particularly if it
be  attended  by  singultus,  death  will  ensue.
When,  however, vomiting is  moderate,  and
when it ceases after the evacuation of green,
or greenish-yellow, or bilious fluids, a favoura-
ble result  often takes place.  The occurrence
of diarrhaa, and  even of looseness, especially
if the motions  are  black, or sanguinolent, or
give out a very offensive, putrid, or unnatural
odour, is  generally  fatal.   On the  contrary,
costiveness, or a natural state of the bowels, at
the commencement and during the increase
and decrement  of the distemper, is a very fa-
vourable circumstance.
  48. e. A  free, tranquil, and easy state of res-
piration furnishes just grounds of hope ;  but
the more serious disorders of the  respiratory
organs are most unfavourable.   A short cough,
short and difficult respiration;  a burning heat
or  pungent pain, or tightness  in the thorax;
bloody expectoration or haemoptysis ; and signs
of pneumonia or of pleurisy, are severally indi-
cations of a fatal issue. Frequent sneezings
and remarkable  fetor of  the   breath,  or  an
odour of putrefied flesh  furnished by the expi-
red air, are indications of approaching dissolu-
tion.  Alterations of the voice,  a rapid or  in-
terrupted, or  very slow or stammering enunci-
ation, inarticulate or confused  speech, are  all
unfavourable  signs.
  49.  /. The urine  generally fails  to furnish
any certain indications  of  the  result; and I
can find no exact  information  respecting  its
chemical conditions  in this  pestilence.  Diem-
erbroeck observes that a turbid urine was un-
favourable  ; nevertheless, some escaped  who
passed this urine, while many died  suddenly or
rapidly, although the  urine was natural,  and
that in some  of these the symptoms did not ap-
pear dangerous.  He adds, that a thick, oleagin-
ous, brown, or  blackish  urine, or that furnish-
ing a  brown  or black sediment,  was generally
a very unfavourable symptom.   Those who dis-
charged blood from  the  urinary organs, either
mixed with the  urine or distinct  from  it,  he
states, died in a short time.  Hodges remarks
that very offensive urine is a fatal symptom.
  50.  g. The  appearance of the catamenia du-
ring this pestilence  is dangerous, even upon a
critical day;  and most writers view this oc-
currence as fatal when it takes place on  a non-
critical day.  Hodges says that every hemor-
rhage is  bad, but a flux of the menses is fatal.
Women who are pregnant, or lying-in, or threat-
ened by abortion, rarely  recover when  seized
by this distemper; and they are in  great dan-
ger of being  attacked when it is epidemic, un-
less excluded from all possible medium of in-
fection.   Infants born either prematurely or at
the full time,  after the mother has been  seized
by the plague, have sometimes presented proofs
of the disease  having affected  them in utero
and the distinctive characters of the distemper'
  51.  A.  The external  surface furnishes  by its
appearances the most  certain evidence of the
issue of the distemper.  When a warm, genial 
228          PESTILENCE, SEPTIC OR GLANDULAR—Causes of Plague.
and general perspiration breaks out, no symp-
tom assuming a worse character, a favourable
result may be  expected.   But when the per-
spiration is clammy, viscid, very offensive, or
cold, or even although it be general, when the
symptoms  are aggravated, or the  patient be-
comes weaker, or feels a sense of sinking, then
the distemper terminates fatally.   Hodges re-
marks that " the most  certain fatality of all is
from such sweats as have a cadaverous smell,
although there was sometimes a disagreeable
scented sweat, with which they recovered, as
with it exhaled the pestilential  venom."  (P.
144.)
  52.  i. The glandular tumours, or buboes, char-
acterizing this pestilence often furnish the best
evidence of the issue.  The early appearance
of these  tumours, especially before or  without
febrile symptoms,  is a favourable circumstance;
but it is very different if they follow the fever,
or if the febrile symptoms are very severe or
intense.  The occurrence of these tumours be-
low the ears or in the neck, and especially if
they increase  rapidly, or  in the course of ten
or twenty hours, or if they  be  soft, fluctuating,
or boggy, either with or without inflammation,
is always  fatal;  and although some patients
with tumours thus  situated and characterized
may not appear  otherwise very ill, they die
nevertheless.   If, on  the other  hand, the tu-
mours are hard at the commencement, tense
and oblong, and increase gradually or slowly,
with  a  moderate degree of pain, and if they
continue hard during their  increase, a favoura-
ble result may be anticipated ; and with more
certainty if they pass on  to suppuration; or
when the fever has ceased, they gradually dis-
appear without suppuration.  But  if hard bu-
boes are surrounded by a circle  resembling an
iris, or if they assume a dark or fiery red, o.
a livid or black hue, or if the buboes disappear
suddenly, the  fever still continuing, death gen-
erally takes place.  Hodges remarks that "the
more buboes there are, so  that they suppurate,
the better.  Carbuncles  are always more dan-
gerous than buboes."  (P. 140.)  Dr. Morea ob-
serves that buboes in the armpits are always
attended by danger, and an inflammatory affec-
tion of the eyes, with difficulty or other disor-
ders of respiration, generally accompanies them,
these  and  other symptoms  becoming  worse
unless they enlarge  and suppurate, when an
amelioration takes place; but if they remain
stationary, or subside, death always results.
(Op.  Cit., p. 427.)
   53. k.  Carbuncles appearing in fleshy parts,
from the commencement of the distemper or
soon afterward, are favourable ; but if they are
seated over or very near the buboes or enlarg-
ed glands, over the spine, or on the fingers or
toes, they indicate great danger.  If they break
out slowly there  is much risk, and if  they are
numerous there is still greater risk.  If, in the
course of two or three days, they are surround-
 ed by a  red  circle, they generally heal easily
 and soon ; but if they continue to extend, with-
 out a disposition to become limited, or if they
 reach a great size, there is danger, or at least
 there will be  great difficulty in  healing them.
 The  prognosis should be still more unfavoura-
 ble  if they are seated on the  spine, or over
 large blood-vessels or nerves.  When  they dis-
 appear suddenly, or when  they dry up, the feb-
rile or other symptoms still continuing, a fatal
termination soon follows.   Hodges says that
" the smaller the carbuncles, and the more re-
mote their situation  from the viscera, greater
vessels, tendons, and nerves,  and the  fewer
they are in number, by so much it is the bet-
ter; and,  on the contrary, when they spread
like a gangrene, and are near  the  principal
parts, as the breast or belly, and also are nu-
merous or livid, the fate of the patient may be
pronounced desperate."  (P. 147.)
  54. /.  Petechia, ecchymoses, or spots of a vio-
let, purple, black, or greenish  hue, whenever
they may  appear, always indicate a fatal issue.
A few escape when the  petechiae are red, but
even  this  is an unfavourable symptom.
  55. m. Dr. Castro remarks that evacuations
occurring spontaneously in the course of febrile
diseases, especially on critical days, are favour-
able circumstances ; that they are quite other-
wise than favourable in plague.  Diemerbroeck
observes that he has  always considered issues
and setons, made with a view of protecting the
individual  from an attack of plague, as most
serviceable, even although  he may be  seized
nevertheless; for if these continue to discharge
fully during an  attack,  the pestilential venom
seems to  discharge  itself by these channels;
but if they dry up, or  cannot discharge,  during
an  early or more advanced period  of the dis-
temper, death will certainly take place.  Of the
protecting and favourable influence of issues on
this malady, he quotes the opinions of Mercu-
riali, Hercules Saxonia, Garnier, Hildanus,
Joannes Herculanus, and others in support of
his  opinion
  56. V. The Causes of Plague.—This snb-
ject, in  some of its  most important relations,
has long engaged the minds of eminent medi-
cal  writers.  It  has  occupied a portion  of the
attention  of the legislature in this country in
modern times ;  and very recently it has been
inquired into and discussed in the Royal A^cad-
emy t>f Medicine in Paris.  I have, in preceding
sections, of this article, fully examined the caus-
es  of the  choleric  and hamagastric pestilences,
and have  demonstrated the existence of infec-
tion as  their thief and efficient  cause.  How-
ever this  may be disputed by the interested, by
the prejudiced, and by the insufficiently inform-
ed, I am confident of its truth.  I have written
with a full conviction of the soundness  of the
opinions I have entertained, and with a firm be-
lief that time will not orJy test, but also prove
their accuracy.   The inquiry upon which I am
about to  enter will  be  prosecuted as follows:
1st. Is  plague caused and propagated by infec-
tion 1   2d. Infection having been demonstrated,
in what does the infectious agent consist, and
by  what media is  it conveyed  or preserved 1
3d.  What are the circumstances, infWences,
and agents  favouring or  determining the ac-
tion  of the  infectious  or pestilential miasm 1
And, 4th.  For  what  period  may infection re-
main latent in the system until its irruption in
a specific  form ; and how long may the infec-
tious poison retain its powers when preserved
in animal or other productions 1
  57. a4.  Is plague caused and propagated by in-
fection?  Conformably  with the meaning at-
tached  to the word infection, in  the use which
I have made of it in the two preceding parts of
this article, and agreeably to what I have sta- 
PESTILENCE,  SEPTIC OR GL.
.ANDULAR—Causes of Plague.          229
ted in the article Infection, there can be no
doubt of the proofs of the infectious nature of
this pestilence being most complete, and con-
vincing to all candid minds.  In that article  I
have classed plague in the third class of infec-
tious maladies, and have stated the tests and
circumstances proving the infectious nature of
this distemper, and of others belonging to the
same category.  (See Infection, (f 4,15.)   Lest
I may be  viewed as having espoused a particu-
lar doctrine without sufficient  evidence of its
truth, I shall first  adduce a sufficient number
of the innumerable facts upon record proving
the infectious  nature of this  pestilence, and
next  inquire into the objections  which  have
been urged against a  most important doctrine
as respects  the  best interests of  the commu-
nity.
   58. a.  Plague has been generally considered
as both an endemic and epidemic distemper;  it
has been viewed as endemic in Egypt and Syria,
where, also, it is frequently epidemic, and only
epidemic after various prolonged  and indeter-
minate intervals, in most of the countries bor-
dering on or approaching to the Mediterranean
shores, and less frequently, or much more rare-
ly, in those which are farther distant from them.
It has been said to be non-infectious or non-
contagious when appearing endemically, spo-
radically, or primarily;  and to be contagious
by some, infectious by others, and both conta-
gious and infectious by many, only when it ap-
pears in an epidemic form.  These views have
been often hastily taken, and the terms in which
they are  expressed have been as loosely as in-
accurately employed.  The meaning which the
numerous writers on the subject have attached
to the words contagion and infection has  been
vague in most instances ; different writers em-
ploying  them with a  different import, or with
a  different range  of meaning; and even the
same writer using them without either precis-
ion or distinction.  From what I have stated
in another article (see  Infection), it will "be
seen that I have used infection as the generic
term, and contagion as a form of infection,  or
as that infection of a healthy but predisposed
body produced by immediate or  mediate con-
tact of a diseased body, or  of the  secretions  of
a diseased body, the contagious agent propaga-
ting a specific malady and perpetuating its kind.
I  have  applied  the  term infectious to  those
maladies which  are propagated and perpetua-
ted without contact, and by means of an ani-
mal miasm or  emanation, proceeding from the
bodies  of the  diseased,  and affecting predis-
posed or susceptible persons with a distemper
identical with that which produced the infecting
miasm or emanation.
  59. Taking the most extended view of infec-
tion,  and  considering  it a  result  of whatever
may  contaminate the fluids  and solids  of  a
healthy body, as I have  done in  that article,
we shall find that contagion is  a mode only of
specific infection; and that while all specific in-
fections proceed from more or less diffusive, or
more or less consistent animal emanations or
secretions, which  affect  the  system  through
the medium of either the respiratory or the cu-
taneous or mucous surfaces, contagion is in-
fection by those secretions which act chiefly
by contact with, and  through the  medium of,
the external surface of the body.   It is obvious
from this that, as the major includes the mi-
nor, so all contagions are also infectious ;  that
infection has a wider range of acceptation than
contagion ; and that,  among the several infec-
tious agents, some act through the medium of
the lungs, others through the medium of the
external surfaces, and many  through  either
channel, or through both, according to the cir-
cumstances or modes in which the  infectious
agent may be presented to  the healthy frame.
Thus infectious emanations  or secretions from
specifically  infectious  maladies  may affect
healthy predisposed  persons :  1st.  When dif-
fused in the air  either directly from the dis-
eased body, or mediately from woollen, or body
or bed-clothes, which had retained these ema-
nations for a longer or shorter period, the air
thus contaminated affecting the healthy through
the medium of the lungs ; 2d.  When applied in
a more or less consistent or tangible form to
the cutaneous surface, or to the outlets of mu-
cous canals ; and, 3d. When presented to the
healthy economy  in either of, or in both these
modes.   Hence some distempers, as the two
pestilences already treated  of, are propagated
and  perpetuated  in  the first  of those modes
only ; while  others are communicated  in the
second of those modes, as itch, syphilis, rabies,
&cc.; and some are transmitted in both modes,
as plague, smallpox, &c.   The first order is
simply infectious,  the  second is contagious, and
the third is both infectious and contagious.  (See
Art.  Infection, §  4.)
  60. Much difference has existed among wri-
ters  as to the country or countries in which
the plague is endemic, or in which it  is genera-
ted or  its germs  preserved ; and as to wheth-
er or not it is always present in few or  rare
instances, although  not commonly  observed,
when it is not generally prevalent—whether or
not it is generated de novo in  those  countries,
after intervals of entire extinction, or  is the
infectious poison always preserved  by means
of few or occasional cases, thereby imparting
to it an appearance in those  places of a sporad-
ic or endemic distemper.   Many of the an-
cients, as well as writers of later epochs,  as
Mead,  Adolphus,  Arbuthnot, Fodere,  and
others,  have considered'Egypt to be the most
productive source of this  pestilence; while
Prosper, Alpinus, Targioni, and Olivier have
believed that, although frequently observed in
this  country,  it  is generally introduced from
Ethiopia, where it is generated by  a hot sun
from a  deep and rich  soil, kept almost  con-
stantly humid by the rains, a malignant miasm
being produced from this source, that constant-
ly gives origin to a malady, whose effluvium
propagates and perpetuates itself.   Whether
originating or not in  these  or other countries
bordering on  the Levant, and whether it arises
from this or other sources, there can  be no
doubt of the  rapid spread  of this  pestilence
from person  to person, especially  in  certain
circumstances which  evidently favour this dif-
fusion, although the exact nature of  these cir-
cumstances are often  not very manifest, or al-
together unascertained.  That this  malady  is
propagated in one or other of the three modes
to which I have just  now endeavoured to as-
sign  some degree of precision, cannot be de-
nied by any one who has perused a portion of
the annals of pestilential diseases with an un- 
230          PESTILENCE, SEPTIC OR GI.
'.ANDULAR—Causes of Plague.
prejudiced mind ; but the chief difficulty is to
determine the particular mode in which it is
transmitted ;  and it is by no means a matter of
small importance that the exact mode or chan-
nel of transmission observed by this pestilence
should be ascertained, inasmuch as upon it all
protective and  prophylactic measures should
be based.  After perusing  the evidence which
I shall have to furnish respecting the transmis-
sion  of this distemper from person to person—
and  this evidence can  only be, owing to my
confined limits, a very small portion of that
which  might be adduced—the reader will  read-
ily come to a conclusion as  to the channels by
which  this transmission takes place, even  with-
out that assistance which it is my duty to afford.
  61. Dr. Hennen, who took great pains to in-
vestigate the origin and propagation of the
plague  in Malta  in  1813, and  who has con-
firmed the accounts of this  epidemic furnished
by Drs. Calvert, Faulkner,  and Tully, re-
marks that "it has been among medical  men,
I am sorry to say, that doubts have principally
arisen as to the contagious nature of plague.
This gross and dangerous error, in  point of
fact, has sprung from that most fruitful source
of deception—preconceived theory ; and it has
been aggravated  by neglecting to  define the
terms  employed, which is altogether inexcusa-
ble, and which has exposed  us to no small por-
tion  of ridicule among the better-informed non-
professional men who have interested  them-
selves on the subject."
  62. The signs  or  tests by which a disease
may, with the  utmost certainty, be proved to
be infectious or contagious,  or both the one and
the other, have been fully stated in the article
Infection ($ 15).   Now whoever will examine
the accounts  of the plague furnished by those
who  have witnessed its ravages, will find  most
convincing evidence of the following truths :
1st.  That it is most liable to attack those who
approach patients affected  with it, and that in
proportion  to the nearness of the approach;
2d. That those who avoid all intercourse with
persons affected with the plague, generally es-
cape the distemper.  These  are  facts recog-
nised and acted upon by all persons who have
had  opportunities of observing the progress of
this  pestilence;  and there are few facts in
medical history so well supported by evidence
as these are, and as to which the experience
of past and present times is so uniform and
conclusive.  A recent writer has  remarked,
that  the most  remarkable examples of the
communicability of this distemper are afforded
by the introduction of it into countries which
had  long been free from it, in consequence of
intercourse with  places in  which it was then
raging.  The clearness with which this inter-
course has been often traced is truly wonder-
ful,  considering the many  temptations which
travellers, traders, mariners, and  commercial
men, coming from countries where the plague
is prevailing, have to clandestine intercourse,
and  the frequency of deception  practiced by
illicit dealers, smugglers, and others.  Of such
histories, there  are  so many on  record that
the  difficulty is which to  select; although  it
must appear very  difficult, if the  subject be
viewed in a proper light, to trace the origin of
an infectious malady,  especially  when  such
malady may be propagated by the  poison  re-
tained, even for a very considerable period, in
articles of clothing and  bedding.   Indeed, in
many cases of the importation of plague  into
places remote  from or even  approximating the
Levant, several circumstances and occurrences
have taken place, proving the introduction of
the infection  not by one channel, article, or
person merely, but by several in the course of
a few days; and thus the accounts given of
the origin of the distemper have varied in some
instances, and have thereby apparently weak-
ened, although actually strengthening, the  evi-
dence of imported infection.   Besides, the dif-
ficulty is greatly increased as respects this pes-
tilence, as well as others, by the circumstance
of a very-large number, and sometimes all, the
very earliest cases  being either concealed or
denied, or mistaken for some other fever: a
fact  of more  importance than  generally  ac-
knowledged in tracing the early history of an
epidemic.  Owing to the difficulties now ad-
verted to, and to the fact of the plague appear-
ing in places holding frequent intercourse with
countries where it was raging at the time,  the
infection having been conveyed  in more ways
than one, several of the outbreaks of it in vari-
ous parts of Europe during the 15th, 16th, and
17th centuries have been either imperfectly de-
scribed or unsatisfactorily accounted for;  but
such is by no means the case with others, and
especially the  more  recent.   The plague  ap-
peared at Marseilles  in 1720, after an immuni-
ty of seventy years.   A vessel from Seyde, in
Syria, arrived  in that port on the 25th of May,
after having lost several of the crew and of
the passengers during the voyage by this dis-
temper, and among these the surgeon  of  the
ship.   On the arrival of the vessel, the crew
and cargo were landed at the lazaretto.   Soon
afterward the disease attacked, in succession,
another of the crew, an officer put on board to
superintend the quarantine,  a boy belonging to
the ship, two  porters employed in unloading
her, then four other porters,  the priest who had
administered the last sacrament to the sick,
the surgeon  of the  lazaretto, and  his whole
family.   Notwithstanding these  events,  the
passengers, having performed a  short quaran-
tine of less than twenty days, were  allowed to
take up their quarters in the town, and to carry
with them their clothes and packages, conform-
ably with the  advice of the anti-contagionists
of that place  and time.   a\s  Dr.  Gooch has
very justly remarked, when passengers, after
a voyage of nearly four months and a quaran-
tine of nearly three  weeks, are at length let
loose in a large city, their first employment is
to roam about the streets ; they have things to
sell, and to buy, and to  see.  They come in
contact,  in the streets and in the shops, with
persons whom they think no more  about, and
who think and know no more about them.
   63.  It is not surprising, therefore, that  the
exact traces of the distemper should be lost in
all such  circumstances,  and that it should be
often  difficult, and even  impossible, to follow
the progress of it in its various courses towards
the general  infection of a  community.   Dr.
Bertrand, a resident physician at  Marseilles
at the  time, states that it is most certain that
the plague was on  board Captain  Chataud's
ship; that it was communicated to  the infirm-
ary by the merchandise  with which  it was 
PESTILENCE, SEPTIC OR  GLANDULAR—Causes of Plague.          231
freighted ; that one of the first who fell sick in
the city had been passenger in the ship, and
had only quitted the infirmary a few days with
his clothes and merchandise; that among the
very  early  victims of the distemper were the
family  of  a famous  contraband trader near
the convent of the Carmes, and those of con-
traband traders residing in the Rue de l'Escale
and vicinity ; and that the suburb adjoining the
infirmary was attacked nearly at the same time
as the Rue de l'Escale.  I leave my readers to
make the  reflections  naturally suggested by
these facts.
  64. Numerous incidents occurred, during the
early prevalence of the pestilence in this city,
proving the channels  or modes of its  exten-
sion  ; but  it is sufficient to notice  one or two
of them only.  The H6tel Dieu contained be-
tween  three and four hundred foundlings of
both  sexes, besides the officers and attendants.
A woman from the Rue de l'Escale presented
herself at this hospital, stating that she was
ill with a common fever; for in  this pestilence,
as in many others, the first cases were not ad-
mitted to have been the  plague, and numerous
misrepresentations were made respecting them;
and  hence the unrestrained progress  of the
mischief, and the loss of much valuable time,
or, rather, the entire loss of that time, in which
alone it could have been limited.   She was ta-
ken in  and conducted to  her bed by two maid-
servants.   The  next  day the  two  maid-ser-
vants fell ill and died in a few hours.   The day
after, the matron, who had visited the patient,
fell ill,  and died almost as suddenly.   The dis-
ease  spread with amazing rapidity, and de-
stroyed all the children, with every person be-
longing to  the house, excepting about  thirty,
and these  took the infection, but recovered.
  65. An  official report transmitted  to Paris
stated that the physicians and surgeons of Mar-
seilles  unanimously declared, " that when one
person in a family was attacked and died, the
rest  soon  underwent the same fate, insomuch
that  there were  instances of families entirely
destroyed  in that manner; and if any one of
an infected family fled to another house, the
contagion  accompanied  him, and proved fatal
to the  family where he had taken refuge."
   66. The removal and interment of the dead,
as the pestilence extended, were  among the
greatest difficulties experienced by the authori-
ties  of this city.  At  first, beggars and vaga-
bonds were employed in  casting away the dead
bodies  ; but these soon were seized by the dis-
temper, " and those who followed them in their
offices  soon  followed  them  in their  fate."
Convicts were then supplied from  the galleys
to carry away the dead, and promised their lib-
erty if they survived.  The first supply amount-
ed to 133,  but these perished to a man in less
than  a  week.  A hundred were next granted,
and in  six days they were reduced to twelve.
The  population of Marseilles was calculated, at
the outbreak of the pestilence, at about  90,000
souls ;  but many left the  city when the distem-
per began  to spread.  Upward of 40,000  per-
sons died ; so that, comprising those who recov-
ered  and who left the city, very few escaped an
attack.  But this pestilence was carried to Aix,
Toulon, and various other places in Provence,
in which upward of 80,000 persons died of it.
  67. While the horrors attendant  upon this
 pestilence were going on, intercourse was al-
 most unrestrained, excepting in some places in
 which precautions were used to prevent com-
 munication with the infected, and which either
 escaped altogether,  or in a great degree,  ac-
 cording to the strictness with which the pre-
 cautions were observed.  When the distemper
 was  admitted  to  be the plague,  the  galleys
 were detached from  the shore, anchored in  the
 middle of the  port,  and separated from other
 vessels.  Three hospitals were appointed ; one
 for the crews, the others for  the convicts.   In
 the former, those infected with the plague were
 placed ; in the latter, those labouring under oth-
 er diseases were kept.   To the third, all  doubt-
 ful cases were sent.   The population  of  the
 galleys amounted to 10,000, yet 1300 persons
 only were attacked,  and about half recovered.
' There are various ways in which precautions
 against  intercourse with infected persons, and
 against the introduction of infected substances,
 may have been evaded  without detection ;  but
 there  is a very remarkable difference between
 the  numbers  attacked  where no precautions
 were taken and where  precautions were adopt-
 ed, although they were most  probably partially
 evaded.  A certificate  given  by the Bishop of
 Marseilles states  that  "the plague has  not
 penetrated into the religious communities who
 have  had no  communications  with  persons
 abroad, and who have used the precautions  ne-
 cessary to protect them ;" and another, given
 by the first sheriff of this city, states that "the
 families which were  shut up and had not com-
 municated abroad, particularly the nunneries,
 had been protected against this scourge, which
 was introduced into  some of them by commu-
 nications with strange  persons."
   68. De MaErtens, a  physician of eminence
 practicing in Moscow, has given a full account
 of the  plague which visited that city in  1771,
 after an absence of a century and a half.   War
 commenced in 1769  between Russia and Tur-
 key ; the next year the  plague  appeared  in
 Wallachia and Moldavia ; and many Russians
 died of it in the city of Yassy.  The following
 summer it entered Poland, and was conveyed
 to Kiow, where it carried off 4000 persons.  A^t
 first, all communication was cut off between
 Kiow and Moscow ;  but a colonel and two sol-
 diers left Choczin, where the plague was  ra-
 ging, for Moscow.   The colonel  died  on  the
 road, but the two soldiers reached Moscow,
 were taken ill at the military hospital, and died
 there soon after their  arrival.  This occurred
 in November,  1770.  Towards the end of this
 month  the demonstrator of anatomy  at this
 hospital was attacked  by this distemper, and
 died on the third day.  The male attendants
 lived with their families in two chambers sep-
 arated from the others; and  in one of these
 eleven persons fell ill in a very short time with
 a putrid fever, attended by petechiae in  some,
 and  by carbuncles or  buboes in others, and
 most of them died from the third to the fifth
 day.  The same distemper attacked the attend-
 ants  residing  in the other chamber.  On  the
 22d of December eleven physicians assembled,
 and ten out of the eleven declared the disease
 to be the plague.  The hospital was closed, and
 a military guard interrupted all communication.
 Those  affected by the distemper, with their
 wives and children,  were separated  from  the 
232
PESTILENCE,  SEPTIC  OR GLANDULAR—Causes  of  Plague.
rest, and the clothes and moveables of those who
had died of the disease, and who were still ill
with it, were burned.  The weather became in-
tensely cold, and the traces of infection  were
lost in the hospital and in the city.  The  com-
munications with  the  hospital were opened in
February, 1771, but on the 11th of March the
physicians were again  convoked,  and Dr. Ya-
gelsky stated that eight persons  had been at-
tacked in a large manufactory of military cloth-
ing, containing 3000 persons, situated in the
centre of the city,  with symptoms  similar to
those observed in the patients in the hospital
three months  before.   The  work-people de-
clared that in the beginning of January a wom-
an who had a tumour in the cheek had gone to
the home of one of them, and  that the disease
had afterward spread in the manufactory, and
117 persons had died of it.   The manufactory
was closed and guarded ; nevertheless, several
of the work-people escaped on the  following
night by  the windows.  Precautions were ta-
ken to prevent the spread of the distemper, and
an abatement of it became manifest;  but these
precautions were  relaxed, and the progress of
the malady became  rapid.   " Towards the end
of July the mortality  amounted to  about 200
daily ; by the  middle of August, to 400; to-
wards the end of the same month, to 600; at
the beginning of September, to 700 ;  some days
afterward, to 800 ;  and at  length to 1000 dai-
ly.   On the evening of the 5th of September
the populace rose, broke open the hospitals, put
an end to the quarantine, and  restored the re-
ligious ceremonies used for the sick ; the ima-
ges of saints were carried with great pomp to
the sick, and kissed by every one successively.
The people, according to ancient  custom, em-
braced the dead,  and buried  them within the
city, declaring that human precautions  were
odious to the Divinity ; they hunted  down the
poor  physicians,  broke  their  furniture,  and
sacked their houses.   This riot lasted only a
few days, but it was followed by the addition
of two  or three hundred  to the daily  mor-
tality.  Almost all the priests  perished."   The
pestilence began to decline in October, and at
length ceased with the end of the year.   The
mortality was estimated at more  than 80,000,
exclusive of that  in the towns and villages to
which the distemper had extended.  In these
the deaths were  upward of 20,000; but  they
suffered much less, because in most places the
inhabitants, taught  by the miserable example
of Moscow, readily permitted precautions  to be
used.  Criminals  were  employed to bury the
dead, and when these perished, the poor  were
hired to do it, and  provided with  covering of
oil-cloth  to protect them ;  but these, and the
advice given them, were neglected.  Most of
them were attacked about the fourth or fifth
day, and most of them perished.  The plague
was most fatal to the poor ; nobles, gentlemen,
and merchants generally escaping, owing to the
precautions they had taken.   Dr. De Mortens
states that the distemper was communicated
only by the touch of infected persons or clothes,
and that the physicians, who only inspected the
patients, and who touched neither the bodies,
nor the clothes, nor beds of the sick, generally
escaped, but that a number  died of the  sur-
geons and assistant surgeons who touched the
patients.
  69.  While the pestilence was ravaging the
city, the Foundling Hospital afforded a remark-
able proof of the salutary effects of seclusion.
It contained 1000 children and 400 adults.  AH
communication was cut off, and the plague nev-
er entered the building.  One night  four at-
tendants and as many soldiers escaped from it,
and on their return were attacked by the mal-
ady ;  but they were separated from the rest of
the house, and no others were infected.  The
contrast between the  fate of this hospital and
that of the foundling hospital at Marseilles (fj
64) cannot fail to strike the reader.
  70.  The plague raged in Cyprus from April,
1759,  until June, 1760.   Dr. Russell states
that it was introduced by a large Turkish ves-
sel from Alexandria that was wrecked on the
island in the month  of A^pril; and of the crew
who were saved  a great part were  infected
with the plague ; and that, while numerous ca-
ses were occurring  in consequence at  Limsol
and the vicinity, where the vessel was wreck-
ed,  a  ship from Damietta arrived at  Larnica
and landed, on the  22d of May, infected pas-
sengers and sailors, who lodged in the houses
and communicated  freely with the natives.
.Mother  vessel from  the same  place arrived
some  time afterward with infected persons on
board.  During the hot months of July, August,
and September little  was heard of the pesti-
lence, " but it continued lurking in these parts,
showing itself only by starts," until October,
when  it greatly increased in those places where
it had been introduced, and  in the adjoining
villages.   The plague soon afterward appeared
at Nicosia, to which place the annual fair had
drawn a great concourse of people  from most
parts of the island.  But the nature of the dis-
temper was concealed,  and  the bodies were
buried during  the night to prevent alarm.  It
increased  rapidly from this time, and destroyed
about a third  of the population of  the island.
The convents and European merchants observ-
ed seclusion, and wherever this precaution was
strictly observed the distemper did not appear.
  71.  Dr. Russell, in his account of the plague,
which raged  in Syria during 1759, and three
following years, states that it appeared first at
Saffat in October, and had been brought there
by some infected Jews,  who  came  from Alex-
andria.   It afterward spread to Sidon, Acre,
Latakea, and Tripoli,  and prevailed greatly in
these  places  and the vicinity during the first
six months of 1760.   " Jerusalem received the
contagion in  January, and in the beginning of
March it  reached Damascus; in both which
places, as well as in the smaller towns and vil-
lages  of Palestine, it made dreadful havoc du-
ring the subsequent months."  Dr. Russell,
who was  residing at  Aleppo, remarks that at
this time  an  extensive  commerce  existed be-
tween this city and  infected places, and a total
inattention to the means of prevention opened
many channels for the reception of the distem-
per.  Accordingly, the introduction of it soon
took place; and in  the following way: Three
Turkish merchants, who had come in the Da-
mascus caravan, were lodged in a public khan,
near the British consulary house, and after  a
stay of a few days they set out from Aleppo on
the 16th of May.  Next day the porter of the
khan, an Armenian, and his son  were sudden-
ly taken ill, and soon afterward the  brother of 
PESTILENCE, SEPTIC OR GLANDULAR—Causes of Plague.
233
the porter.  The son died on the 19th.  These
men  had been in  attendance  on the Turkish
strangers, and had assisted in moving and pack-
ing their baggage.   Dr. Russell visited these
two men on the 21st, and  ascertained the ex-
istence of the plague, of which they died on the
22d and 23d.  Towards the end of this month
caravans arrived from Jerusalem and  Damas-
cus, in which were  infected persons.   These
were, under various pretexts, refused admis-
sion into the  city, but they encamped  without
the walls, and buried several  persons during
their  stay; but several  individuals  found pri-
vate lodgings in the town.   The pestilence be-
gan now to prevail both in the suburbs and
within the city ; and the cases were  numerous
early in June ; but it did not become very prev-
alent, and soon afterward subsided, although it
extended to the villages  scattered between the
neighbouring  mountains, and to various Arab
tribes, and to the Bedouins, among whom it
was remarkably fatal.  During 1761 and 1762
the distemper continued, with varying  degrees
of prevalence and  fatality, throughout  this
country.  It became epidemic  in these years,
during May, June, and July, in Aleppo, and was
most  fatal in the last year; during the  three
years of its prevalence in  Syria, the infection
appeared to spread with varying degrees of ra-
pidity in different places.   While only strag-
gling  cases were observed in  Aleppo, it was
rapid  in its progress among the Arab tribes in
the vicinity;  and when  less prevalent among
these, it extended  more generally among the
Turkish  inhabitants  of  Aleppo.   The higher
classes  and the merchants, especially Euro-
peans, used more or less strict precautions, or
entirely shut themselves up,  and escaped in
every instance where the precautions were
strictly observed.
  72.  Mr. Jackson, in his account of the Em-
pire of Morocco, states that the plague has vis-
ited  this country about once in every twenty
years ; and that the visitation of 1799 was more
fatal than any previously known.   It  first  ap-
peared in Old Fez,  and was imputed to the im-
portation  of  infected goods from the Levant,
by some ; and to the destruction  of immense
swarms of locusts, which  had infested West
Barhary during seven years, and been  immedi-
ately  followed  by  epidemic smallpox, which
had preceded the plague.  This pestilence per-
vaded the whole empire, and  in many places
did not leave persons living sufficient to bury
the dead.  Mr. Jackson resided at Mogadore
during its fatal prevalence in that  city.  He
States that the European merchants shut them-
selves up in their respective houses, as is  the
practice in the Levant, and escaped the  pesti-
lence ; but that he  " did not take this precau-
tion, but occasionally rode out to take exer-
cise."   He remarks that his daily observations
convinced him  that  the distemper  "was not
caught by approach, unless that approach was
accompanied  by an inhaling of the  breath, or
by touching the infected  person."  (P. 278.)
He farther adds that, during the epidemic, he
took " no farther precaution than that of sep-
aration, carefully avoiding to touch the hand
or inhale the breath;"  and he is of opinion
that  the plague  is  not  produced by  the  at-
mosphere, but is "caught solely  by touching
infected substances, or by  inhaling the breath
of those who are diseased."  It has been said,
he observes, " that the cultivation of a country,
the draining of the lands, and  other agricultu-
ral  improvements, tend to eradicate or dimin-
ish  the plague ; but we have seen countries de-
populated where there was no  morass or stag-
nant water for many days' journey, nor even a
tree to impede the current of air, or  a town,
nor anything but encampments of Arabs, who
procured water from wells of great depth, and
inhabited plains so extensive and uniform as to
resemble the sea."  (P. 279.)
  73. The plague of Malta, in 1813, is rendered
memorable by the proofs of the introduction of
the infection, and by the measures used to ar-
rest it, founded on a belief of its infectious and
contagious nature.  The history of this plague
has been recorded by Calvert, Faulkner, Tul-
ly, and Hennen, all  of whom  agree as  to the
fact of the introduction of the distemper.  The
pestilence had not appeared in Valetta for 137
years,  and was now introduced  by  a vessel
from Alexandria, where it was then prevailing.
Two sailors had died of it on the passage, and
after the arrival of this ship, the captain and his
servant; soon afterward, a smuggler of the name
of Borg, his wife, children,  and  father, were
seized  with it, and all died; then a  midwife
who attended the wife of Borg in the prema-
ture confinement caused by the plague, a young
woman who slept in her house, a kinsman who
entered her chamber and touched her body, the
child of a master  of a  wine-house near  the
quarantine  harbour, where, among others, the
servants  of the health-office who guarded the
infected vessel in the harbour, and some of the
guards of this vessel themselves, with whom
Borg, the  smuggler, had frequent  dealings.
While the distemper was attacking in succes-
sion the  above-mentioned persons, it appears
by the  official statements  that no other individ-
uals were affected by it in any other part  of
Malta.   It  is admitted that there was no posi-
tive evidence beyond rumour  of communica-
tions between  this vessel and Borg  and  his
family; but what evidence can  be expected in
this and similar cases of undetected smuggling 1
Rumour in such cases is often near the truth ;
and that it should be true in this, as to the se-
cret conveyance of articles  from the  infected
ship, is extremely probable.   The facts of Mal-
ta having been free from plague for 137 years ;
the arrival of an  infected vessel, from an  in-
fected port, at the principal city of the island;
and the almost immediate appearance of this
pestilence after the  arrival of this vessel, are
of themselves demonstrative of the introduc-
tion of it,  without the particulars connected
with the communications between the vessel
and the city being proved—particulars, from
their nature, and the  circumstances of their oc-
currence, that cannot admit of proof,  as being
secret;  and  of a nature which, if  detected,
would  have led to the severe punishment  of
those engaged in them.  But it is not the mere
introduction  from  a  distance  that proves  the
infectious nature  of  a distemper, but  also  the
subsequent diffusion of it, and the means found
to be successful in guarding against it.
  74. At first the  malady was confined to the
crew of the vessel which came from  Alexan-
dria, and to Borg's family and those who had
communicated with them; but it soon after- 
234          PESTILENCE, SEPTIC OR GLANDULAR—Causes of Plague.
ward appeared in Ihe town of Valetta.  At this
time the medical men contended that the mal-
ady was not  the plague ;  and those  attacked
concealed their sickness from fear of  being re-
moved to the lazaretto, clamoured against pre-
cautions, and did all they could to thwart them.
Hence the distemper spread not only through
Valetta, Floriana, and the  adjoining towns, but
also to many villages.
  75.  The efficacy of strict seclusionwas demon-
strated by some striking instances  during the
prevalence of the distemper in  Malta.   The
Augustine Convent stands near the top of one
of the main streets  of Valetta.   When  the
plague appeared, the strictest precautions were
used  to prevent all communications  with  the
town ; but a servant went  into a part of the
town  where it prevailed, and purchased clothes
supposed to be infected.  Soon after his return
he confessed what  he had done; he was  im-
mediately shut up, with one  of the brotherhood
who volunteered to  attend him.   Both of them
were seized and died  of the distemper, but no
other person  in the convent suffered.  " When
the plague was in Malta in  1675, Cavallino,
who described  it, states  that all public estab-
lishments which cautiously shunned intercourse
with the community, enjoyed perfect exemption
from the disease ; as did the prisons and mon-
asteries, besides all the vessels  in the harbour.
In the late plague it was the same ; the hospi-
tal of St. John of Jerusalem, the prison, and
several public offices, and private houses, which
early  adopted, and steadily kept up,  a rigid sys-
tem of insulation, were not less fortunate."
  76. A large building in Valetta had its ground
floor  divided into seven separate apartments,
occupied by as  many Maltese families ; and its
upper stories used as a military hospital for pa-
tients affected with common diseases.  During
the plague of 1813 the ground floor was  pene-
trated by it; the inhabitants of  four of  these
apartments were destroyed by it, and two only
of each  family escaped  in  the other three.
While this was going on  below, the  sick ten-
ants of the upper stories were shut in, all com-
munication was cut off, and every individual
among them escaped the  pestilence, although
it was raging in the houses around, and  pene-
trating  from the lower to  the upper stories.
Dr. Greaves, whose house  was  within a few
feet  of this hospital,  related this fact to  Dr.
M'Lean, at Valetta, and led him  over the hos-
pital,  but no mention is made of it  by this un-
candid writer and ignorant physician.  I  say
this from  personal knowledge.
  77. The anti-infectionists  contend that  the
plague of Malta was not introduced by the ship
which arrived from  Alexandria very shortly be-
fore its outbreak,  but from " a  noxious  state
of the air;"  and it  has been shown, at other
places,  that  they  attribute  the  choleric and
haemagastric pestilences also to noxious states
of the air ; but  how is it that this noxious air,
which plays so  important a part in the produc-
tion of plague according to  them, did not pro-
duce one  of the other pestilences^   We have
Been that these three several forms  of pesti-
lence have ravaged the same places at different
times; and, taking it  for granted that they all
arise from " a noxious state of the air," as the
anti-infectionists would have us to believe, in
what does the  noxious air  producing the one
pestilence differ from that producing the others!
it  has now been shown by numerous proofs,
and many more may be, and some will be, far-
ther adduced, that,  while the  distemper was
depopulating numerous houses and streets, oth-
er houses and institutions, completely surround-
ed by these houses  and  streets, remained en-
tirely uninfected, by observing the strictest sep-
aration.  If the  mischief was solely in the air,
how came  these isolated places to escape, not
only during the  prevalence of plague, but also
during the prevalence of the other two pesti-
lences,  as  shown in the appropriate  places.
And, moreover,  how came " the noxious state
of the air," causing the  plague of Malta, after
137 years, the  plague of Moscow,  after 150
years,  and the plague of Marseilles, after 70
years, to occur at such distant  periods, and no
indications of its existence in the intervals to
have appeared ?  And how can the anti-infec-
tionists prove this " noxious state of the air,"
this undefined, this supposititious, this airy, this
baseless entity or non-entity, and account for
the wonderful reappearance  of it, after so very
many years, just at  the moment  most desired
to serve as an argument against  the introduc-
tion of the  plague by an infected vessel .  And,
again, from whence came the " noxious  state
of the air," which, according to the anti-infec-
tionists, produced the choleric  pestilence, and
which had  never previously  existed, inasmuch
as its imputed effects, this particular distemper,
was not known to have  ever appeared before
1817.
   78. Dr. Mackenzie resided at  Constantino-
ple and Smyrna for about twenty years, in the
middle of the last century ; and during that pe-
riod scarcely  a  year passed without some ap-
pearance of the plague in one or  both of these
cities.   He communicated his observations on
the distemper to Dr. Mead and Dr. Clephank,
which were published in  the forty-seventh vol-
ume of the  " Philosophical Transactions." The
plague raged with great violence  at Constanti-
nople in 1751, and destroyed about 150,000 per-
sons ;  and  Dr. Mackenzie, who was then re-
siding in this city, remarked respecting it, that
" he could  see no other apparent cause of the
virulence of the disease  this year, besides the
occasion of greater communication.  In  the
months  of February, March, April, and May
last, the distemper was so strong at Cairo, as
appears by  letters from the English consul there,
that no doors were  opened  for three months.
In the mean  time there arrived  here, in May
last, four ships laden with Cairo goods, which
goods and men being landed, spread the infec-
tion over all the city at once, after which one
conveyed it to another by contact.  In  the vil-
lage where we lived there died  only sixty per-
sons of the plague.   The French ambassador's
palace, next door to us in the village, wa3 in-
fected, because five of his people went at mid-
night to a  bawdy-house,  where the father
Demetry, the mother, and daughter  had  the
plague, and died of it afterward, all three ; so
that two of his excellency's servants were in-
fected by them, one of whom died, and the other
recovered and is still living, after taking a vom-
it, some doses of the bark mixed with snake-
roOt and Venice treacle, by my advice.   We
found this  last time, and upon all such occa-
sions, that  whoever kept their door shut ran 
PESTILENCE, SEPTIC OR GL.
ANDULBR—Causes  of Plague.          235
no risk, even if the plague were in the next
house ; and  the contact was easily traced in
all the accidents which happened among the
Franks."
  79.  Samolowitz, who had extensive experi-
ence of the plague in Poland, Moldavia, Walla-
chia, and, lastly, in the epidemic of Moscow,
states that it is certain that this distemper is
propagated by contact;  and Orr/eus, who was
sent by the  Empress Catharine of  Russia to
advise during the plagues at Yassy and Mos-
cow, remarks that the  most common mode of
contracting the disease was by contact.   When
Mr. Howard went, in  1785, to visit the chief
lazarettoes in France and Italy, he carried with
him a set of questions  concerning the plague,
drawn up by Dr.  Aiken and Dr. Jebb, which
were to be submitted to the most experienced
practitioners in the places which  he  visited.
On his return, Dr. Aiken methodized and abridg-
ed the answers, and the result  is given in the
celebrated work on the  Lazarettoes of Europe.
"They all,"  says  Mr. Howard, "in the most
explicit manner, concur  in  representing the
plague as a contagious  disease, communicated
by near approach to, or  actual contact with, in-
fected persons or things."
  80. During the war, at the end of the last and
commencement of the present century, the med-
ical officers  of both the French  and English
armies had  numerous occasions  of observing
the plague, and they almost unanimously con-
cluded that it was a contagious disease.   Even
Dr.  Bancroft, who  strenuously  contended
against the infectious nature of the haemagas-
tric pestilence, and who was present with the
English army during a part of the Egyptian
campaign, states that " the facts which prove
the necessity of actual contact with some in-
fected person or thing to communicate  the
plague, are so numerous, and many of them so
notorious, that it  must  be unnecessary for me
to enter upon a detail of them, after what Dr.
Russell and others have published, and after
the experience  of the  British  army in Egypt,
which invariably  demonstrated this necessity,
by showing  that all those who  avoided contact
invariably escaped the disease, while those who
did otherwise in suitable conditions, were very
generally infected.  Nor was there, so far as I
have been able to discover, any instance, in the
French-Egyptian  army, of a communication of
the disease without contact, though the physi-
cians to that army who have written  on the
subject do not, I believe,  positively assert the
impossibility of such communication."
  81. Sir James M'Grigor, physician to the In-
dian army in Egypt during the Egyptian cam-
paign, in his medical sketches of that expedi-
tion, gives the following account of the arrange-
ments at the pest-houses, and their results :
" In the pest-houses of the army thirteen med-
ical gentlemen did duty, who in the Indian army
might be said to  have  had the  post of honour.
In order to take from  our medical  gentlemen,
in the pest-houses, some of the most dangerous
part of the duty, it was my wish  to  procure
some of the Greek doctors of the country to re-
side in the pest-houses,  to feel the pulses there,
draw blood,  open  and dress buboes, &c.  The
most diligent search was made for those peo-
ple, and very high pay  was promised to them,
but we could tempt none of them to live in our
pest-houses :  a plain proof of the opinion which
they entertain of the contagious nature of the
disease.  The thirteen gentlemen first  men-
tioned were those only that were directly in
the way of contagion, for it became their duty
to come in contact with the infected, and  seven
of them caught the infection, and four died.  To
the atmosphere of the disease all the medical
gentlemen of the army were exposed, as they
saw and examined the cases in  the  first in-
stance ; but, except from actual contact, there
never appeared to be any danger."
  82. The medical officers of the French army
came to similar conclusions.   Desgenettes, in
his Histoire Medicale de  VArmee d'Orient, thus
sums up his  opinion on  the  subject of the
plague: "The plague is evidently contagious,
but the conditions of the transmission of this
contagion are not more exactly known than its
specific nature.   The dead  body has not ap-
peared to transmit it—the  animal body in  a
heated state, and still more in a state  of febrile
moisture, has appeared to communicate it more
easily*; the contagion has been known to cease
in passing  from one river to another of the
Nile ; a simple trench made before a camp has
been known to stop its ravages; and on obser-
vations of this kind is founded the useful insu-
lation of the Franks,  the practice of which has
been sufficiently detailed  by different travel-
lers."
  83. Baron Larrey states a similar opinion :
" But however strong may have been these af-
fections (moral), their effects cannot be com-
pared to those which  resulted from the commu-
nication of the healthy with  the sick, or  to the
effects of contact with contaminated objects.
We may be convinced of this truth by the rav-
ages which the plague made in the  year 9 (1801)
among the Fatalist Mussulmans.  It  were to
be wished that, on the first  days  of the inva-
sion of the plague, its true character had been
presented to  the army.   This would have di-
minished the  number of victims; instead of
which the soldier,  imbued  with the opinion
which was at first propagated, that  this dis-
ease was not pestilential, did not hesitate to
seize and wear the effects of his companions
dead of the plague.   The pestilential  germ de-
veloped  itself in  these individuals, who often
sunk under the same fate.  It was only when
they had gained  a perfect knowledge of this
disease,  that  many  preserved themselves by
the precautions which were  indicated."
   84. Dr. Sotira, another of the physicians of
the French army in Egypt, relates the follow-
ing  striking  circumstance:  " In  the  seventh
year of the French republic  about eighty med-
ical officers died of the plague.  In consequence
of this mortality, an order was issued to em-
ploy Turkish  barbers in  the pest-houses, to
dress  the patients,  and  to  undertake all the
medical treatment which required actual con-
tact.   The result was,  that during  the next
two years only twelve of the medical officers
died of the plague ;  but half the  Turkish bar-
bers caught it."   I now arrive at
  85. B. The Opinions of contemporary Writers
as to the Infectious Nature of the Plague.—a. The
French government,  with the view of causing
an alteration  of the quarantine laws, lately re-
ferred the consideration of the communicabili-
ty of this pestilence  to the Royal Academy of 
238           PESTILENCE, SEPTIC  OR GLANDULAR—Causes  of Plague.
Paris ; and this body appointed a commission
to inquire  into  the matter.   This commission
has  published its report, and with it numerous
documents from medical men who have served
in Egypt and Syria  during  the last twenty or
twenty-five years.  Certain of these documents
are  answers to questions which were sent to
the British consul in Egypt  by the foreign min-
ister ; and others are essays on the subjects in
question  by  various  medical men attached to
the army and civil establishment of the govern-
or of that  country.   From these the Academy
has  drawn  up  its report;  which, however,  is
of much  less importance and  interest than the
papers on which it is founded.  The  opinions
conveyed in all these  papers  agree as to the
communicability of this distemper from person
to person ; they differ  merely  as to the modes
of communication  and  the circumstances fa-
vouring  and  preventing infection.*   It is thus
  * It should be kept in recollection that French writers
limit the term contagion to the communication of a disease
from the sick to the healthy  by immediate contact,  and
that they apply the  term infection to the  transmission of
disease by miasms proceeding from the sick, and contami-
nating the air respired by the healthy.   In many of the
writings of French  pathologists, " Foyers Epidemiques,"
epidemic for.i, influences or centres, play a very prominent
part; and, according to many, no infectious disease can ex-
tend without this epidemic centre or influence be present.
Some even suppose  that the epidemic influence is itself
the infecting agent; and  they, with many others, argue
that this influence, as well as all emanations from the soil,
from matters decaying or putrefying in or on the  surface of
the earth, and from the bodies of the  sick, are severally in-
fectants, without, however, distinguishing between each,
and confining, as British pathologists have uniformly, the
word infection to the spreading of a disease from the sick
to the healthy by means of emanations proceeding from the
former, and producing and perpetuating in the  latter the
same disease, possessing the same property of disseminating
and perpetuating itself.  In this report of the Academy, as
well as in  some of  the papers on which  it is based, the
"foyer epidemique" has a most prominent place assigned to
it.  If a case of plague occurs without spreading to others
—if the several circumstances preventing the extension of
the distemper be present or are observed—if a free ventila-
tion of the sick, or of their effects, <fcc, be enforced—if the
sick be not approached, and other means of prevention be
observed—if  those  communicating with  the  infected be
 rotected by a previous attack of the  distemper—if the air
 e pure, dry, very cold, or very hot—if, in short, the  cir-
cumstances favouring the extension of the malady are not
present, then the occasional appearance of it (as  in the in-
stance of smallpox occurring in solitary cases when it is not
epidemic) is said to be sporadic or endemic : but when va-
rious filiations of the distemper are traced from the person
or persons  first infected, to various  streets, or to distant
parts of a town—when a person becomes infected in a par-
ticular house, and the attendants or  friends from different
parts have  left him, and  convey the  distemper to their
homes and to their attendants, and these  latter to others,
then, according to the reporters of the Academy and many
of the French-Egyptian physicians, a "foyer epidemique"
is kindled, and is breaking out in various  places.  A poor
devil of the rational  school of physic may have some idea
of the manner in which a humid, still air, close apartments
and streets, imperfect ventilation, &c, favour the concen-
tration of an animal effluvium proceeding from  the sick,
and its operation on the healthy, as well as heighten the
predisposition of the latter to be infected.  He even admits
that these conditions may so alter the electro-motive states
not only of the air, but also of animal bodies, and of other
objects placed on the earth's surface, at the particular pla-
ces where  they occur, as thereby to heighten the effects
otherwise produced by them.  But the " foyer epidemique"
is beyond his comprehension, unless it means something re-
sembling what 1 have now endeavoured to explain.  If it is
anything else, it is only a term employed to conceal an ig-
norance which would have been better candidly confessed.
One thing cannot be disputed, and  this is, that the " foyer
epidemique" plays a very harlequin part; it is here, there,
and everywhere, but not at the same  time, at least at first.
It exists in a given circumference, and not in the centre ;
or in certain radii, and neither at the centre nor at the cir-
cumference ;  and yet it admits not of recognition  but by its
effects.  It is the supposed source of plague, of pestilen-
tial cholera, and of  pestilential yellow fever—these three
stated by the reporters that nearly all the phy-
sicians  in Egypt  (there are  considerably up-
ward of a hundred  French and  Italian physi-
cians in  this country) believe in  the transmis-
sion of the plague by means of the emanations
proceeding from the bodies of plague patients ;
and that Dr. Grassi, physician  to the lazaretto
at Alexandria, alone espouses  the doctrine of
the  communication  of the distemper by imme-
diate or mediate contact only, and without the
interposing medium of the air;  and they add
that the Egyptian  physicians consider that a
prolonged stay in the chambers of those affect-
ed is particularly dangerous,  and the more so
the  more that ventilation is neglected.
  86.  Dr.  Grassi, who has written a long me-
moir on  the dissemination of  the plague, has
had an  experience  of twenty-nine years  in
Egypt and Syria, during which  time his oppor-
tunities of observing this pestilence, especially
as physician to the  lazaretto, have been great
beyond   all  others.   He  adduces numerous
proofs in support of his opinion ;  but Dr. Clot-
bey and  some others contend,  in opposition to
him, that they would not have  taken place, or,
in other  words,  the same results would  not
have followed the circumstances  adduced, if
observed at other periods, or in  other places,
than those of epidemic  influence.  The facts
are  so numerous and so  well authenticated of
the  communication of the distemper, that they
cannot be denied; but those who espouse the
doctrine  of conditional  infection, as many of
the  Egypto-European physicians  appear to do,
contend that the infectious property exists only
in respect of the epidemic, and not of the spo-
radic or endemic malady ; and that if the epi-
demic  influence  did  not  exist,  no  infection
would take place.   According to  this view, the
distemper  cannot spread by infection without
the  epidemic circle ;  and when  the infection is
conveyed to a distance  by persons or clothes,
it cannot propagate itself unless there be exist-
ing at the time and place an epidemic influence

great pestilences being very generally attributed to this
cause by our neighbours.  Now, as there are three pesti-
lences, there must necessarily be, according to this view,
also three different " foyers epidemiques ;" fur each specifia
malady must have a  specific "• foyer" for its source.  With-
out, however, inquiring into the origin and nature of these
"foyers"—for such inquiry is never thought of by them, it
being quite sufficient to assume their existence—it must he
inferred that they are most unaccountable things, seeing
that  they possess neither length, breadth,  nor thicknesi,
nor other material characteristics, and yet produce mate-
rial effects ; that they are neither recognised nor recognisa-
ble, and yet they destroy large portions of  the human race ;
that  their existence is a hypothesis, a supposition, and yet
they  produce ruin and devastation ; that their hypothetical
presence is only for a few weeks or months, and then, after
many hundreds of years,  never again to return, or then af-
ter short intervals, according to the manner of their recep-
tion.  How veiy odd  is  their  occurrence!  In one yeaj
there was a "foyer  epidemique." viz.,  that of pestilential
cholera, which  visited the countries of the Levant, and,
among very many other places, Paris in particular, whert
the doctrine of " foyers" is so much in vogue; yet, in ilie
following two years  another " foyer epidemique," namely,
that of plague, followed the one of pestilential cholera, tns
latter emulating the  former in its destructive powers, us if
enraged at the usurpation of a " foyer" never before known.
Believing that there are certain conditions of the atmo-
sphere favouring more or less the spread  of infectious dis-
eases, on the one hand, and restraining it on the other,  I
cannot subscribe to the all-efficient and  absorbing ''foyers
epidemiques" of our  neighbours, nor attempt to shelter my
ignorance by a constant recurrence to a term which either
means something appreciable and determinate, as in the
light in which I would view it; or which ia anything or
nothing as it may suit an hypothesis, subserve a purpose,
conceal a sophism, or mask a design. 
PESTILENCE, SEPTIC OR GLa\NDULAR—Causes of Plague.          237
 favourable to this effect.   In what this influ-
 ence consists is not shown.   It is not admitted
 to be merely a humid, stagnant, or impure air,
 as this  state of the  atmosphere is frequently
 observed without the distemper becoming prev-
 alent ; it is, therefore, believed by the support-
 ers of this doctrine, that there  must be some
 other superadded property, constituting,  with
 or without the other properties of humidity,
 stillness, and a certain range of temperature,
 the epidemic influence in question ; and that it
 is developed generally after lengthened inter-
 vals, or after terms  of ten, fifteen, or twenty
 years, the terms being of different durations in
 different countries.  In tracing the filiations of
 this influence according  to these writers, nu-
 merous and singular  vagaries are usually ob-
 served, especially as respects its attachment to
 certain persons and places, and its aversion to
 others.   These filiations proceed sometimes in
 a hop,  step, and jump  manner, and straight
 ahead ; then  zigzag; now circuitously,  next
 centrically, afterward eccentrically;  but  in
 whatever way they  shoot  forth, they show a
 remarkable respect for certain places and per-
 sons, more  particularly for  those who  shut
 them out or who keep out of their way.  Now,
 instead of attributing, with the abettors of the
 all-sufficiency of epidemic influence, the oddi-
 ties so remarkable in the spread of this pesti-
 lence, to this influence solely, I consider  that,
 when viewed in a proper light,  there are nei-
 ther vagaries nor oddities  to be  recognised ;
 but merely the communication of the infection
 from person to person, favoured by proximity,
 and a temperate, humid, and still condition of
 the atmosphere; and that places  and persons
 are exempted from it, according as the former
 may shut it out, or be out of its way; as it is
 conveyed in the person or in the clothes worn
 by the infected, or as the  latter  may be pro-
 tected by a former attack, or be but little sus-
 ceptible of the infection.
 I 87. Much of the skepticism  which has re-
 cently appeared  in the East as to the infec-
 tious nature of this pestilence is  to be attrib-
 uted to the preconceived ideas entertained by
 the  young French and Italian surgeons and
 physicians who have  entered into  the serviee
 of the Pacha of Egypt, and who have thought
 it a most distinguished feat to brave the  dan-
 gers, as well as to oppose the doctrine,  of con-
 tagion and infection.  The experienced Dr.
 Grassi states, with reference to this fact, that
 the champions of non-contagion disseminated
 an error which  soon brought destruction on
 themselves and on many who had communica-
 tion with them ;  that, in 1843—a year in which
 the distemper does  not  appear to have  been
 very prevalent, unless in Cairo—numerous in-
 stances  of contagion were furnished in some
 of the provinces of Lower  Egypt, of which he
 adduces a few, showing the consequences of a
 disbelief in this property, on the part of those
 who ought to have known the truth, and to  have
 acted accordingly; that,  owing to this cause,
 the plague was introduced into several  regi-
 ments, the surgeons of which were anti-conta-
 gionists; and that those surgeons, and many of
 those committed to  their care, were thereby
 sacrificed.  Dr. Mareschi, he adds, physician
 to the 5th regiment,  fell ill and died at Man-
sour.  He was attended by Dr. Certani, of the
3d regiment, and the plague commenced in both
regiments.   The apothecary became infected,
and  died.  Dr. Certani persisted in  denying
the infectious nature of the distemper, and pur-
chased the carpet used by an officer in his regi-
ment who had died of it.   He slept on this car-
pet, but he never again arose from it.   Dr. Bou-
teille, of the 4th cavalry, attended  Dr. Cer-
tani, the apothecary, and  his wife, who had all
died of the plague, was  congratulating himself
on his escape, when  he was  attacked and died.
Dr.Valencogne, who had succeeded Dr. Mares-
chi at Mansour, and who  was also a  non-con-
tagionist,  having acquired some things which
belonged to,  and had been  used by,  Dr. Bou-
teille,  would not attend  to the recommenda-
tion of purifying them before  using them, and
he fell a victim to his incredulity.  Dr. Rossi,
of the 7th regiment, was  attacked by the dis-
temper and recovered.  This young physician,
two years before, had written a memoir against
the infectious nature of  the  plague ; but he
afterward changed his opinion.  Four apothe-
caries, of whom three died,  and most of their
families, in all twenty-three Europeans, nearly
all those living in the province, were thus sac-
rificed.
  88. Numerous other instances of  the com-
municability and importation of this pestilence
have  been adduced  by  Dr.  Grassi,  from his
own observations in Egypt, Syria, and Pales-
tine.  My limits admit not of a farther notice
of them ; but they may be found in the Report
of the French Academy of Medicine.   He con-
cludes as follows :  1st. That  the plague is a
disease entirely sui generis, possessing charac-
ters which are proper to it,  and which distin-
guish it from all other maladies.  2d.  That  it
is transmissible  and transportable, and conse-
quently eminently contagious.  3d.  That  its
origin, like that of some other contagious  dis-
eases, is unknown ;  that it is not reproduced
de novo; but  that its seminium is preserved in
one or other  province or provinces of Turkey
—sometimes in one, at another time in anoth-
er.   4th.  That,  like smallpox, it very rarely
attacks those persons who have been  previous-
ly infected by it; and if it does, the  attack is
slight.   5th.  That  it prevails  chiefly in  tem-
perate climates.  And, 6th. That if it were com-
bated and restrained in all directions, it might
be ultimately suppressed,  if the ignorance  and
fanaticism of some  people would not oppose
the attempt.
  89. M. Lacheze states (Rapp. de VAcad., &c,
p. 567) that he arrived  in Alexandria during
the prevalence of the plague there  in 1834,
and that he proceeded soon afterward to Cairo,
where  the distemper broke  out on the 2d of
February,  1835,  and became  remarkably de-
structive.   Mehemet A\a shut himself up in
the palace of Schoubra, with 300 persons com-
posing his suite, and surrounded it with a double
cordon of troops.   Three persons only were
seized with the early symptoms of plague, and
they were instantly  dismissed.   Captain  Va-
rin,  who commanded the School of Cavalry,
informed Dr.  Lacheze that 515  persons com-
posing it were subjected to strict seclusion un-
der his orders; that during their seclusion they
enjoyed the same diet, regimen, and exercises
as before ; and that in the four months during
which the quaiantine lasted no case of serious 
238          PESTILENCE, SEPTIC OR G:

disease, and none of plague, occurred among
them.  Captain Varin adds, that the town of
Gizeh, in the midst  of which the  School of
Cavalry was placed in quarantine, experienced
a greater mortality in proportion to its popula-
tion than even Cairo,  in which one third of the
inhabitants died, and yet strict seclusion in that
town  was followed by the most complete pro-
tection.  Surely, if the disease was so entirely
dependant  upon  epidemic influence, as  con-
tended for by the anti-infectionists, it should
have  appeared among the persons secluded in
this instance, seeing that they were surrounded
by this, to their minds, all-powerful influence.
  90.  M. de Segur Dupeyron, secretary to the
Superior Council  of Health (Rapp. de VAcad.,
(fee, p. 593), states that during his several mis-
sions  he has visited  nearly all the places in
the East and  in  Africa where  the  plague has
appeared, with the view of determining its or-
igin in those places ;  that his researches have
proved that this  distemper has generally ap-
peared  in  consequence  of scarcity following
too great or too  low a rise of the Nile ; that
the occurrence of this pestilence in Europe, es-
pecially in Venice, Trieste, Livournia,  Genoa,
and Marseilles, before the formation of quaran-
tines, was frequent, and always connected with
the prevalence of it in  the Levant, especially
during peace, when communication was  unre-
stricted and  frequent ;  that from  1721  until
1830  the plague has been imported thirty-three
times into these  ports by  means of  vessels
which have been  detained in quarantine; and
that of these thirty-three importations eighteen
came from Egypt; that this distemper was not
constant in Constantinople until after the con-
quest of it by the  Turks, when it became fre-
quent, and at last  almost permanent, owing to
the return of numerous pilgrims from Mecca in
vessels which, with  the pilgrims  themselves,
were  often infected;  that he has seen the pil-
grims arrive in small, crowded vessels, in a
frightful state of dirt and disease ;  but that the
plague has scarcely appeared in Constantinople
since 1837, when  quarantine and sanitary es-
tablishments were formed in that  city ; and
that the plague is endemic in Egypt; but that
it is  not endemic, although frequent, in Syria,
Constantinople, and Barbary.   M. Segur con-
cludes with some  apposite remarks on  its con-
tagious nature, in which he  firmly believes,
both  from his  own observation and the evi-
dence of others.   He considers that this  pesti-
lence will never be arrested in its progress un-
less it be rigorously treated as contagious, un-
til it has destroyed all those  susceptible  of in-
fection, or until the temperature and state of
the atmosphere become unfavourable to its far-
ther extension ; and  he refers  to the very de-
cided measures adopted by General Maitland,
who on four different occasions—in Malta, Goz-
zo, Corfu, and Cephalonia—put a stop to the
distemper by a strict system of separation and
seclusion.   M. Segur adduces numerous in-
stances of passengers and other  persons de-
tained in quarantine in various ports, who were
seized with the plague on opening their trunks
and exposing their clothes to the  air, the dis-
temper extending to one or more of the health-
guards.  One or two of these instances is suf-
ficient for my argument.   In July, 1832, some
passengers from Constantinople and Scio, where
aANDULAR—Causes of  Plague.

 the plague was prevailing, were landed at the
 Lazaret of Syra.  On the sixth day after their
 entrance they opened their  baggage, and  eight
 of them were soon afterward attacked, and six
 of them died.
   91.  A Greek vessel arrived at the lazaret at
 Venice, in 1793, from Syria and Napoli de Ro-
 mana.  This vessel received on board,  in Syria,
 a supply of five sailors.  Four of them left the
 ship in the Morea, where they brought  the con-
 tagion.  One  only, named  Apostoli, remained
 when  she arrived in quarantine.  After unload-
 ing the cargo,  which was not considered capa-
 ble of conveying contagion, the sailors opened
 their chests and changed their clothes. Apos-
 toli was first attacked.   Twenty-one were in-
 fected, and  sixteen died in the lazaret.   Of the
 health-guards,  eight were attacked and three
 died.  In 1818  the plague appeared in the same
 lazaret, on board of a ship which had only two
 days to complete the quarantine.  A passenger,
 who had not opened  his trunk  until then, was
 soon afterward seized, and died in two days.
 His health-guard was next attacked, and also
 died.
   92.  Dr. Morpurgo  (Rapp. d VAcad., p.  609)
 resided eight years  in  Egypt, Syria, and  Tur-
 key, and was charged, in 1829, to organize the
 central hospital  in Cairo by  the  pacha.  In
 April, 1831, he quitted Alexandria and  went to
 Constantinople.  On  his arrival there  were no
 cases  of plague in the city ;  but cholera pre-
 vailed.  Subsequently a Greek vessel arrived
 from Cyprus with the plague, and  the distem-
 per soon afterward appeared in the Greek quar-
 ter of the  city.  Dr. Morpurgo left Constanti-
 nople, and arrived at Smyrna  in April, 1832.
 The plague had not appeared there for several
 years,  but  the pestilential  cholera had made
 great ravages.   Soon after his arrival in Smyr-
 na he was charged by the European inhabitants
 to organize  a  house  of refuge  for  the poor of
 all nations and of all religions, and was brought
 in constant communication with  the poorer
 classes.  But until the  month of May,  1833, he
 did  not meet  with  a single  case  of  plague;
 proving that this malady is not endemic in this
 port.   During  the five  years that he passed in
 Smyrna he observed  four epidemics of the
 plague.   The  first  appeared   in May,  1833.
 The  distemper was  introduced by a vessel
 whose crew and passengers were  landed and
 placed under tents while the process of purify-
 ing the vessel was proceeding.  Dr. Morpurgo
 traces the several filiations  of the infection un-
 til the cases became numerous.  It would ap-
 pear from his  details that, during the winter
 months of 1834, 1835, and 1836, the distemper
 lurked in this city, appearing during the spring,
 and becoming  more  and more prevalent  until
 the  spring of 1837, when it became very fatal,
 and many of the wealthier inhabitants either
 fled from the city or placed themselves in strict
 seclusion.   During this most severe epidemic
 the  plague  made the earliest and greatest rav-
 ages in the most airy and cleanest quarter, and
 the latest and the least  in the  closest, the most
 dirty, and the most miserable district.  During
 these epidemics, or, rather, epidemic—for the
 disease was introduced and continued for four
 years, slumbering for certain periods, and break-
 ing out and prevailing more or less during oth-
 ers, according  to circumstances, which will be 
PESTILENCE, SEPTIC OR  GLANDULAR—Causss  of Plague.           239
 explained in the sequel—several occurrences
 were remarked by Dr. Morpurgo deserving no-
 tice.  A Dr. Justiniani, of the Faculty of Paris,
 arrived at Smyrna, and  saw neither  contagion
 nor infection in the plague, or nothing else than
 a gastro-enterite.  He was soon afterward at-
 tacked, and  died in three days.   The Prussian
 consul shut himself up with his family, and had
 recourse to  the strictest precautions; never-
 theless, a chambermaid was attacked, and con-
 fessed,  when near  her  end, that she had re-
 ceived through a window linen from  her lover
 to wash, who lived in an  infected quarter, a
 circumstance proving the difficulty of preserv-
 ing a strict seclusion in  cases even of the most
 imminent risk.   In the most unhealthy locality
 of the city,  where several  drains and sewers
 meander through margins of filth, a barrack is
 situated containing from 1200 to 1300 troops.
 The physician advised the colonel to  adopt the
 most rigid quarantine, and it was strictly ob-
 served.  Not  an individual was  attacked, al-
 though the distemper was raging  around them ;
 and during their seclusion  they had  the same
 food  and rations as before  and after. All the
 convents which observed seclusion were  com-
 pletely protected, as also was the college, al-
 though situated  in an unhealthy locality.  The
 Greek and  Catholic sick, not infected by the
 plague, were received into the same hospital
 with  plague  cases, but in different wards ;  none
 of them caught the distemper, a circumstance
 which Dr. Morpurgo considers a strong prdof
 of the spread of the malady by contagion, and
 not by infection.  He concludes  his communi-
 cations to the Academy by  stating his convic-
 tion  that the plague is not peculiar to any par-
 ticular locality; that it is propagated by a semin-
 ium or germ, distinct from  any other, and re-
 sembling those of syphilis and smallpox; that
 it always  proceeds from and perpetuates the
 same distemper; that the isolation of the sick
 is the only  protection ;  and that three things
 are necessary to the spread of the pestilence  ;
 namely, its  seminium or germ, a favourable
 state of the atmosphere, and susceptibility of
 infection.
  93. Among the most experienced physicians
 who  have communicated to the Academy the
 results of their observations, Dr. Gaetani may
 be adduced.   He is first physician to the vice-
 roy, and has resided many years in Egypt.  He
 states (Rapp. a VAcad., p. 627) that from 1825
 until  1834 he met  with no case of  plague in
 Egypt; but  .hat since 1834 this pestilence has
 appeared in  a great number of towns and vil-
 lages of Lower Egypt, and has occurred in many
 of these places during the months of Septem-
 ber, October, and November, generally sporad-
 ically or in isolated cases ;  that it becomes ep-
 idemic in January and February, and subsides
 in June ; and that he has not met with the dis-
 temper in Upper Egypt, but that during the ep-
 idemic of 1835 several cases arrived at Syouth,
 Fayoum, Cosseir, and other  towns  in Upper
 Egypt, without propagating the malady.  Du-
 ring the epidemic of 1835, he  states that more
 than fifty of the principal families of Cairo put
 themselves in quarantine, either  at the desire
 of the viceroy, or from their own conviction of
 its necessity, and that not a case  of the plague
occurred in  more than three  or  four of these
families. When a  case  appeared in a house
 placed in quarantine, it was always found that
 some suspicious circumstance or communica-
 tion had taken place.  In the palace of Sche-
 rib-pacha two compartments existed, one for
 the men, the other for the women.  In that for
 the men, who  communicated with  the city,
 many cases occurred, but in that of the women,
 which was  strictly secluded, not a case was
 seen.   At the commencement of the epidemic
 in  Cairo, this  city  had a  garrison of 22,000
 troops, independently of 2000 invalids.  These
 last alone were left to guard the city, and the
 troops were placed under tents, in an intrench-
 ed  camp; and, although this camp was only a
 quarter of a league from the city, the plague
 did not appear among them ; while it carried
 off one half of the invalids who remained in
 the city.
  94. Dr. Gaetani adduces, in proof of the trans-
 mission of the pestilence by clothes, the fact
 that there existed  at Rosetta a magazine of ef-
 fects belonging to  plague patients.  This mag-
 azine  was opened after two years, and  three
 persons were seized with  the  distemper, al-
 though the town was in a most salubrious state,
 but they did not communicate the malady to
 others.  He believes that the effects of plague
 patients will convey to a distance the malady,
 when the circumstances favouring infection are
 present; that the  beds, bed-clothes,*and body-
 clothes of the infected  are most to be dreaded ;
 and that  merchandise never  or  very rarely
 transmits the disease.  He also thinks that the
 pestilential miasms,  during  the  prevalence  of
 the malady, in  a close, low, wet, and thickly-
 populated locality,  may accumulate in the hu-
 mid and still air to such an extent as to trans-
 mit the distemper without any nearer or per-
 sonal  communication; and  that  it is to this
 contamination of the air, by the effluvia of the
 sick,  that the extension of the pestilence  to
 houses in which strict seclusion had been ob-
 served is to be attributed ;  for the state of the
 locality, the narrowness of the streets, and the
 circumstances just stated, in all such instan-
 ces, could sufficiently account for  the occur-
 rence, without referring it to clandestine inter-
 course.
  95.  I believe that I have now adduced suffi-
 cient evidence of the infectious nature of the
 plague—infectious by  direct or mediate con-
 tact, or by a humid air, conveying the pestilen-
 tial miasms.  I might have  adduced ten times
 more evidence of the matter; but my limits
 will not permit me to do that which will ap-
 pear to all candid minds as altogether unneces-
 sary.   There are, however, certain topics con-
 nected with the subject that  yet require farther
 notice, in order to  complete  the full considera-
 tion due to it.
  96.  C. The propagation of this distemper by in-
 oculation has been  believed  by some to be an
 important and necessary part of the evidence
 of the contagious  nature imputed to it.  But
 this proof is  neither necessary to the complete-
ness of the evidence required, nor is it of im-
portance in this or in any other respect. There
is  almost no  other febrile  disease, besides
smallpox and cowpox, that  admits of certain
communication by inoculation.  All other infec-
tious maladies have presented only a few con-
tingent and doubtful  instances of infection by
this method.   As  respects smallpox, cowpox 
210         PESTILENCE, SEPTIC OR GLANDULAR—Causes of Plague.
 and some chronic contagious maladies, we ob-
 serve  a  specific contagious virus or secretion
 formed at an advanced stage of the malady,
 capable of propagating it, unless in those very
 dry states of the air which is unfavourable to
 the propagation of all infectious and contagious
 maladies, when  it frequently, also, fails of im-
 parting the disease.   If other secretions,  or
 the blood itself, of a smallpox patient be used
 for inoculation, no more certain results would
 follow than those which have been observed to
 follow the employment of these fluids in at-
 tempting to inoculate the plague, scarlet fever,
 or typhus  fever, or the measles.   In the case
 of the  plague, there is no consistent or specific
 virus or secretion proper to and characteristic
 of the  distemper, that may be employed in this
 way with any rational hopes of its perpetuating
 the disease.  The ichor or discharge  from a
 carbuncle is merely contingent upon a local ac-
 cident of the malady ; the purulent matter from
 a bubo is equally such, and is chiefly met with
 during an early period of amendment; the blood
 of the infected can no more be expected to trans-
 mit the distemper  than  the blood in any other
 infectious  disease, which has  repeatedly been
 found to fail.  Even granting it possible to pro-
 cure the pestilential miasm, seminium, or mat-
 ter of  the plague, the difficulty would still ex-
 ist as to  the application of it to the frame of the
 healthy in that state, and to that particular or-
 gan  and tissue by which its  effects would be
 most certainly developed.  I shall have in the
 sequel to infer, from the great mass of evidence
 I have perused, a part only of which I have here
 adduced, that it is chiefly owing to the pestilen-
 tial miasms or effluvia proceeding either direct-
 ly from the diseased, or preserved  in their bed
 or body clothes,  and  given off upon their  first
 exposure to the air, and inspired by suscepti-
 ble persons, that the distemper is propagated
 and  perpetuated.  A near approach, amount-
 ing almost to contact, sometimes accompanied
 with contact, is often necessary to this effect;
 contact merely will often fail, or, rather, it will
 succeed  in communicating the malady only
 when  it  is attended by the inhalation of the
 effluvium or pestilential miasm, whether pro-
 ceeding from the diseased body or from fomites.
 Now how can the same effect be produced by
 the inoculation of fluids which have not been
 proved to possess the property of perpetuating
 the distemper, which, reasoning it priori, can-
 not be  supposed to possess this property, and
 which, even granting them the  possession of it,
 cannot be  conveyed to that channel through
 which  the  observing mind must admit  the in-
 fection to be principally, if not solely, admit-
 ted  and transmitted through the economy?
  97.  From this it may  be admitted that at-
 tempts at inoculation must be nugatory in re-
spect of  this pestilence, as well as of the two
 pestilences already considered;  or if any at-
tempts to inoculate succeed, their  success is
liable to be imputed, as it actually has been by
the  anti-infectionists, to the operation  of the
epidemic influence, and in no way to the inocu-
 lation,  the persons infected being attacked  al-
together  in consequence of this constitution of
 the  air, and independently of  any  pestilential
 miasm,  seminium  or  effluvium,  proceeding
 from the diseased and inhaled with the air by
 the healthy, for the existence of which semin- j
! ium I, in common with other infectionists, con-
 tend.  If attempts at inoculation  should  fre-
 quently prove futile,  it must be obvious, from
 our knowledge of the operations of the digest-
 ive organs, that the experiments made by cer-
 tain nasty fellows, in the excess of their  sci-
 entific enthusiasm, in order to show the non-
 contagious nature of this and the other two
 pestilences, by swallowing the secretions and
 discharges  of persons labouring under these
 distempers, must necessarily prove still more
 futile, insomuch as no effects beyond nausea or
 vomiting could be expected from these  experi-
 ments.   Indeed, it is most probable that  the
 extent of the probable or possible mischief was
 clearly seen, and safely, as well as most cour-
 ageously, attempted by these experimenters.
   98. However,  the  attempts at  inoculation
 which have been made  require a still more
 particular  notice.   M. Desgenettes,  finding
 the French troops in Egypt much depressed by
 their dread of the plague, attempted to inocu-
 late himself with the  distemper ; but, to  secure
 himself  from risk, he afterward washed the
 part with  soap  and water; and, according to
 his own statement, he not only used this pre-
 caution, but he employed "the pus of  a bubo
 of a convalescent patient"—using,  in fact, the
 matter  of what had  become a healthy  suppu-
 rating sore.   Soon afterward, Dr.  Whyte,  an
 anti-contagionist, in the English army, hearing
 of this  feat, but not of the precautions which
 had been taken, repeated the experiment in a
 much more  efficient  and dangerous manner.
 "He rubbed some matter, from the bubo of a
 woman,  on the  insides  of his thighs.  The
 next  morning he inoculated himself  in the
 wrists with matter taken  from a running bubo
 of a sepoy."  This was done on the 2d and  3d
 of January, 1802,  and on the 6th he was at-
 tacked with  ngpur3  and  other  febrile  symp-
 toms, succeeded  by  heat and  perspiration,
 much  affection of the head,  tremour  of the
 limbs, a  dry, black tongue, great thirst,  a full,
 hard, irregular pulse, great debility and  anxie-
 ty.  He still persisted that the disease was not
 the plague, and would not allow his groins and
 armpits to be examined.   He became delirious
 on the 8th, and died on the 9th.
   99. Dr. Goocn, in his paper on the contagion
 of the plague,  has stated that Dr. Valli, an
 Italian  physician  who resided some  time in
 Turkey, made some experiments on the inocu-
 lation of the plague.  He  diluted the pestilen-
 tial matter with smallpox  matter, with oil, &c.
 This compound he called  his pommade.   If a
 Mussulman came  to  consult him for  an oph-
 thalmia, he ordered him some of his pommade
 to rub on his eyelids ; if  another came, com-
 plaining of pain in the bowels, he ordered it to
 be rubbed on his belly.  In this murderous way
 he  gave, it is said, the distemper to  thirty per-
 sons.  The Turkish government at last arrest-
 ed  the pharmacopolist who vended the  pom-
 made, and cut off his head, but Dr.  Valli es-
caped.
   100. Dr.  L. Delaporte  states, in a memoir
addressed to the Royal Academy of Medicine
in Paris (Rapp a VAcad., &c, p. 321), that Dr.
Gaetani-Bey communicated to him the fact
that a person in Cairo, having persuaded sever-
al of his acquaintances that he would protect
them from any future  attack of the plague by 
PESTILENCE, SEPTIC OR GLANDULAR—Causes of Plague.
241
inoculating them with the sanies taken from a
person recently dead of the  distemper, found
no less than eleven who, with himself, submit-
ted to the experiment.   They, however, were
all attacked, and died, the experimenter him-
self only escaping; but he was not altogether
recovered when Dr. Gaetani saw him.
   101. It might be supposed  that these experi-
ments are tolerably decisive, not only of the
contagious nature  of the distemper, but also
of the great probability of the communication
of it,  in its most deadly form, by inoculation.
Yet the  anti-contagionists will, nevertheless,
contend  that the  individuals thus inoculated
and killed by the experiment were actually not
inoculated with the distemper, but were all at-
tacked by the epidemic influence,  which alone
produced the  disease  of which they  died!
This  mode of accounting for the result in no
less than twelve instances, although admitted
to have occurred at a time when the distemper
was prevalent, shows  the shifts to  which the
supporters of  this doctrine  resort to evade  a
most conclusive piece of evidence, happily fur-
nished by a most respectable physician, al-
though the experiments were as happily not
performed by a medical practitioner.   Now, the
supporters of the all-powerful  epidemic influ-
ence in  the propagation of  this distemper al-
low, that in Egypt the plague is epidemic only
from February to the end of June ; and as Dr.
Whvte's inoculation of himself (, 98) was  per-
formed on the 2d of January, his infection in
consequence, therefore, could not be imputed
to this  influence—for it  had not then com-
menced—but to its right cause, the inoculation.
Now, seeing the disease actually follows inoc-
ulation in some  instances (of which I have ad-
duced only a very few out of the many which
I  have seen recorded), although it fails in oth-
ers, and may be expected to fail  for the rea-
sons stated when  commencing the considera-
tion of the topic, there is nothing that can be
reasonably desired farther to prove  the conta-
gious, as well as the  infectious nature  of this
pestilence, according  to the  meaning which I
have fully and explicitly applied to these terms
at the setting  out (y 58, 59).
   102.  The immense importance of the vari-
ous  topics connected with the contagious na-
ture of plague will not admit of my relinquish-
ing the consideration of this part of the  subject
without  noticing certain of the conclusions at
which the commission  of the French Academy
of Medicine has arrived.  The necessity of
making  some  alterations  in the quarantine
laws, without endangering  the safety of the
community, especially during the now more
frequent and  more rapid  communications be-
tween the several ports in the Levant and the
south of France, induced the French govern-
ment to refer the subject to the Academy, who
appointed a commission, whose report is now
before me.  It is most likely that much of this
report will be  used by  the anti-infectionists in
support  of their arguments,  not so  much for
the  facts and evidence which may  appear to
favour their views, but for the use of terms to
which this commission has attached  a different
meaning to that which is applied to these terms
in this country.  In noticing, therefore, some-
what farther certain topics connected with the
origin and propagation of the plague,  I  shall
     III.            16
make some remarks upon this laboured, but not
very perfect performance.
  103.  D.  Of the origin of plague, nothing can
be asserted with any degree of certainty.  The
earliest indications of its  existence have been
already noticed, and its antiquity shown (y 4);
but whether or not it has always been, from
the remotest period of its existence, propaga-
ted by a certain germ or seminium, sui generis,
conveyed from one part to others, more or less
distant, by  persons or clothes, preserved  in
some one or other of the countries of the Le-
vant, prevailing in some places, then subsiding,
sometimes smouldering on  with  few or scat-
tered cases, at other times  breaking out into
more open combustion as circumstances fanned
the fire ; or whether it  has  been  produced, de
novo, on several or many occasions, and when-
ever various local circumstances have  arisen
to generate it, are questions which have not
hitherto been solved, although severally enter-
tained by numerous observing and experienced
physicians.   The proposition involved in the
first alternative has received considerable sup-
port from the investigations of Dr. Russell in
Syria,  who completely established the fact that
a second  attack of plague,  among the  thou-
sands  of cases comprised  by  his researches, is
of much rarer occurrence than a second attack
of  smallpox.   Having  established  this  most
important  fact, which subsequent researches
have fully confirmed,  but which the commis-
sion has entirely disregarded and  never men-
tioned, a very convincing  proof is thereby fur-
nished of the contagious nature of the distem-
per, as well  as a strong  presumption of the
truth of that proposition ; the plague thus ap-
pearing in the same category  with smallpox,
haemagastric pestilence, &c, and the same ar-
guments which were employed when discuss-
ing  this question in respect to that pestilence
being  equally applicable to  this.   (See Pesti-
lence--HaEMAGASTRIC, y 125, et SCq.)
   104.  a. The  protection furnished  by a first at-
tack being thus established,  with but very few
exceptions, it must be  obvious to the candid
inquirer that  numerous occasions will occur,
in the countries of the Levant, in which a very
large proportion of the inhabitants is protected
by a previous attack; and that the spread of
the  distemper will often be limited by this
cause, aided by others connected with the tem-
perature and states of the atmosphere.  This
fact will also explain the  occasional failure of
the  very  imperfectly-informed and inexperi-
enced  experimenters among Egypto-European
physicians to communicate  the distemper by
contact and inoculation.  Thus it will be found,
in the  report to the Academy, that a felon, hav-
ing  been  made the subject  of inoculation  in
Egypt, caught the distemper  and  recovered.
Having thus earned his life, he was neverthe-
less experimented upon subsequently, and not
being  reinfected,  the  circumstance  was  ad-
duced  as a proof of non-contagion, although
actually being, to the  mental vision of all who
can see, and duly estimate the most prominent
and important truths in medicine, the strongest
evidence which could be brought in aid  of the
opposite and orthodox doctrine.  But there is
every reason to believe that, as in the cases of
smallpox  and the haemagastric pestilence, the
infection  of plague may be so mild, the febrile- 
242          PESTILENCE, SEPTIC OR GLANDULAR— Causes  of  Plague.
disturbance so slight, the pains in the glands so
evanescent, and the swelling so small, as to al-
most  escape  notice, or to  pass away without
recollection of the disorder, and knowledge, or
even suspicion, of its nature.  Indeed, a very
mild grade of the distemper has  been described
above (y 21), and is frequently remarked, when
this pestilence has been  introduced   into a
crowded city or place.   Protection  from sec-
ond attacks may thus become much more nu-
merous than actually apparent from this cause.
  105. B. The second proposition  involved in
the alternative stated above (y 103), namely, is
the plague generated, de novo, whenever  circum-
stances favourable to its generation arise ? is an-
swered in the affirmative by the Academy.  It
would have been  instructive,  probably most
beneficial,  if the  French commission,  during
the long period they have taken  to consider the
matter, had ascertained the several circum-
stances which combine to  generate this pesti-
lence, de novo, and  distinctly  stated  them,  be-
fore they took the proposition for granted, and
proceeded  to reason upon  it  as an established
fact;  the more especially as it has  been con-
troverted by the ablest writers on the  distem-
per, and doubted by many.   But the commis-
sion adopts,an easier course, and without any
such preliminary and fundamental inquiry, asks
themselves the question,  What is the  place or
places where the plague has arisen spontaneously ?
And,  after taking a very roundabout  way of
answering it, they state, without any doubt or
reservation, " that the plague has been gener-
ated spontaneously not only in Egypt, in Syria,
and in Turkey, but also in  a great many other
countries of Africa, Asia,  and  Europe."  The
spontaneity of plague, according to the com-
mission, is thus tolerably latitudinarian,  but
many will doubt, notwithstanding the greatness
of the  authority,  the wideness of the range,
even  if they do not dispute the accuracy of
the principle adopted.  Certainly the question
of the origin of this pestilence  cannot be read-
ily or easily answered, especially  by one who
is cognizant  of the difficulties which beset it,
and of what may be said for and  against the
doctrine of spontaneity.  I confess that I can-
not arrive at a positive conclusion as to the
matter.  There are many circumstances which
favour  the opinion, and many which  militate
against it: first of the former.
   106. Of all cities or places, Cairo furnishes the
most  numerous circumstances conducive to the
production of this pestilence  de novo; a crowd-
ed population in dirty, close, and ill-ventilated
chambers, especially in the  Coptic quarter ;  nar-
row streets, with open sewers  in many places,
and abounding with filth ;  the  accumulation of
decomposing animal excretions and exuviae ; a
rich,  deep soil, saturated with  animal  matter;
low, close, dirty, and ill-ventilated habitations ;
the burial of the dead within the walls  of most
of the  Coptic  habitations  ; contaminated and
unwholesome water ;  adjoining inundations ;
great humidity of the air during'part of the
year, and a temperature from  50° to 75° Fah-
 renheit, are a combination  of conditions suf-
 ficient to generate a  pestilential malady, or,  at
 least, a putro-adynamic form of fever, especial-
 ly when  they  exist in marked grades, or, are
 aided by scarcity of food, by great humidity and
 stillness of the air, and probably, also, by a neg-
ative state of tho electro-motive agency in the
atmosphere and on the earth's surface.  If these
do not actually give rise to the pestilence, with-
out any  pre-existing germ  or seminiuni, thej
may be inferred, at least, to be most influential
in developing, propagating, and even in perpet-
uating such a  germ ;  and in giving rise to a
susceptibility or predisposition of the popula-
tion to be infected by it, as far as these favour-
able circumstances extend, and among all who
are not  protected by a previous attack  or by
other causes.
  107. Dr. Legasquie, the member of a com-
mission which visited Egypt in 1828, 1829, and
1830, to  investigate the causes of plague, and
to try the action of the chlorides on  the  pesti-
lential miasm  or  virus, believes that, although
the plague existed before the sixth century, it
became more frequent in Egypt in consequence
of the practice of embalming  the dead having
been relinquished after the introduction of sep-
ulture by the early Christians, and that it  is en-
demic in Lower Egypt.  He considers "that the
practice adopted for so many ages in the Cop-
tic  quarter, which is situated  in the centre of
Cairo, of burying the dead within the houses,
exerts a  powerful influence upon the health of
the whole city.  There can be  no doubt of this,
especially aided as it is by numerous other cir-
cumstances of an injurious tendency, the chief
of which have been already enumerated (y 106),
and he imputes the origin  of the plague to ani-
mal decomposition ; want  of cleanliness, scar-
city, poverty, the inundations of the Nile, ru-
inous state of the canals, and insufficient ven-
tilation being only accessory causes.   (Rapp. a
VAcad.,  p. 590.)  The same opinion  is enter-
tained, also, by several of those who have com-
municated on the subject with the French Acad-
emy.  M. Delaporte, in a very able memoir,
attributes the development of the pestilence to
the same causes ; but admits that, when thus
produced, it perpetuates and reproduces itself,
1st. By  pure contagion, or  immediate cutane-
ous contact; 2d. By infection or internal  pneu-
mogastric contagion.  It  cannot be doubted
that, if we admit the spontaneous generation
of the pestilence on occasions when all the cir-
cumstances concur  most efficiently to this ef-
fect,  that the towns and  villages  of Lower
Egypt furnish them in the most marked de-
gree ; but it cannot be also admitted that they
stand alone in this respect, for many towns sit-
uated near the  shores  of the Mediterranean
present  conditions almost as  favourable  to the
production of this effect as those of Egypt.
   108. In opposition  to the doctrine of spon-
taneity  it may be  contended, seeing that the
circumstances that combine to generate  it, ac-
cording to this view, must necessarily exist in
 many places and towns in other countries en-
joying the same  range of temperature as those
of the Levant, and  in many cities in Western
 Europe  during the  warmer seasons, that this
 pestilence ought also to be generated in coun-
 tries eastward of Arabia, as well as in some
 parts of A^merica.   Those who believe that it
 is propagated by a seminium analogous to small-
 pox, but not capable of being so long preserved
 as that of smallpox, are of opinion that the cir-
 cumstances favourable to, as well as the occa-
 sions of, the  conveyance of  this  seminium to
 the eastward of some parts of Arabia, and to 
PESTILENCE, SEPTIC OR  GLANDULAR—Causes of Plague.
243
the westward of Europe and Africa, have not
existed ;  and that when this distemper has ap-
peared, as it has on rare occasions, in some of
the northern cities of Europe, on the one hand,
and in some of the hot countries of Africa and
Syria on the other, it has always spread by the
contagion and infection  conveyed  by persons
and the clothes of the sick ;  but that the low
winter ranges of temperature  in the former,
and the high ranges of the  summers of the lat-
ter, have always destroyed the poisonous se-
minium, either by the influence of the extremes
of temperature  upon it, or by  the loss  of the
power of perpetuation after a certain period.
   109.  That those very circumstances and oc-
casions which would appear the most favourable
to the production of this pestilence de novo have
often not produced it, even in countries where
the pestilence is met with sporadically, and is
considered as being endemic by many writers,
is a fact  which has  been  demonstrated, and
which militates  strongly against the doctrine
of spontaneity, but which supports  that of  a
specific seminium ; for, on these occasions, the
absence of this specific contagious or infectious
agent accounts for the non-appearance of this
pestilence; other maladies, which these  occa-
sions generally produce, being the only results.
Thus it is stated by Dr. Rossi,  that when the
Egyptian  army were in Syria  they were ex-
posed to many of the circumstances supposed
to originate the  plague,  and, especially  when
obliged  to evacuate  the  country, they  were
crowded into ill-ventilated transports.  Malig-
nant typhus and dysentery, hospital  gangrene,
&c, then became most prevalent and fatal, but
no case of plague occurred.  This appeared to
be the case especially with the regiment to
which Dr. Rossi was attached, and which was
not attacked by this pestilence  until after its
return  into Egypt, when it became exposed to
the infection during his absence, and, no meas-
ures of precaution or prevention having been
taken, the distemper  had become general
throughout the  corps.   He sent all the infect-
ed  (about  400)  into  the hospital, and caused
those who appeared in health  to bathe  in the
Nile, to put on clean and  purified clothes, and
to encamp on a dry and  arid soil.  As soon as
one  was attacked he was  sent to the hospital,
and thus the camp was preserved healthy, and
the distemper ceased.  Although the occasion
of generating the  pestilence de novo was most
favourable in this instance, still it  did not ap-
pear until  the return of the troops  to a place
where cases of the plague existed  ; the neg-
lecting of precautions against infection having
diffused the distemper,  and the adoption of
precautions having arrested it.   When the pes-
tilence was introduced into Smyrna, as shown
by the authority referred to above, it appeared
first in the most open and  healthy quarter, and
advanced the latest, and prevailed the least, in
the lowest, most crowded, and unhealthiest quar-
ter ;  and this in a city supposed by some  to re-
produce the distemper de novo.  Besides, it is
fully shown by recent researches, and by the
recent adoption of sanatory measures by Turk-
ish  and  Egyptian governments, that the  more
or less continued presence  of cases of this pes-
tilence was not owing so much to the existence
of the local causes supposed to generate it de
novo, as  to the want of all precautions and
 quarantine  regulations, and  to the neglect of
 separating the infected from the healthy, where-
 by the specific  infectious seminium  was  pre-
 served and  propagated.
   110. Without, therefore, denying the frequent
 reproduction of the plague in Lower Egypt, by
 the causes stated above, still the doctrine of an
 original specific germ or seminium presents
 many considerations in  its favour, and of the
 same nature as I have adduced when consider-
 ing the origin of the haemagastric pestilence.
 According to the former view, the circumstan-
 ces above stated (§ 105, et seq.) give rise to the
 sporadic or endemic cases, as they have been
 called, but they are insufficient of themselves to
 spread or to diffuse the distemper in an epidemic
 form, until the epidemic influence or constitu-
 tion,  for which certain modern writers contend
 —the "foyer epidemique"—is actually developed.
 According to the latter view, the  specific con-
 tagious agent produces but few, scattered, and
 isolated cases, in certain  localities and towns,
 as long as the circumstances unfavourable to
 its propagation  exist, as observed in  respect
 of smallpox; while the extremes of temper-
 ature, a dry atmosphere, free  ventilation, ab-
 sence of susceptibility in  many, and cautious
 avoidance of crowding, and of intimate or close
 communication, afford protection ;  these strag-
 gling instances being sufficient, especially when
 re-enforced  by importations from other places
 furnishing occasional cases of the distemper,
 to  perpetuate the specific agent of contagion.
 But when the circumstances favourable to the
 diffusion and operation of this agent appear, as
 moderate atmospheric warmth, conjoined with
 humidity and stillness of the air, and probably,
 also, with a negative state of the electro-motive
 influence, and with  noxious  exhalations from
 the soil, with crowding, and close or frequent
 communication with the affected, then the  dis-
 temper becomes more or less prevalent with
 the grade and combination of these and other
 favourable circumstances ; and these alone, or
 chiefly, constitute the epidemic  influence or
 " foyer," to  which so much is imputed by some
 recent writers.
   111.  Now we find  that the plague  becomes
 epidemic at one year, or even during two or
 three  successive years, in some  countries of
 the Levant, successively appearing to a most
 destructive  extent in one country, then subsi-
 ding,  and breaking out in one or several coun-
 tries ; but much more rarely, or not for ages,
 appearing in more distant  countries where pre-
 cautions against its ingress are taken, and nev-
 er where these precautions are strictly observ-
 ed.  If we admit, with the anti-infectionists,
 that this pestilence arises  from an  epidemic in-
 fluence alone, such epidemic influence must be
 of a specific  kind, since it produces specific and
 determinate  effects, and occasions neither ady-
 namic fever nor adynamic dysentery,  nor ei-
 ther of the two  other specific pestilences con-
 sidered above ;  and, seeing that this pestilence
 migrates from one place and country to  anoth-
er, and is actually as eccentric in its migrations
and courses as I have described it (v 86),  the
epidemic constitution to which it has been thus
absolutely imputed must necessarily be equally
 migratory.   Moreover, as it has been most sat-
 isfactorily shown, and as sufficient evidence to
 demonstrate the fact has been adduced, that 
244          PESTILENCE, SEPTIC  OR GLANDULAR—Causes of Plague.
this  pestilence may be shut out for ages from
places where  it was almost a  yearly visitant,
by strict measures of separation and seclusion ;
and that it may even be shut out and excluded
from a house or houses, while all the surround-
ing houses are  infected, how are  the persons
taking these  precautions, I ask, enabled thus
to prevent the epidemic influence to which it is
imputed from occurring in  the town, country,
or place from which it is excluded 1   And if
the town or place be invaded by this aerial in-
fluence, how are they able  to shut it out from
any house, or part, in  which neither infected
persons nor infected clothes are allowed to en-
ter]   The persons  taking  these wise precau-
tions  are  admitted to  be  quite incapable of
keeping off a single shower of rain, by all the
scientific  means they can use ; how comes it,
then,  that they can  prevent  a most destructive
epidemic constitution of the atmosphere from
visiting a country, although they profess their
ignorance of the nature of that constitution,
excepting from its effects ;  and  that, when they
have carelessly or ignorantly admitted it, they
can,  as we have seen, ward it off,  and prevent
its ingress into any house  they please .   Can
anything more completely show the absurdities
of the  doctrine of epidemic constitution and
non-infection, than  a knowledge of the  facts
connected with the  development and spread of
this pestilence 1
  112. The truth is, that infection is introduced,
however it may originate, by persons or clothes,
or by both, in  a town or place;  and if the con-
ditions favourable to its communication to sus-
ceptible persons are present—if the temperature
be in  neither extreme, or be moderately warm;
if the air be humid and still; if the houses are
crowded,  low, damp,  and  ill-ventilated,  the
streets narrow and abounding in filth ; and if the
communications be frequent and a large number
of the population are susceptible, owing to their
not having been previously attacked, or to some
other  cause, constitutional  or  otherwise,  the
pestilence soon spreads and becomes epidemic.
These circumstances conjoin to constitute the
epidemic  constitution—the  "foyer epidemique"
of our neighbours, to  which they impute  the
pestilence.  But I contend  that they  are mere-
ly the conditions—the circumstances which fa-
vour the operation, spread, and  reproduction of
a poisonous  agent—of the pestilential miasm
or infectious emanation produced by the infect-
ed.   As  soon as these conditions and  occa-
sions  disappear—as soon  as the  temperature
sinks to freezing, or rises above 75 degrees of
Fahrenheit, and more especially if the air be-
comes at  the same time dry, if high winds oc-
cur, and free  ventilation in houses or tents is
adopted, the  infectious poison ceases to be con-
centrated, is more diffused in  the air, and is
less capable  of reproducing itself, by infecting
others, from its being weakened or  otherwise
changed,  and from its ceasing to affect persons
who  have become,  owing to these atmospheric
conditions, much less susceptible of its opera-
tion, then as  soon  does the pestilence subside
and entirely disappear; unless it be allowed to
smoulder  on  in low,  dirty, close, damp,  and
crowded plaees, furnishing a few of the circum-
stances favouring  its  occurrence, and  some
persons still susceptible of its action.  Thus in
Levantine countries, the distemper is said to
be endemic or sporadic, occurs in isolated ca-
ses, and  is ready to become epidemic as soon
as the circumstances combine to favour its dif-
fusion.  The dose of the infecting poison in the
former or  favourable circumstances is large,
strong, and efficient, and the recipient suscep-
tible of its influence ; in the latter, or unfavour-
able conditions, it is small, weak, and inopera-
tive, and the recipient insusceptible of its im-
paired  power.  What has  now been stated of
the infection  of this pestilence does not pertain
to it only, or to two or more pestilences mere-
ly, but is true of all other maladies of a malig-
nant and epidemic nature, especially of the two
other pestilences, of smallpox, and of the other
exanthemata.
  113.  iii. The arguments which have been used
by the anti-infectionists to support their doctrine
hardly deserve any notice, after the ample evi-
dence—after the undeniable facts I have ad-
duced, completely proving that the three pesti-
lences here considered are  infectious in a most
remarkable manner, under circumstances which
are fully described.  As  the arguments which
have been used by the objectors are the same
as respects these three distempers individually,
I have deferred the consideration of them until
all the three  have been brought fully before the
reader.   I even hesitated  to  consider these
arguments at all; because, when  a  matter is
fully and irrefragably established on facts, any
argument which can be brought against it—all
special  pleadings, however ingenious,  argue
either the fractious spirit of the  objector,  or
some motive actuating him to prevent a belief
in the truth.   On this account, therefore, the
arguments, or,  rather, the sophistical puerili-
ties which have  been adduced by ignorant, in.
terested, or  captious and  splenetic persons,
hardly  deserve  a notice, and only when they
seem to possess an  air of importance—an  im-
portance derived only from unwarranted as-
sumptions, confident assertions, and ill-founded
pretension ; and, in some instances, also from
the official or professional position of some of
those who have  ventured into the field of con-
troversy—and not from any solid array of facts
or of inferences logically  drawn  from facts.
But, irrespective of the want of every element
of sound argument, a very  large proportion of
the anti-infectionists betray, as shown above,
an utter ignorance of the distempers respect-
ing the  nature of which they speak with confi-
dence,  and even with disgusting pretension—
and not only of  these distempers, but even of
others, either allied or analogous to them, of
which  they  have incidentally  taken  notice.
This assertion may be conceived by some, who
have not had opportunities of judging for them-
selves in the matter, as severe or ill-founded;
but it could be very easily.proved if it deserved
the space which would be wasted  in proving
it.  Whoever has perused some of the writings
to which I allude, and which I have referred
to, or  others which  I have considered  unde-
serving of notice, with that amount of knowl-
edge which  enables him to form  a tolerably
correct estimate of medical writings, will read-
ily admit the accuracy of the assertion ;  and
the attentive reader of what has preceded, and
of what has  yet to be adduced, will find suffi-
cient reason  to arrive at  the same conclusion.
   114. A. It has been argued by the anti-infec- 
PESTILENCE,  SEPTIC  OR GLANDULAR—Causes of Plague.          245
 tionists that the three pestilences now consid-
 ered are  not governed by the laws of conta-
 gious, but of epidemic diseases.  Now this as-
 sertion shows, even  of itself,  that those who
 make it know nothing-of these laws, and still
 less, if less be possible, of the matters respect-
 ing which  they attempt  to  argue.   What is
 there known of the laws of infectious disease
 which these pestilences do not actually possess
 and present]  The  chief law, admitted even
 by the  objectors, is,  that contagious or infec-
 tious  diseases present precise,  specific, and
 distinctive  characters.  Has  not  the whole
 history of the three pestilences now considered
 demonstrated  the  possession of these very
 characters by them in a most remarkable man-
 ner]  Is  even smallpox  more distinctive or
 specific than they are all 1  Is there any one
 at the present day, who has  had the smallest
 amount of experience, who will not  admit the
 special character of these distempers,  unless
 he be blinded by ignorance or prejudice, or by
 both, for they are both often combined]  But
 the anti-infectionists say that other  maladies,
 admitted  by them  to be infectious, affect a
 person only once in his life, but that this is not
 the case  with the pestilences now described.
 Here, again, their ignorance,  or  their  dishon-
 esty,  is most barefaced and  egregious; for
 they should know, if they really do not know,
 that  a second infection is even more rare, as
 shown by facts out of number, as regards two
 out of these three distempers, than  even the
 exanthematous fevers, whose infectious nature
 they admit; and that opportunities  have not
 yet been afforded, at least in Europe, to test a
 similar property in the third  of these distem-
 pers.  In  truth, there should  be an end of all
 argument with such  persons, as being unwor-
 thy of the distinction conferred by fair argu-
 ment ;  for they will neither see, nor acknowl-
 edge, Bor  appreciate  fairly, any fact which may
 be construed unfavourably to their views ; but
 will  endeavour to controvert it  by  misstate-
 ments and drivelling doubts, when they find it
 to be otherwise unassailable.
   115. Oh! exclaim these pseudo-philosophers,
 who wish to make infection appear a  prejudice,
 a  vulgar error, and who,  in the fulness of their
 vanity, desire to seem altogether above every
 thing that can be accounted a vulgar or general
 belief—these pestilences are merely epidemics,
 observing the laws of epidemics, and are hence
 not infectious. Yet what do they know more
 of the laws  of epidemics  than their opponents,
 who admit that these pestilences are very fre-
 quently epidemic,  and are mostly known as
 such  in Europe ;  but who also contend that
 they are likewise met with in  solitary or scat-
 tered cases, in the countries which present the
 climate and circumstances favourable to their
 preservation during all seasons ; and that their
 occurring  in an  epidemic form—their more
 general prevalence—is only the result of the
 existence of the several conditions and circum-
 stances which admit  of the concentration or
 accumulation of the  infectious miasm  which
 favour the  development and  operation of it,
 and which thereby promote the diffusion of in-
 fection, especially among susceptible persons,
 and those who have  not  passed  through the
distemper;  and still  more remarkably when
these are collected in numbers, or are crowded
 in towns and cities, or are otherwise placed  in
 circumstances predisposing them to the inva-
 sion of the pestilential emanations from those
 already infected.   According to the non-infec-
 tionists, the pestilential cholera was considered
 an epidemic depending upon  aerial conditions,
 and was hence termed epidemic cholera.  The
 calamitous consequences of opposing a sup-
 posititious  aerial or tellurial  influence,  or  a
 combination of  both—for  suppositions  were
 varied, and even numerous as to the matter—
 to a  manifest property  of the  distemper to
 spread from the sick to the  predisposed among
 the healthy, like  all other infectious maladies,
 and the confident assertions  and  assumptions
 employed to conceal ignorance, have  been al-
 ready beyond the power  of human calculation
 to estimate as respects this single  pestilence
 merely; they are still frightful and extensive,
 and they may even become  much more so, and
 be indefinitely perpetuated.
   116 Still, the non-infectionists exclaim, these
 pestilences, choleric, haemagastric, and glandu-
 lar or septic, are merely epidemics, prevail only
 as far as the epidemic influence  extends, and
 are the results of the " epidemic foyers."  Has,
 however,  the choleric  pestilence, which  has
 continued  to prevail, more  or less, for nearly
 thirty years in India, been an epidemic during
 all that time]  Or has it  not rather been, as I
 have shown, an infectious distemper preserved
 in that country, by the absence of all attempts
 to prevent infection, or to limit the  spread of
 it, and by  the circumstances of the climate,
 but prevailing more or less, or becoming more
 epidemic at one  place  than  another, as occa-
 sions arose favouring its diffusion, and predis-
 posing those exposed to it ]   The truth is that,
 when the various occasions and circumstances
 concur to develop lurking cases  of either of
 these pestilences into an epidemic form, it pre-
 vails to an extent influenced  and limited by
 these occasions and by the numbers of the pre-
 disposed within the boundaries to  which infec-
 tion  has extended, and then subsides  ; some-
 times having exhausted itself for want of sus-
 ceptible subjects, when the circumstances fa-
 vourable to its diffusion  have continued with-
 out mitigation ; at other times subsiding with-
 out occasioning great fatality, when these cir-
 cumstances have  either  been  but slightly fa-
 vourable to its  propagation,  or  when others
 have tended to  arrest  or limit its extension.
 In most countries where these pestilences pre-
 vail without attempts  having been made  to
 limit  or destroy the infectious agents, they are
 perpetuated, by communication with the siek,
 and  by the clothes of the infected, in  solitary
 or scattered cases—scattered more or less pro-
 fusely in some localities, and in certain sea-
 sons, than  in others—until the favourable oc-
 casions of temperature, humidity, and stillness
 of the air, conjoined  with  susceptibility and
 crowding  of the  population,  have developed
 them into an epidemic prevalence.  In  other
 countries  or climates,  where  the infectious
 agent is destroyed, or is allowed to extinguish
 itself by removing it from the reach  of sus-
 ceptible subjects, or where  it dies away from
 the occasions requisite to  its propagation being
 absent, the pestilence is no longer  heard of for
 a time, until an  infected person  or  infected
clothes  again introduce the distemper, which 
246          PESTILENCE, SEPTIC OR G

becomes more or less prevalent according as
circumstances favour its spread ;  and thus it
may prevail, then subside, extend to another
place, disappear, return, and become epidemic
in succession in various situations, as  usually
observed in respect of the plague in the Le-
vant.   The opposers of infection — the sup-
porters of the doctrine which attributes all the
effects observed  in  the course  of epidemic
maladies to epidemic constitutions or influences
merely—to "foyers  epidemiques"—cannot pro-
duce a single epidemic  of any pestilence, the
several  phenomena of which can  be fully ac-
counted for by the agency or  influence which
they invoke, but of which  they can  neither
demonstrate the existence, nor assign any indi-
cations of its presence, beyond the mere cir-
cumstance of the spread of the distemper from
the sick to the healthy,  with more or less un-
usual  or remarkable frequency.  Now the  in-
fectionists contend that this propagation of the
disease is the result of a morbid effluvium pro-
ceeding from the sick and infecting the sus-
ceptible among the healthy, all other occasions
and circumstances existing at the time being
only aids of this efficient cause ; and they chal-
lenge  their opponents to  an examination  of
both doctrines with  an honest  regard to facts,
more especially to those facts which are open
to the  scrutiny of all  candid minds, and  from
which alone, and not from argument, the truth
is to be elicited.
   117.  The non-infectionists contend, as  a
proof that pestilences are not infectious, that
" they break out at a certain season, last  for a
certain time, and then subside and  remain dor-
mant until a favourable season returns;" while,
on the other hand, they assert that " contagious
diseases can be propagated at any time and
among any number of persons ;" and that " a
disease  depending upon a specific contagion
must prevail alike in all seasons, in a pure as
well as  in an impure atmosphere, among the
rich as  readily  as among  the  poor; and that
the only influence of these adventitious  cir-
cumstances would  be to  render the  disease
more or less severe."   Now I have, on more
than one occasion, accused the non-infection-
ists of ignorance  of that science with which,
unfortunately for the causes of humanity, they
have meddled ;  and some  may have supposed
the accusation harsh, or even ill-founded ; but,
can a more convincing proof of the fact he ad-
duced than the very arguments they have em-
ployed to  support their doctrine — the  very
weapons which  they have wielded in a  conflict
involving the interests of the community]  Is
there  one medical  man — one who  has the
smallest right to  a title, which should claim
respect  from all well-constituted minds—who
could make the assertion contained in  the lat-
ter part of the above quotation, with the least
shadow of truth  as  regards any one disease
which is either contagious or infectious]  On
the contrary, it is known to all who have either
observed  for themselves, or read the observa-
tions of others, that all contagious or infectious
maladies, propagated in the natural  way, spread
readily at one time, and scarcely at all at an-
other ;  that hooping-cough, scarlet fever, mea-
sles, smallpox, and even rabies, are more prev-
alent at  certain seasons than in others; that
either of these maladies may for some time be
LANDULAR—Causes of Plague.

 rarely or never  seen,  then break out, and be
 more or less prevalent.  There is  no disease
 more demonstratively both contagious and in-
 fectious than  smallpox,  or in  many respects
 more analogous to plague.  Now  let us see
 what was  the usual  mode of its appearance
 before it  was controlled  by  inoculation  and
 vaccination.   Before smallpox was thus inter-
 fered with, it is  well known that it used to lie
 dormant, then appear, rage for a time, and then
 subside, like those pestilences now considered,
 and  which have been imputed by the non-in-
 fectionists to epidemic influences.   There can
 be no  greater authorities  adduced respecting
 smallpox, before the introduction of inoculation,
 than Sydenham, Boerhaave,  and Van Swie-
 ten; and  they  describe it as appearing  and
 running  its  course like  epidemic  diseases.
 Sydenham  remarks that "one and  the same
 disease kills an infinite number at some certain
 seasons, and at  another time seizes  only here
 and  there one, and goes no farther; and this
 is very apparent in the smallpox, and especial-
 ly in the  plague."  Boerhaave observes that
 " this disease is generally epidemical, begin-
 ning  in  the  spring,  increasing  in  summer,
 abating in  autumn, ceasing almost entirely in
 the following winter,  to return again in  the
 spring;"  and Van Swieten states, "I have
 seen  many  variolous  epidemics,   and  they
 agreed in most  things with  the observations
 of Sydenham."
   118. B  So much for the medical knowledge
 of the non-infectionists as  evinced by their ar-
 guments, and on occasions when exact knowl-
 edge, and not ignorance, should have been put
 prominently forward.   I  shall next furnish an
 example of the  " suppressio vcri"—of the hon-
 esty of their arguments.   " People are attack-
 ed," states a pillar of the non-infectious faith,
 " not in proportion as the inhabitants of the
 affected mix with  those  of the unaffected pla-
 ces,  but in proportion as  the inhabitants of un-
 affected expose  themselves to the  air of Af-
 fected  places.   The visits of the sick to  un-
 affected  places  is  [are]  followed  by no in-
 crease of  disease ;  the  visits of the inhabi-
 tants of an unaffected to an affected place is
 [are] attended with a certain increase of sick-
 ness.  On  their removal from a noxious to a
 pure air, the sick often  rapidly recover;  but
 they do not communicate the disease to the in-
 habitants  of a pure atmosphere."  Now I can
 affirm that, amid the numerous worthless state-
 ments which I have been doomed to peruse—
 of the multitude  of medical facts or medical lies
 which  have come before me—none has been
 more impertinently false  than the above.  The
 short passage now quoted conveys, with its un-
 mitigated falsehoods  and  bad grammar, two
 distinct propositions, in  several  ill-expressed
 forms :  1st. That when the people of htallhij dis-
 tricts visit the affected districts, they lake the  dis-
 ease  not from the sick, but from the air; 2dly. That
 when the  sick move from an affected to a healthy
 district, they speedily recover, and do not gice the
 disease to  others.   These propositions are the
 basis upon which the  non-infection  faith repo-
 ses,  and are extended by the apostles of this
 faith to the three pestilences which I have been
 considering.  I shall,  therefore, bestow some-
 what more notice  on them than they deserve,
I and  show—what, indeed, most of what I have 
PESTILENCE, SEPTIC  OR GLANDULAR—Causes of Plague.         247
adduced  in any way connected with the sub-
ject must have already shown—that they are
as baseless as the visions which haunt the im-
aginations of the trembling  and sickly drunk-
ard when deprived of his accustomed stimulus.
Having demonstrated the non-existence  of the
grounds upon which a belief in non-infection is
based, this most dangerous doctrine—a doc-
trine pregnant with the worst consequences to
the community—is consequently swept  away,
and entirely  removed  from  rational minds, a
belief in it being rfterely a matter of history,
and an illustration of the progressive advance-
ment of the human mind.
   119. a. If, according to the first proposition of
the  non-infectionists, those who come out of a
healthy into an infected district take the distemper,
not from  the sick, but from the atmosphere of the
district, then it follows that those who avoid the
sick, or the clothes of the sick, shall be as lia-
ble to the distemper as those who approach or
touch them.   Now  is  this  the  case with the
plague, or with any of  the other pestilences I
have discussed ]  The  contrary is  so notorious
as to require no farther demonstration than it
has received in  the preceding articles; and  if
farther demonstration be required, let a mere
reference to the numerous  instances of the
protection afforded by seclusion in the midst of
an infected population, on  occasions of the
prevalence of either of these pestilences,  be
sufficient ;  and a sufficient  number  of  these
instances has been  adduced, in the course of
the  preceding  pages,  to  satisfy  the candid
mind.  Let the reader  peruse the  facts I have
adduced, proving, as respects each of  these
distempers, that the healthy will  remain pro-
tected amid a dense infected  population—while
surrounded by the sick and the dead—as long
as seclusion and avoidance of all  communica-
tion with infected persons or infected clothes
are observed.  These facts are undeniable, and
are not to be assailed by the loose statements
of  ignorant men, expressed in the bad gram-
mar, and worse English, indicative of minds
insufficiently informed  for those investigations
which are  necessary to elicit the truth, and to
trace its relations to matters held  in dispute.
   120. b. The second proposition, that when the
sick move from an affected to a healthy district,
they speedily recover, and do not give the disease
to others, has been sufficiently characterized  by
me above (y 118), and is entirely false, as may
have already appeared from what I  have ad-
duced  in various places.   That  the infected
should be less severely attacked when remov-
ed from  crowded, close, low, or  ill-ventilated
places, to  dry,  elevated,  and well-ventilated
situations, may be inferred.   It is one of the
circumstances most strongly insisted upon  by
the infectionists, with  reference to the  three
grand pestilences of modern times ; and  it has
been more  efficiently acted upon by them than
by their opponents, as demonstrated at Gibral-
tar and other places.   But,  unfortunately, nu-
merous exceptions to the generally good effects
of removal occur;  for, once the  infection has
taken place—once  exposure to infection of a
manifest  or concentrated kind has occurred—a
severe and  fatal grade  of distemper will often
be developed notwithstanding that the removal
to a pure atmosphere has immediately followed
the infection.  Instances proving this fact are
 numerous, and too familiar to every experienced
 observer, as respects the three pestilences un-
 der consideration, to require a more particular
 notice than that which has been  already taken
 of the subject.  It has, moreover, been shown
 that a more or less elevated temperature and
 stillness of the air are necessary elements in
 the development of the epidemic  prevalence, of
 at  least  two of the pestilences in  question, if
 not of all three ; and, consequently, it follows
 that a reduction of that temperature  and free
 ventilation will be  favourable to the infected,
 and will  be more certainly secured by removal
 Hence removals, with  advantages as to tem-
 perature and  ventilation, will prove more es-
 pecially beneficial.  But it may be inferred that
 a  removal, even to a purer air,  when the re-
 duction of the temperature of that air is slight,
 will not be so manifestly advantageous  as when
 it  is much more considerable.   Thus it was
 shown, on a very recent occasion, that when
 the crew of the " Eclair" steam-ship, the in-
 fected  and the healthy, were removed from this
 vessel, which, according to the non-infection-
 ists, was the cause of the disease to all those
 who were  not exposed to malaria in Africa,
 and were landed at Bona Vista, the distemper
 was not thereby mitigated  in any degree, but
 continued to spread among the crew, and sub-
 sequently to the inhabitants of the island.
   121. The assertion made  by the writer quo-
 ted above (y 118), that the visits  of the sick to
 unaffected places are not followed by the propa-
 gation of disease, is the most outrageous and
 unblushing falsehood which has ever desecra-
 ted medical doctrine or disgraced medical wri-
 tings—a  falsehood, moreover, which, if believed
 in  and acted  upon, would on numerous  occa-
 sions endanger the lives of the majority of the
 community in every civilized, or even partially
 civilized, country.   Can such an assertion de-
 serve  the  least notice,  after the numerous
 proofs to the contrary adduced in the preceding
 pages ]—after the  instances I have referred to
 —and thousands more  might have been men-
 tioned  if my limits could  have admitted  them.
 I shall, however, notice two which I have just
 seen in the course of my reading.  Mr.  How-
 ard, in his celebrated work, states that " when
 the plague raged in London in 1665, the  infec-
 tion was conveyed by  means  of a parcel  of
 clothes to  the remote  village  of Eyam,  near
 Tidewell, in the Peak of  Derbyshire.   In this
 place it broke  out in September, 1665, and con-
 tinued  its ravages upward of a year, when 260
 of  the inhabitants had died  of it."  " In the
 surrounding fields are many remains denoting
 the places where tents  were  pitched ; and
 tombs are still existing of large families entire-
 ly  swept away by this  devouring pestilence."
 (P. 24.)  The  plague is very  rarely introduced
 into Arabia, the passage across the desert, and
 the state of the climate in many parts of the
country,  being unfavourable to  the  develop-
 ment  and spread  of its  infection ; and  it  is
generally admitted that the pestilence has nev-
er  appeared there  unless when  imported, as
was the case in 1815, by the army of Mohammed
A li, which crossed the desert  into Arabia on
an expedition against the Wahabees.   Dr. Bab-
ington, the eminent physician to  Guy's Hospi-
tal, who came  over land from India at this time,
remarks,  in a  communication to Dr.  Gooch' 
248         PESTILENCE,  SEPTIC  OR GLANDULAR—Causes  of Plague.
that the plague had  then visited Yambo and
Jedda, and crept down the coast as far as Gam-
fada, and that  each  of these towns had lost
nearly half the population.  He, moreover, adds,
that when he was at Milo, in the end of 1815,
a vessel came into the port having one  person
on board ill with the plague.  This vessel was
ordered  by the  Greek authorities to quit  the
harbour.  She put into  Mitylene, where those
in command, being less cautious, allowed  the
sailors  to land, several of whom had by this
time become infected.  The distemper imme-
diately afterward broke  out among the  island-
ers, and many fell victims to it.   It is unneces-
sary to adduce  farther  proofs not only of  the
utter worthlessness, but of the insane reckless-
ness of the assertion, which I have  now suffi-
ciently noticed.  Indeed, the full evidence  I
have brought forward of the infectious  nature
of each of the pestilences considered  under this
head,  completely overthrows the position so
rashly assumed  by the non-infectionists.
  122. But, as  shown above, and admitted by
the contagionists or  infectionists  themselves,
the plague is not  always propagated ;  when
those sick of it, or the clothes of the infected,
are removed to a place or places which is alto-
gether healthy,  or free  from the pestilence.
This circumstance has  been fully explained ;
but because, like all other infectious  maladies,
this requires certain conditions for its epidem-
ic prevalence, and because it is not universally
diffused ; because it is not widely and generally
propagated on all occasions and circumstances
whatever, the non-infectionists raise an argu-
ment against its infectious nature.   The occa-
sions and circumstances favouring the  spread
of this distemper are hereafter shown  (y 124,
127, et seq.), and those preventing the propaga-
tion of it also stated (Y 126).   That there should
exist such occasions, is only in accordance with
the laws of nature, and with the phenomena
characterizing  all acute  infectious  maladies.
The same takes place in respect of the small-
pox and the rest of the exanthematic, and it is
notoriously the case as regards the other pesti-
lences.  Before the  introduction of inocula-
tion, smallpox,  as respects its epidemic preva-
lence,  presented the same laws as the plague
and other infectious maladies which  frequently
appeared in an  epidemic form.  Van Swieten,
who saw the smallpox when it was propagated
only in the natural way, remarks  as follows :
" I have sometimes observed large towns to be
free from the smallpox,  while it raged epidem-
ically in the neighbouring villages ; and, on the
contrary, some large towns universally  visited
by the complaint, while the villages in  the neigh-
bourhood remained in health, though  the  in-
habitants of both mixed daily with each other.
I also perfectly remember that I once removed
two patients of mine from a place where  the
smallpox raged to a large town, without propa-
gating the contagion there; and many excel-
lent physicians, with whom I have  cultivated
a  friendly commerce with respect to medical
knowledge, testify that they have observed  the
same thing."   A similar fact is mentioned by
Sir John Pringle.   He states that "  the small-
pox, being carried into  a  camp by some new-
jaised recruits, quickly disappeared without be-
coming general, although  it is notorious that
other camp diseases are but too apt  quickly to
spread themselves."   Dr. Odier, in a letter
from  Geneva to Dr.  Haygarth, says : " We
have frequently inoculated, at Geneva, a great
number of children in the years during which
the smallpox was not epidemic ;  these children
have gone out every day, even after the erup-
tion had broken out; they have been  in the
streets, and  in  the public walks;  they have
communicated freely with other children sus-
ceptible of the infection, and not only the small-
pox did not spread, but there did not occur, to
my knowledge,  any distitfct  instance of the
communication  of the disease from one indi-
vidual to another in the streets or promenades."
  123. I have now taken as much notice of the
chief arguments  of the non-infectionists as they
deserve.   Who will not  be convinced by what
has been  adduced above, are not likely to  be
convinced of the infectious nature of the pesti-
lences here considered, by anything whatever
that may be advanced.  I can only add, for the
consideration of the inexperienced and incau-
tious, that, after what I have stated on the sub-
ject, with a perfect conviction of its truth, and
after the fullest and most extended research it
was in my power to bestow upon the subject.
if they neglect those measures which are cal-
culated to prevent infection, in the several cir-
cumstances in which it may be likely to appear
and extend;  if they act  recklessly,  as the nu-
merous occurrences of these pestilences have
presented many examples, and despise the doc-
trine of infection and all protective  measures,
they will open the flood-gates of an overwhelm-
ing calamity, in which they themselves, among
many others, may be  swept away ;  or, if they
should survive,  they will have an  account to
settle with their own consciences of no small
amount.   At the present day, persons are en-
deavouring to overturn belief in a doctrine moat
essential to the  safety of the community, and
are attempting to oppose their opinions to the
views  and doctrines inculcated by the master
minds in  our science—inculcated for the pro-
motion of the best interests of humanity, and
inculcated, moreover, with a perfect conviction
of their truth.
  124. iii. There  are some circumstances which
predispose to,  and others which appear to counter-
act, the infection of plague, besides  those just
referred  to.  My limits  will only admit of a
brief notice of them.—a. It has already been
remarked that extremes of temperature arrest
the spread of this pestilence.   It has long since
been stated by Volney and others that the win-
ter temperature  of Constantinople puts out, but
that spring and summer heats rekindle, the dis-
temper.  But it  is very  questionable whether
or not the infectious miasm is destroyed by the
cold, or is merely rendered inoperative or dor-
mant ; and, although  the spring and summer
heats  resuscitate  the pestilence,  it  is very
doubtful whether this effect is produced by the
generation of the distemper de novo, by the in-
fluence of a higher range of temperature upon
the decomposing animal exuvise and other ma-
terials ; or whether the  dormant infection is
thereby rendered operative and called into ac-
tivity, or even whether the  infection is intro-
duced  on several occasions,  and  at several
points, by infected vessels and travellers, and
especially by  the numerous pilgrims returning
to or passing through this city, and that the 
PESTILENCE, SEPTIC  OR GLANDULAR—Causes  of Plague.         249
infection spreads as soon as the occasions fa-
vourable to its extension supervene.  That this
last is the true reason of the prevalence of the
distemper during summer in this city is shown
by the almost total disappearance of  it since
quarantine regulations were adopted  in 1839.
In Cairo and other towns in Lower Egypt, as
well as in  some parts of Syria, where the win-
ter temperature is much higher, the  distemper
becomes epidemic, or, at least, more or less
prevalent, usually at a much earlier period of
the year, generally in March, April, and May,
and subsides when the temperature rises above
75 or 80°.
   125. b. It is, however, not so much the tem-
perature as the humidity of the air which fa-
vours the extension of this  pestilence, and  the
former may be  said to be operative only when
it is conjoined  with  great humidity.  This is
evinced at Constantinople,  where the air is
very humid in spring and summer,  owing to  the
influence of the adjoining seas, the  extensive
forests, and  high  ranges  of mountains.   In
Lower  Egypt and Syria, especially  in places
near the coast, the winter and spring are  hu-
mid and rainy, and  the atmosphere  close and
still;  and although  the range  of  temperature
is not high, still the close and moist air favours
the accumulation of the emanations proceed-
ing from sporadic cases of the pestilence, or
from  clothes  retaining these emanations, and
renders those exposed to them more  suscep-
tible of their influence.   When, however,  the
atmosphere becomes dry,  whatever  may  be
the range of temperature, the  pestilential  mi-
asm loses much of its power, and the popula-
tion, or those exposed to it, much  of their sus-
ceptibility.  It is, therefore, chiefly  owing to  the
combination of heat with humidity that the for-
mer is influential in the diffusion of  this pesti-
lence.
   126. c. The winds have no mean influence in
the development and spread of plague, espe-
cially in the East. At Constantinople, the north
wind, called the Tramontana, which is dry  and
cool,  prevents  or arrests the progress of  the
distemper; while the Sirocco, or south wind,
which is both warm and moist, favours the de-
velopment and spread of the  malady.  High
winds, especially when they are dry, remarka-
bly diminish the infectious disposition, and re-
strain  and arrest the propagation of  the  dis-
ease,  chiefly  by dissipating and  diluting  the
miasms proceeding from the infected,  and giv-
ing rise to freer ventilation in crowded streets
and houses.  The salutary effects  generally de-
rived  from placing infected  troops or  commu-
nities in tents, upon a dry, arid, or healthy soil,
proceed chiefly from the readiness with which
the winds pass under the tents and dissipate
morbid emanations, or dilute them  so as to ren-
der them inoperative.  Dry winds, also, render
the human constitution less susceptible of con-
tagion.  Thus it has repeatedly been observed
that the Harmattan, a remarkably dry north-
east wind, occasionally blowing  for  several
days on the west coast of Africa, suspends  the
infection of smallpox, and that even  iuocula-
tion of that disease is  generally inoperative
while it blows.
   127. d. The electrical conditions of  the atmo-
sphere have been supposed  to be more or less
influential in producing epidemics of plague and
of the other two pestilences ;  but the particu-
lar electrical conditions have not been shown,
the negative state being  most frequently  ac-
cused.  Very probably electricity, as  it circu-
lates  through the animal economy and  other
objects on the earth's surface, and passes  off
into the atmosphere, by its varying states and
its influence upon the nervous system, impairs
in some cases,  and increases in others,  the
nervous  power  and vital resistance  of  the
frame, thereby rendering them more  or less
disposed to the  invasion of infectious agents,
and, as observed in respect of its influence on
dead  animal matter, imparting more or less of
a septic tendency to the fluids and soft solids.
Still,  the actual amount of influence  of this
agent on the living body is unascertained, and
probably much exaggerated by many, especial-
ly by those who  impute  epidemics to atmo-
spheric conditions, without admitting the effi-
cient  agency of specific infection.
   128. e. Local or endemic  conditions have been
much insisted upon by some  writers,  and  by
several of those  who have communicated with
the French Academy on the subject of plague ;
these conditions, especially  the accumulation
of animal exuviae, the decomposition of dead
animals,  incomplete modes  of human sepul-
ture, and burying the dead in vaults and crowd-
ed  churchyards  situated within or nearly con-
tiguous to towns and cities ; imperfect drainage,
and the passage of decomposing animal fluids
and excretions into cess-pools,  into a low, wet,
and rich soil, or  into canals,  open drains,  &c.;
collections of animal and vegetable matters left
to decompose in the air surrounding low, damp,
and ill-ventilated dwellings,  or in narrow and
crowded streets; living in cellars or in  close
apartments on the ground, and  having merely
the soil  impregnated with animal secretions
and the fluids from  animal decomposition,  for
a  floor ;  adjoining  marshes,  estuaries, low
grounds  subject  to  inundations,  ruinous and
obstructed  canals, stagnant waters,  &o. ; a
deep, rich, and humid soil, accumulated for ages
from  the decay of animal and vegetable matter,
and from the mud and slime  produced by  re-
peated inundations and evaporation by a warm
sun ;  scarcity and unwholesome food, and  the
use of water contaminated by  animal  mat-
ter, by the decomposition  of organized bodies,
or by the infusoria,  severally  exert no mean
influence in  the development  and spread of
plague and  other pestilences.   It is  seldom,
however, that one or two merely of these con-
ditions are found existing in  a locality or  town
in the East  without being associated with oth-
ers, or even with nearly all those now enumer-
ated ; and if they be singly  injurious, as they
roust  he  admitted to be,  how much more  so
must  they  prove when  associated, and  the
emanations  from  them are elicited by  heat,
and accumulated in  a humid and stagnant  at-
mosphere.   It is  to the combination of a  num-
ber of these, aided by moderate  warmth and
humidity, that many recent writers impute, as
I have shown above (y 106, et seq.), the genera-
tion of this pestilence de novo,  and its endemic
and sporadic  existence ;  while  others  have
maintained, in opposition to  this view, that, so
far from these circumstances having generated
the plague, or given  rise to sporadic cases, or
to an  endemic form of the pestilence, they have 
 250         PESTILENCE, SEPTIC OR G

actually been unfavourable to the prevalence of
it when it has been epidemic, and that quarters
of cities where they have been most remarka-
ble have suffered the least from it on these epi-
demic occasions.  It has been stated, even by
the supporters of the origination of this distem-
per in these causes, that the Jews' quarters,
and others the most filthy, and combining most
of the conditions just specified, have  suffered
the least  in various epidemics which ravaged
Cairo, Smyrna, and other towns  in the East;
and an argument against the accuracy of their
own views, as to the  origin of the pestilence,
has thus been furnished by themselves.
   129.  There can be no doubt of  the injurious
influence,of these causes, acting either singly
or in combination,  upon human health ;  and of
the fact of putro-adynamic fevers, typhus, ady-
namic dysentery, and other maladies having ori-
ginated in a combination of two or more of
these circumstances, more especially when aid-
ed by warmth, humidity, crowding, and imper-
fect ventilation ; but that they generate de novo
this pestilence, may be disputed, as shown above
(y 41), or even  that  they constitute  the sole
source or  centre of epidemic influence  during
fatal prevalences  of this distemper.   Indeed,
the  precise part which these circumstances
perform, the  amount  of influence which they
severally  or conjointly exert in the generation
or in the  diffusion of this pestilence, has not
been clearly ascertained.  Their noxious influ-
ence has been more a matter of inference than
of demonstration ;  and numerous facts seem to
show that other circumstances, often  associa-
ted with  these,  although not necessarily con-
nected with  them, are  more  concerned than
they in the spread of the distemper; that crowd-
ing, and the close and frequent communications
with infected persons, and pestilential emana-
tions from the clothes  and  bedding of  the af-
fected, and  from their  persons,  and  the con-
centration of these in  a stagnant and humid at-
mosphere, are the principal and efficient agents
of general infection ; and that the several local
or  endemic states above enumerated (§ 128)
are operative chiefly in  as far as  they concen-
trate or accumulate these emanations, and pre-
vent their dilution or dissipation in  the sur-
rounding  air, [and displace pure air.—T.]
   130. /. Modes  of sepulture  have not  received
due attention, especially with reference to the
generation and diffusion of pestilential diseases.
In many places in  A\frica, especially among the
pagan  and negro  tribes, and even among the
Copts, the dead are  generally buried  in the
houses or huts of the living; and as many of
the dwellings have no  other floors than the
earth itself, it must follow  that,  in the more
populous and older towns, a most fruitful source
of disease exists in the very  dwellings of every
family.  This practice may be concerned in the
origination or propagation of the haemagastric
and septic pestilences,  especially the  former;
but how far it is actually so  concerned cannot
easily be  determined.  That it is  injurious  to
health, cannot  be  disputed.   I believe  that it
is more influential in the generation and spread
of pestilence than the other  local  causes above
specified (y 128), especially in humid and stag-
nant conditions  of the  atmosphere, and when
aided by several of these causes.   It was ob-
served, during the  French Revolution, that the
LANDULAR—Causes of Plague.

 trenchings, &c., made in many burying-grounds
 in order to obtain nitre, occasioned malignant
 fevers.  And M. Borrini, secretary to the sana-
 tory establishment at .Alexandria, states that a
 cemetery  near the city, in which  more than
 500 bodies were interred, during  the plague of
 1834 and 1835, was opened in 1837 for the foun-
 dation of an edifice, and the plague appeared in
 the following spring.  But it is difficult to de-
 termine, in this instance, how far this circum-
 stance was concerned in originating or in propa-
 gating the distemper of the following spring.
 Although facts have been adduced having some
 reference to  this matter, they have been super-
 ficially observed and loosely described.   That
 these occurrences are productive of malignant
 fevers  and  adynamic  dysentery,  cannoi  be
 doubted.  I have met with instances of ady-
 namic and putro-adynamic or malignant fever,
 which have proved fatal as early as the sixth
 day, caused by the foul air emitted from bury-
 ing-grounds  and  vaults  in this city, and that
 foul  air from similar sources in warm climates,
 and even in colder countries in warm seasons,
 and in a more concentrated form, should occa-
 sion plague, is not improbable,  although not so
 fully demonstrated.  The  evidence as to the
 origin, de  novo, of the specific form of pesti-
 lence now under consideration from this source,
 is too deficient to admit of my connecting them
 as cause and effect.   The  subject requires far-
 ther investigation before either the affirmative
 or the negative can be admitted.  There is one
 circumstance which may  be mentioned, that,
 although in the great plague of London about
 100,000 dead bodies were put in the  ground
 very near densely-inhabited places in London,
 and although they were thrown into pits, each
 containing many thousands, and were covered
 only by a shallow layer of earth, still this pesti-
 lence was not continued during the years im-
 mediately following ; but a malignant typhoid,
 or putro-adynamic  fever, caused  by the efflu-
 vium proceeding  from the  burying-places, and
 an  adynamic or  putrid dysentery, occasioned
 by the water contaminated by these sources,
 were remarkably prevalent in  London during
 several years immediately consequent upon the
 plague.  Similar  occurrences are recorded to
 have followed very fatal epidemics of plague in
 other cities, but their causes have rarely been
 recognised or even inquired into.
    131. It is, indeed, a matter of surprise that a
 chief source  of the most malignant diseases—
 a source rendered manifest to the  senses in the
 most disagreeable manner, and so easily con-
 nected with  its effects—should be allowed so
 long to exist in civilized countries, and more
 especially in this, without the least interfe-
 rence ;  but this is  only  one of numerous in-
 stances of the disregard of health and life by
 governments in which particular classes obtain
 the power of legislating for  their own  inter-
 ests, and  in  favour  of property,  with a  total
 disregard of  the public health, and of the pro-
 tection  of human life.   The loaf of bread ex-
 posed to the tempted gaze of the starving is
 protected  from his grasp,  and the miserable
 wretch who cannot withstand  the temptation
 placed in  his way is made  the subject of the
 severest punishment, contrary to the Mosaic
 law, so conveniently adopted in other matters;
 while the interests involved in the traffic of 
PESTILENCE, SEPTIC  OR GLANDULAR—Causes of Plague.          251
burial  vaults  and grounds in the  midst of
crowded localities, prosper by the  increasing
amount of mortality  they produce ;  and, while
the proprietors are fed  and made rich by the
very deaths they occasion, their interests are
respected by the law and by the legislature, and
the murderous traffic is allowed to  proceed.
But this is not the only way in which the pub-
lic health  and  human life are  made the whole-
sale objects of commercial speculation and pri-
vate gain, protected by the glorious stringency
of the laws in  behalf of property.  The vender
of poisons, whether with the  intention  of de-
stroying, or with the avowed object of restor-
ing health, is allowed to pursue his murderous
vocation not only without hinderance, but is ac-
tually more efficiently protected in the exer-
cise of it than  the educated and scientific phy-
sician, who has devoted his whole energies to
the honest and  salutary  performance of what
he professes.  Both  kinds  of depredators on
human life have obtained, by the favours of the
laws and  of the expositors of these laws, by
the forbearance of the  legislature, by the ig-
norance of the  aristocracy, by the devotions
paid to wealth to the neglect of worth, and by
the  state of society generally in this country,
vested  rights  in  their vocations;  and  at the
present day they are  encouraged by church
and state, and even  applauded by numbers in
the community, during the unblushing exercise
of their hideous  iniquities—
   " Murders most foul, as in the best they are ;
     But these most foul, strange, and unnatural."
   132. g. There  are few causes more  acces-
sory to the prevalence of plague than scarcity,
and unwholesome  articles  of food.  Insufficient
and unhealthy nutriment  increases  the septic
tendency so remarkable in this pestilence, and
favours glandular enlargements.  The use of
tainted animal food, of half-putrid meats and
fish,  of unripe or injured  grain, and of numer-
ous other unwholesome articles, often partaken
of during  periods of scarcity or want, although
not originating the pestilence, certainly increa-
ses the susceptibility to,  and  the spread of, in-
fection.   Hence the remarkable prevalence of
the distemper on several occasions when the
infection  has been introduced  into a place sub-
ject  to scarcity  or famine.   Fatigue, all ex-
hausting  causes, especially sexual indulgence,
mental depression, dread of infection, and want
of sleep, dispose the system to an attack.
   133. h.  There is much difficulty in determin-
ing the influence  of sex, age, and occupation in
favouring  the infection  of   this  pestilence.
Much  depends upon  the exposure  to  which
each is liable during an epidemic ; and this will
necessarily vary in different countries and epi-
demics.  There is no doubt of medical men and
hospital attendants, and next to them the min-
isters of religion, having  been more frequently
attacked than any other class—a circumstance
altogether arising from their greater exposure
to infection.  All those who were employed in
burying the  dead, in removing and attending
upon the  sick, or whose avocations brought
them in contact with the affected, or with their
clothes, or even  near to them, have rarely es-
caped in any epidemic of which particular ac-
counts have been furnished, unless they were
protected  by previous attacks of the pestilence.
It is said  that  the water-carriers, and the  oil-
 pressers and preparers in Cairo and other Mo-
 hammedan cities, generally have escaped, and
 that the immunity of these classes was very
 evident in  the epidemic of 1835. Tanners, cur-
 riers, and  skin dressers have been found more
 exempt  from plague than  other  artisans, as
 shown in numerous epidemics in both Europe
 and the East.
   134. i. The  plague,  like smallpox, spreads
 more rapidly, generally, and fatally among the
 negro and  other dark-skinned races than among
 the  Caucasian race.   In  this  respect it is op-
 posed to the haemagastric pestilence, which at-
 tacks more especially  the  latter.   It was ob-
 served in the Egyptian epidemic of 1835,  that
 the negro  inhabitants were attacked and died
 in much larger proportion  than others.  The
 natives of countries, also, approaching the trop-
 ics,  and even of those of the south of Europe,
 have been  considered more liable to the plague
 than those of the  north ;  and  persons  having
 weak and  susceptible  nervous systems,  and
 feeble or disordered digestive organs, also have
 been said to be more predisposed than others;
 while those who are labouring under diseases
 attended by purulent or other  discharges gen-
 erally escape.  Larrey remarked that the sol-
 diers who  had  been wounded,  or had sores or
 ulcers,  were  not attacked so long as their
 wounds or sores yielded a puriform  discharge,
 but that  they were not unfrequently seized as
 soon as the discharge ceased.   During periods
 of the plague in  Europe,  numbers  of persons
 have had  recourse  to  artificial purulent  dis-
 charges  as a prophylactic  measure, and  fre-
 quently with  success.
   135. iv.  The hypothesis of insect life as a cause
 of disease has been applied to plague and other
 pestilences.  Dr. Holland  has discussed  this
 hypothesis, in connection with the choleric pes-
 tilence, with great ability and eloquence (Medi-
 cal Notes and Reflections, &c, 8vo, Lond., 1839,
 p. 560), and adduced every consideration that
 can be entertained in its favour.  Much of what
 may be said regarding the origin of  that pesti-
 lence in  this  cause is equally applicable to the
 plague.   Admitting that swarms of insects  suf-
 ficient to cloud or to obscure the atmosphere
 may exist  in  it, and yet be so  minute individu-
 ally as to elude the unassisted vision ; that the
 numerous  infusoria, &c, detected in fluids by
 powerful instruments is a strong argument, from
 analogy,  in favour of this opinion ;  that these
 swarms of insects may be generated from the
 decomposition of dead  animal matter, and that
 the circumstances which  favour such decom-
 position may  also favour other modes of exist-
 ence too minute to be detected by our grosser
 senses ;  and  admitting, moreover,  that  these
 insect swarms may be  inhaled  into  the lungs,
 or be absorbed, they or their  ova, from  these
 and other surfaces, and occasion the  most nox-
 ious and fatal effects, and that they may so trav-
 el as to explain certain courses taken by this
 and the choleric pestilence, still there are many
 facts and considerations which weigh strongly
 against  this hypothesis.  Indeed, all that  has
 been adduced against the opinion of the atmo-
 spheric origin of these pestilences apply equal-
ly to this doctrine.  If swarms of insects pass-
ing through, or floating  in the  air, too minute
to be perceived, and hence capable of passing
into  the circulating vessels, and there produ- 
252
PESTILENCE, SEPTIC OR GLANDULAR—Causes of Plague.
cing fatal distempers, were actually capable of
occasioning what  has been imputed to  them
in respect of either of the pestilences in ques-
tion, we should expect a more or less simulta-
neous  affection of the population of the dis-
trict through which they passed ; and seclusion
or separation could  not  be  viewed  as  being,
more likely to protect from this cause than
from the atmospheric constitution contended
for by others.  It would be  difficult, also, to
connect what can be believed possible of such
insect swarms with the several epidemic man-
ifestations, and sporadic or endemic appearan-
ces of this and the other pestilences.
   136. But these insect swarms have not been
proved to exist in connection with individual
cases,  or with  the  epidemic  prevalence  of
plague or other pestilence.  Those  manifest
and palpable swarms which  have been  occa-
sionally observed in most countries, to such an
extent as to darken the air, and to colour  the
objects on which  they rested, and which fur-
nish the  chief argument  for the  existence of
those supposed to be productive  of plague or
other pestilence, have not been found destruc-
tive  of  human  life,  although  productive  of
more or less disorder.  The transmission, also,
of these  distempers from one place to another,
the transport of plague from the east to places
jb the west or north of Europe, and the various
circumstances connected with the transport or
appearance of pestilence in various distant, or
even adjoining places, are not consistent with
insect swarms existing in the atmosphere.
   137. It is more  probable that  the  material
emanating from the infected, whether denomi-
nated the pestilential miasm, emanation, or ef-
fluvium,  and infecting the susceptible among
the healthy, either by direct  or mediate con-
tact, or by the respiration of  the air more im-
mediately surrounding the sick, actually con-
sists of innumerable, impalpable,  and invisible
but living and organized existences, generated
during the distemper, and thrown  off" as the
distemper proceeds, in so minute but specific
forms as not to be  visible  to the eye,  although
often admitting of  recognition by the sense of
6mell.   It is no very extravagant notion to
conceive, what has the support of numerous
circumstances and analogies, that during the
more or less  rapid  effluxion of the vitality en-
dowing the frame iu this and other pestilences,
the effluent vitality may associate itself with
certain materials or molecules furnished by the
diseased body, and thus may assume the state
of organized existences,  of specific  form, but
invisible and impalpable size, capable of infect-
ing the healthy, and, by means  of the malady
they produce, giving rise to similar specific ex-
istences, thereby propagating, spreading, and
perpetuating their kind.   These  innumerable
and invisible existences, or organized swarms,
whether thus equivocally generated by changes
in the states of vitality and organization in the
highest of animals, or capable of perpetuating
themselves by ova, may be supposed to assume
certain determinate forms in each specific pes-
tilence, the specific characters of which may
depend upon the determinate forms thus  as-
sumed, and  upon the manner these forms in-
vade and affect the organs of our frames.   It
might be futile to add more in favour of infec-
tioo by means of organized existences or para-
sites generated by the diseased, although much
more might be added  in support of the doc-
trine ;  but we well know that in proportion as
the vital energies of the frame languish or are
impaired, so are the parasitical animals peculiar
to each of the higher animals more numerous,
swarming, and fully developed ; and it is not un-
reasonable to  infer, that  as vitality, apparently,
changes its form, its conditions, and material
alliances in these cases,  probably without even
the intervention  of ova, and merely from  the
effluence of the vitality of the parent, and  the
combination of that effluent portion of vitality
with molecules of matter which it fashions into
certain  specific  forms,  and which, moreover,
although  thus equivocally  generated, it may
even endow with  the  power and with the or-
gans of reproduction.   Rejecting, therefore, on
the one hand, the doctrine of insect swarms
floating in the air and producing pestilence, as
being deficient in the evidences of their exist-
ence, and of their operation on the economy
consistently with the phenomena presented by
pestilence, and believing, on the other hand,
that the opinion as to the material or emana-
tion infecting the healthy is a living and organ-
ized material, consisting of innumerable and
invisible forms or existences given off from
the diseased body, has sufficient analogies and
other evidences in its favour, I would recom-
mend the future  investigation of this subject
by means of those aids which are now so much
employed in physiological and pathological  re-
searches.
  138.  v.  There  are certain conclusions respect-
ing the causes and propagation of plague at which
I am disposed  to arrive,  after the best consid-
eration  I could devote to these matters.   I be-
lieve that they are consistent with the best ev-
idence  I can obtain, and  with the actual state
of our knowledge.  If any of them be found in-
accurate, the disposition to correct them shall
not be wanting.
  139. a. The amount of evidence (as I do most
firmly believe  the proofs of the last century
equally  valid with those of the present) favours
a belief in the  communication of the plague by
contact  of infected persons or  clothes.   Al-
though the contact of these will very frequent-
ly fail  of producing  this effect, and although
the evidence  on  some  occasions may appear
equivocal, and admit of other special explana-
tions, still the  frequent infection after  the con-
tact of these, the sequence of occurrences, and
the connexion of sensations, conspire to the
formation of a well-founded belief that the re-
sult is produced in the way usually accredited,
  140.  b.  From what I have stated above, I in-
fer  that the inoculation  of the plague may be
effected. That while its accomplishment proves
the contagious nature of the pestilence, its fail-
ure, for the reasons I have given (y 96), cannot
be justly considered as  disproving the conta-
gious property;   and  that,  although the evi-
dence of the communicability of plague by in-
oculation is not quite complete, it is sufficient-
ly so, viewing  it in connexion with other modes
of propagation, to  warrant the  belief  that the
plague may be communicated in this way also.
  141.  c.  That in  addition to, and even  more
frequently than, the infection  by contact  of
persons and clothes, infection is produced by
the emanations or effluvia given off from the 
PESTILENCE, SEPTIC OR GLANDULAR—Causes of PLAaun,         253
 sick, and inhaled by the susceptible upon  near
 approach, remaining near or long with the in-
 fected, especially in humid and still conditions
 of the air, and in ill-ventilated apartments.
    142.  d. That the  pestilential emanation,  or
 effluvium, is absorbed and retained by bedding,
 bed,  and body clothes, more especially when
 these consist of animal products  ; and that, if
 these articles are shut up immediately, or  soon
 after they have been used by the sick, and ex-
 cluded  from the atmosphere, they may retain
 this effluvium, and  by giving it off upon expo-
 sure  to the air, they contaminate  the surround-
 ing air, and infect the susceptible who may re-
 spire the air thus contaminated.
    143. e. That numerous occasions may occur
 in which it cannot be determined  in which way
 or through what channel the infection is  con-
 veyed, although no rational doubt as to the ac-
 tual communication of the distemper from one
 person to another can be entertained, and that
 in many cases where the distemper appears to
 be communicated by contact, the proximity ne-
 cessary to this act  brings the susceptible  per-
 son within the sphere of infection produced by
 a pestilential effluvium, or emanation from per-
 sons or clothes.  Hence the  experiment made
 in 1835, in the Hospital Esbeki, at  Cairo, on
 two  criminals, who, after  having put on the
 body-clothes of two persons  who  had recently
 died of the plague, lay down on their beds, prove
 infection either by contact, or by the air con-
 taminated by the clothes, which were used and
 respired by the subjects of the experiments, or
 by both modes.  In these two instances infec-
 tion was manifested on the  fourth and sixth
 days.
   144. /. That the period during  which either
 the bodies of the  dead  or  the contaminated
 clothes may  retain  the power of  infecting the
 living has not been ascertained, and most prob-
 ably no particular period can  be assigned, as it
 may  rationally be supposed  to vary with the
 physical and other circumstances by which ei-
 ther source of infection is surrounded.   There
 can, however, be no doubt that the dead body
 retains the power of infection during  a period
 of considerable duration, and that  the same
 may be said  of the clothes and bedding of the
 infected, when these have been excluded from
 the influence of air and light.
   145. g. That, however we  may speculate as
 to the nature of the specific  miasm, effluvium,
 or  emanation propagating plague or either of
 the other pestilences, we only know actually
 that it is specific, or of a determinate kind, in
 each  distemper ; and that it  is so, is an infer-
 ence the truth of which is demonstrated by its
 effects, and especially by the  fact  of its propa-
 gating and perpetuating its kind.  The effects,
 as  well as other considerations, suggest the
 belief of a certain grade of vitality and organi-
 zation in the material given off by the diseased,
 and affecting the susceptible among the healthy,'
 and consequently of a specific conformation or
 constitution of the infecting  material in each
 distemper, and they  favour, but by no means
 prove, the idea of infection by the generation
 of invisible living existences  by the diseased,
 that, either directly or by contact, or mediate-
ly, or  by the air contaminated by  these exist-
ences floating in it, affect the healthy in a sim-
ilar and determinate manner.
    148. h. That the chief and most frequent chan-
  nels of infection are the  respiratory passages
  and organs ;  the air inhaled conveying with it
  the contaminating or infecting agent, whatever
  this may be,  and thereby infecting the healthy,
  whenever this agent is sufficient in quantity or
  concentration relatively to the susceptibility of
  the person exposed;  but that  infection may
  take place  in  some instances  and circumstan-
  ces from the cutaneous and digestive mucous
  surfaces, although much more rarely, and  mere-
  ly contingently.
    147. j. That we have  no valid evidence, in
  respect of plague, more than as  regards the
  other pestilences and the exanthemata, that
  this distemper may be generated de novo by cer-
  tain sources, namely, by the emanations from
  dead animal  matter, or from  the  exuviae and
  dead bodies of our own species, although  nu-
  merous circumstances  favour this doctrine,
  while others  militate against  it, and  support
  the opinion that the pestilence is  perpetuated
  by contagion  and infection, during circumstan-
 ces favourable to the communication of it; and
 that it is prevented from being extinguished by
 the transport of it from one place to another,
 its existence  and prevalence #n one or  more
 places, when  it  has  disappeared from others,
 furnishing the means of its return to those pla-
 ces from which it had entirely disappeared for
 a time.
   148.  k. That  many  of  the circumstances
 which suggest the doctrine of spontaneity, or
 the generation de novo of the plague, on occa-
 sions of its appearance and prevalence in pla-
 ces where  these circumstances exist in the
 most evident  manner,  remarkably favour the
 propagation and perpetuation of the pestilence,
 and, in  fact, constitute the  condition which has
 been denominated epidemic constitution, influ-
 ence, source,  centre, or foyer; but they require
 the presence  of the pestilential germ or  in-
 fection,  whether already existing sporadically
 or endemically,  as incorrectly termed, or be-
 ing latent in certain fomites, or imported  from
 more or less distant places, before the malady
 can be  developed and disseminated.
   149. /. The  period of incubation, or the  time
 elapsing from the moment of exposure to the
 infecting agent to that at which the effects be-
 come manifest, has  been variously  estimated.
 It evidently varies in duration with the concen-
 tration or amount of the dose of infection  rela-
 tively to the susceptibility of the recipient.  It
 maybe so short as not to admit of recognition,
 as in the occasion of a cart conveying a number
 of bodies to the pit dug  to receive them, when,
 upon the jolting of the cart, a most overpower-
 ing gush of foul air proceeded from the bodies
 which it contained, and almost instantly struck
 down a person who was near it, and who  died
 in an hour or two afterward;  and the period
 may extend to ten or eleven days.   The period
 has not  been  supposed to  be longer than this
 by most of those  who have communicated with
 the French Academy of Medicine on  this  sub-
ject.
   150.  77i. That an attack  of plague protects
 from a future seizure as certainly as an attack
 of smallpox, or of any other of the exanthemata,
 protects  from  a second infection.  That  this
fact, folly proved by Dr. Russell and others
 has not been sufficiently recognised by several 
254     PESTILENCE, SEPTIC  OR GLANDULAR—Mortality from Plague, etc
 recent experimenters;  although  it is of great
 importance in selecting attendants on the dis-
 eased, and in our speculations as to the propa-
 gation, prevalence, and sporadic or endemic ex-
 istence, of the pestilence, and as to the escape
 or  insusceptibility of many of those exposed
 to it.
   151. n. That the occurrence of infection from
 merchandise or goods, of any other description
 than clothes and bedding used by the sick, must
 be  very rare,  as the circumstances in which
 these can be infected by plague must necessa-
 rily be rare; and even when clothes and  bed-
 ding are contaminated, exposure  for no  very
 long period to due ventilation, especially when
 the air is dry and the wind is high, will be  suf-
 ficient to deprive them  of any infectious prop-
 erty.
   152. o. That the various predisposing and ac-
 cessory or determining  causes of plague have
 not been fully ascertained, and their influence
 determined  farther than may be inferred from
 what I have stated above (y 124, 127, et seq.);
 and extremes of temperature, dry states of the
 air, and free perflation  and ventilation always
 either arrest or restrain the spread  of this pes-
 tilence.         «■
   153. VI.  Mortality from Plague.—This
 pestilence is probably the most fatal of any to
 which the  human frame is  liable. At Mar-
 seilles, it was believed that above one half of
 those seized died of it; and  in certain  places
 and institutions, the proporlion  of fatal cases
 was even  higher.  Thus, in the " Hopital de la
 Charite,"  1013  cases were received, and  585
 died.  In the "Hopital du Jeu de Meril," 1512
 persons were received,  and 820 died ; and in
 the lowest classes the proportion of deaths was
 still greater. a\s respects the plague of Lon-
 don in 1665, and all the  more recent outbreaks
 of 4he distemper in  other cities and districts,
 there is no evidenee that the mortality has been
 much less, but we have no statistical informa-
 tion upon  which any  reliance can be placed.  It
 is very generally remarked that, at the  begin-
 ning of an  epidemic, although the malady is
 least diffused, it is the most fatal;  that, during
 the increase and  height of the  pestilence, a
 larger proportion recover ; and that, during the
 decline, the numbers attacked are much dimin-
 ished, and  the comparative mortality is much
less.  These facts may be  explained  on  the
 supposition  that, in the early  progress of  the
 distemper,  the  most  predisposed to infection
 are first attacked, and being the most suscep-
tible, are the most liable to sink under it; that,
 as the sources of infection multiply, the less
susceptible are also attacked, but are the  least
severely affected, and recover in greater num-
 bers ;  and  that,  after  a  certain  number of
weeks or months, when the distemper has been
introduced among a dense population in a town
or city, the  least susceptible only remain to be
infected ; and, if these are attacked, they  are
the most likely to recover, unless they are  ex-
posed to a more concentrated infectious efflu-
vium, or  have become more  predisposed to a
severe infection.   Hence  it often  occurs, as
noticed by Dr. Russell  and others, that some
persons, who have been in close communication
with the sick, have resisted infection until the
 decline of the  epidemic, when they have been
attacked, and even died.
   154. The prevalence and mortality of plague
 depend much upon the numbers of those, in a
 district where it has been introduced, predis-
 posed to infection.  If the distemper has been
 frequently epidemic there, or has been lately re-
 markably prevalent, a considerable  number of
 persons protected  from a  second attack will
 necessarily exist.  The  most  susceptible of
 plague, as in  the haemagastric  pestilence, has
 been said to be the young, robust, and plethoric;
 but  this is not fully established, especially as
 regards  the rate of mortality  among  them,
 which has also been considered as high.  The
 greater prevalence  of the  distemper  among
 these persons is  probably owing to the greater
 exposure to infection to which they are liable.
 The  fact of the  mortality being the greatest
 among the negro and dark-skinned races, whose
 frames are much less  powerful  than the Cau-
 casian, would indicate  a comparatively less
 mortality among those which are young and
 strong.  The  recent observations of the Euro-
 pean physicians who have practiced in the East
 do not appear to  confirm the opinions as to the
 greater liability of, and greater mortality among,
 robust and young persons;  indeed, there  is
 every reason to believe that, however suscep-
 tible such persons may be of infection,  at least
 the proportion of recoveries is greatest among
 them.
   155. There is  no datum from which any in-
 ference can be drawn as to the influence of dif-
 ferent modes  of  treatment upon  the mortality
 of the distemper, more  especially during the
 epidemic prevalence of it among a dense popu-
 lation.  The varying characters, severity, and
 complications of  the disease must render any
 particular method of cure altogether unsuitable
 to some cases, although most appropriate to
 others ; and thus all exclusive plans or meas-
 ures must be equally successful, or, rather, abor-
 tive, if universally employed.  It is in this dis-
 temper, as, indeed, in all others, most manifest
 that the careful adaptation of the means of cure,
 and  the  varying  and suitable combination of
 them to existing grades, states, and associations
 of morbid action,  can alone have the effect of
 so controlling  or arresting such action as to in-
 fluence the comparative rate of mortality.
   156. VII. The  Nature  of Plague.— My
 views of the nature of this pestilence may be
 inferred from  what has been advanced above
 respecting the occasions and causes of its out-
 breaks, and the phenomena  presented by the
 infected.   My remarks, therefore, on this topic
 are merely a summary of what appears to be, as
 well as not to be, fully established respecting it.
   157. a.  Plague  is a contagious and infectious
distemper,  according to the meaning attached
to these  words, both  above (y 58, 59), and in
the article Infection, and in the favourable cir-
cumstancej and states of susceptibility already
fully insisted upon (y 124, et seq.); and a per-
son who has been once attacked by  it  is pro-
tected from a second attack, as proved by Rus-
sell, White, and others.
   158. b. The infection of plague may be pre-
served in, and propagated by, the bedding, bed,
and body clothes of those who have been attack-
ed ; and the pestilence has been propagated by
these means, in the circumstances and states
of susceptibility above shown (y 124, et seq.), as
well  as by personal communication or contact. 
PESTILENCE, SEPTIC OR  GLANDULAR—Treatment  of  Plague.       255
   159. c. Goods, or articles of trade or merchan-
dise, not having been used by the sick, cannot
be expected to propagate the distemper in any
circumstances, especially if they have been ex-
posed to the air.
   160. d.  The infectious emanation or poison,
when received into the lungs during respiration,
may so depress the organic nervous energy
and vital power of the frame, and so contami-
nate the circulating fluids, as instantly to pro-
duce manifest effects, or even to destroy life in
two  or three hours, when this  emanation is
very  powerful  or  concentrated, relatively to
the state of vital resistance.  When, however,
this poison is less powerful, or the infection of
the frame differently produced, and when the
vital resistance to its morbid impression  and
contaminating  influence is energetic, then  a
more considerable period is  required to develop
its operation  and noxious effects in a manifest
and specific form ; but the extreme duration of
that period is not precisely ascertained, although
it is generally believed not  to extend to  above
eleven or twelve days.
   161. e. Thechanges produced upon the healthy
by the  infecting miasm evolved  from  the sick
are of an asthenic  and septic character ;  and
however  high  the vascular reaction  may be,
owing to the  powers of the constitution—to the
vital  resistance opposing the poison invading
and  contaminating  the  body—there is a ten-
dency to a dissolution of the crasis of the blood,
and of the vital cohesion of the soft solids : the
capillaries, the lymphatic glands, and the cellu-
lar and mucous tissues, early experiencing and
manifesting the effects of these changes.
   162. /.  As  the phenomena  and characteris-
tics of this distemper have been uniform during
ages, and  in  all countries, however far  apart,
and wherever they  have been observed, so  it
may be presumed  that  the efficient cause is
also uniform  and specific, reproducing its kind
on all occasions, and with the power of perpet-
uation adfinitum.  The distemper being specif-
ically the  same in all ages, the cause may be
also considered to be  of a specific kind,  and to
be preserved  and propagated by the successive
infections produced by  it,  as shown above (y
103,104); and although numerous circumstan-
ces favour a  belief in the generation of this in-
fection  de novo, or in  its spontaneity, still the
evidence  is not conclusive on this point, and
still more numerous circumstances and consid-
erations oppose it (y 108, et seq.).
   163. g.  The  characteristic changes of this
malady are accompanied by various accidental
or adventitious phenomena, arising out  of the
concentration of the exciting cause or morbid
poison occasioning it,  of the state of suscepti-
bility of the recipient, and of peculiarity of tem-
perament, constitution, and habit of body ; and
probably, also, out of the conditions of the di-
gestive, assimilating, and excreting viscera at
the time of infection.   Hence sometimes ap-
pear, in the course of the malady, certain  prom-
inent  affections, or complications, which may
more or less characterize it, in addition to those
which are specific and are constant.  Owing to
this circumstance,  J. Frank and  others have
divided the distemper into certain states or
forms, namely,  the  Simple, the  Inflammatory,
the Gastric, and the Nervous, according to the
predominance of the affections corresponding
with these designations.  But this division is
defective, inasmuch as the most severe  and
most rapidly fatal cases of the distemper are
not comprised  in any  of the above states, the
patient sinking rapidly, owing to extreme  and
rapidly increasing depression or annihilation of
the powers  of  life, without vascular reaction,
or prominent affection of the gastric or cerebro-
spinal  organs.
   164.  h. It is  probable that the circumstances
of locality may also modify the type or charac-
ter of the febrile phenomena of plague—that on
occasions of the extension of infection to places
productive of emanations from marshes, &c,
and  at  seasons when  the malaria  from  these
sources are  most abundant,  the  infection of
plague may be  attended by either an intermit-
tent or a remittent type of fever.  It has been
contended, when plague has appeared in such
localities, and has presented more or less of a
periodic fever,  that the distemper has actually
originated in the increased concentration or in-
tensity of the malaria generated in these places.
But  there is no proof of this actually having
been the case ; but every reason to believe that
the distemper  had  been introduced,  and that
the existing malaria had imparted to it more or
less  of a periodic character.
   165.  i. Although it is admitted that the foul
air generated by the decomposition of animal
substances, and of animal exuviae, will produce
continued fevers of a  malignant or putro-ady-
namic  character, especially when  decomposi-
tion takes place in a warm, humid, and stagnant
air ;  and although it  is probable that plague
may be thus generated de novo, still the evidence
of this actually being  the case is not conclu-
sive; and we are, therefore, led to infer that,
as the  distemper is specific or sui generis, so is
the infectious agent or poison which perpetu-
ates it, however it may have originated (y 103,
104).
   166.  k. Although the plague presents most of
the characters  of a malignant or putrid fever in
the highest degree, it cannot, therefore, be in-
ferred to be identical with that fever, as some
writers have contended, inasmuch as it posses-
ses certain specific signs and lesions which are
not present in the latter, and which do not ap-
pear in those cases of malignant or putrid, or
putro-adynamic fever, which  arise  from in-
fection.
   167.  VIII. Treatment of Plague.'—The
treatment of this pestilence may be said to have
been hitherto altogether empirical.  The great
number of medical men who have, since  the
commencement of this century, visited the East,
and practiced for many years in countries where
the plague is most prevalent,  have thrown no
light upon the cure of it.   The introduction of
quinine and of the chlorides into practice, during
this period, has added somewhat to the means
of cure available for the  distemper; but  the
former is merely a preparation of a substance
previously in general and even beneficial use in
most cases of this pestilence, and the latter has
not always been employed in such modes and
combinations as are calculated to show the full
amount of their virtues.  Even popular reme-
dies, such as olive oil,  have not received that
attention from European physicians which their
reputation among the  Arabian doctors might
have excited.   Indeed, the perusal of accounts 
256       PESTILENCE, SEPTIC OR GLANDULa\R—Treatment  of  Plague.
of the numerous means resorted to against
this distemper, from the beginning of the six-
teenth century down to the present day, leaves
the humiliating and lasting impression on the
mind, of the very inefficient and contemptible
nature of most of them, when we compare
what  is known of the operation of these means
upon the economy, with the obvious nature and
remarkable severity of the changes character-
izing the distemper.  It must be most manifest
to all who endeavour  to combat  the changes
and morbid conditions constituting a malignant
disease,  and who attempt to employ agents
appropriately to pathological states inferred to
exist, that those agents should neither be doubt-
ful as to their operation, nor be of a trifling kind
as to their effects—that they should possess
energetic and determinate properties, and be
employed so as to produce a decided operation ;
and that the activity and the combinations of
the means should be directed with strict refer-
ence to the remarkable  depression of vital pow-
er throughout the frame, and to the poisoned
condition of both fluids and soft solids charac-
terizing this malady.   But have the means em-
ployed against  this pestilence possessed  these
attributes, or been  prescribed with due  refer-
ence  to morbid conditions, or in  those modes
and combinations which could rationally  admit
of any hopes of a beneficial result from their
exhibition]   I can safely  answer that,  in 99
cases out of 100, where the means resorted  to
have  been  described  in  connexion with the
states of the  case for which they  were pre-
scribed, that no such hopes could be rationally
entertained, and that, if any advantage actually
did accrue, it was due  to the efforts  of nature,
to the innate vital resistance to morbid changes,
and not to the agents employed.  Of the treat-
ment of plague, the most important part is that
which relates to the protection of the  community
from its introduction, and of individuals from its
infection, after it has been introduced.   This will,
however, be discussed in the sequel,  when con-
sidering the means of protection applicable to
this and the other pestilences (see Pestilences,
general and individual Means of Protection
from) ; and I now proceed to discuss the cura-
tive treatment of this distemper.
   168.  i. Curative Treatment of Plague.—I
have sufficiently insisted, in the foregoing pages,
on the necessity of removing all affected by ma-
lignant diseases into a pure air, and into a large,
well-ventilated apartment, whenever this can
be accomplished ; and  it is the more especially
required for cases of this pestilence, and more
particularly for those attacked in close, crowded,
and low situations.  But this removal should
be effected with a due regard to the  protection
of the healthy, and to the limitation of the pes-
tilence.   Persons who have already had the
disease should be employed about the sick  in
preference to others, and personal  cleanliness
should be strictly enforced.  There  is nothing
which tends more, as regards not only this, but
 also the other pestilences, to increase the infec-
tious  property, than the use of soft beds, es-
 pecially those stuffed with wool or feathers, of
 woollen bed-clothes,  and  the  neglecting fre-
 quently to change the night and inner  body-
 clothes.  There is every reason to believe that
 the entire disuse of bedding and coverings, con-
 sisting chiefly  of woollen or other animal ma-
terials, in countries liable to outbreaks of pes-
tilential distempers, would  tend much to pre-
vent the diffusion of infection.
  169. A. At the commencement of an attack,
emetics have been much recommended both by
the older and more recent writers.  M. .\ubert
states that, in the more benign cases, they were
always followed by an abatement of the symp-
toms, and generally by recovery, which  would
take place without farther treatment,  but then
convalescence was prolonged ; that  he never
observed any unpleasant effects from them in
any circumstances ; and that, in the more dan-
gerous cases,  the progress  of the distemper
was often arrested for a time by them, thereby
giving time to  act,  and the patient  was not
weakened by them, as by bleeding.   He, there-
fore, regards emetics as most beneficial early in
ihe  disease, in  all cases.   M. Aubert,  how-
ever, offers no remarks as to the emetics which
should be preferred.   But  it is obvious, from
the nature of the malady,  that a preference
ought to be given to those which are least likely
to lower the powers of life, and that these should
be conjoined with stimulants, or warm aromat-
ics.   Thus, sulphate  of zinc  may be prescribed
with capsicum, camphor,  ginger, cinnamon,
&c, and ipecacuanha either with these, or with
ammonia and  aromatics.   Dr. Hodges very
justly remarks,  that the dose of the emetic
should be  large enough  to operate soon, and
to evacuate the stomach completely; that it
ought to be given only in the infancy of the dis-
temper, and not when the  stomach  has been
freely evacuated by  the retchings  which often
accompany the  more full development  of the
malady,  and that antimonial preparations are
not advisable.
   170. B.  Blood-letting has been considered in-
jurious in the plague by the  great majority of
both old and modern writers.  Sydenham, Do-
ver, and a few others have, however, advised
large blood-letting;  but the  former possessed
not the experience of his  contemporary Hod-
ges,  who strongly opposes  this practice; and
the disease for which Dover employed copious
bleedings was not the true plague.  Hodges ob-
serves, with much justice, that " if the author-
ity of the ancients, as well  as the experience
of the moderns, have any weight,  and, indeed,
if my own practice may be  regarded,  it is high-
ly to  be feared,  from many  instances, that
bleeding in a genuine pestilence is not only to
be suspected, but charged as pernicious."  MM.
Aubert  and Rigaud had recourse  to blood-let-
ting  in Europeans, for whom they believed it
to be sometimes of  use ; but they considered
it as generally injurious  in  the Arab  constitu-
tion.  M. Dulong states, that  the violence of
the  fever, and  the  imminent congestion of
some important organ, induced him  to have
early recourse to venesection,  and sometimes
even to repeat  it.   Generally  an  amendment
immediately followed the operation, but it was
of short duration, and he rarely obtained any
signal advantage from the practice.  He, how-
ever, found the application  of leeches behind
the  ears, when  the  head was  prominently af-
fected^ or upon the epigastric region, when the
digestive organs were remarkably disordered,
to be of considerable service.
   171. Massaria  believed  that  blood-letting
was  beneficial in the plague  of  Vicenaa in 
          PESTILENCE, SEPTIC OR GLA]

1576 • and he was  considered by his contem-
poraries as a great  authority.  Opinions, how-
ever, greatly preponderate against this prac-
tice ; yet, in some cases, especially among the
nations of northern and temperate climates, in
young, robust, and plethoric persons, and in the
sanguine temperament,  a moderate  vascular
depletion, early in  the distemper,  may be of
service, and may  dispose the  system to  be
more readily influenced by diaphoretic and re-
storative remedies.  In cases such as these,
Sydenham recommended venesection to a large
amount, and even  to be  repeated ; but, when
he found the practice opposed by the patients
and their friends, he confided chiefly in a mod-
erate blood-letting, and followed it immediate-
ly by full and frequent doses of warm diapho-

  172.  C. Sudorifics  appear  to  have received
the favourable testimony of  almost all writers
on  this pestilence.  Diemerbroeck, Van der
Hoyde, Sydenham, OrRaEus,  Russell, Chenot,
Pugnet,  Desgennettes,  and  many  others,
trusted chiefly in  them, selecting those  of a
warm  and stimulating kind.—a.  Dr.  Hodges
remarks, that  all authors and  practical physi-
cians agree in this,  namely, to throw out the
pestilential poison as soon as possible by warm
sudorifics,  or  Alexipharmics, according to  the
nomenclature of the day.  It would be of little
advantage to notice the numerous and very di-
versified substances which he recommends for
this purpose; but among these are to be found
some of the most  energetic substances which
are  employed  at the present  day.  He adds,
" that recourse should be speedily had to these
remedies as to a sacred  refuge ; and there is
such plenty of them, that nature seems to have
had more than an ordinary indulgence and fore-
cast in providing them against this destructive
enemy of mankind."  Of these remedies,  he
considered the Virginian Snakeroot, with much
justice, " the most efficacious diaphoretic and
Alexipharmic for expelling the pestilential poi-
Bon."   And the next place  he believed to be
due to  the Contrayerva-root, which, as well as
the snakeroot, he  combined with a number of
other vegetables of a stimulating and aromatic
nature, in every conceivable form—in powder,
electuary, infusion, decoction, &c.
   173.  b. Of  mineral sudorifics, there is none
so safe and efficacious as the one first intro-
duced  into practice by Minderer, and  so long
known by his name—the Spirit of Minderer, or
liquor ammonia acetatis;  and, when given with
the  ammonia very  considerably in excess, it is
more to be depended upon—more febrifuge and
diaphoretic, especially in all low, pestilential, and
exanthematous fevers, than any other medicine
with which I am acquainted.  In all these mal-
adies, and especially in plague, it may  be con-
joined with the infusion of serpenlaria,  or with
the decoction of bark, or with camphor,  or with
all these, when the powers of life are much de-
pressed, and unable to resist the poisonous ten-
dency of the  infection on  the frame: but in
such cases the ammonia should be also greatly
in excess, unless the urine indicates an ammo-
niacal tendency, when the aromatic acetic acid
may be substituted, and it be allowed to be in
excess.
   174. c. Many years ago, frictions of the sur-
face with warm olive oil was much recommend-
     III.               17
IDULAR—Treatment of Plague.        257

ed by Baldwin and others in the treatment of
plague, with  the view of promoting a copious
sweat,  which  seldom failed of supervening.
The practice was common in the East from the
earliest times ; and the oil was also taken in-
ternally with the belief of its possessing, both
prophylactic  and curative properties.  Several
experienced writers are much  in favour of it,
and the evidence is very conclusive as to its
diaphoretic operation when employed external-
ly ; but it is by no means so as to its curative in-
fluence, yet even in this  way it appears some-
times  to have been  of use.  Mr. Jackson, in
his  account  of the  very  destructive  plague
which was introduced into Morocco in 1799,
recommended it to many, both  as a preventive
and as a cure; and  he states in both charac-
ters it was eminently successful.
   175.  D. Purgatives have been found general-
ly injurious by most writers on  this  pestilence.
Bockel states that  they were remarkably so in
the plague of Hamburgh in  1565 ; and Palma-
rius, Demerbroeck, and Russell,  as well as
most recent authors, have been  equally decided
in  the reprobation of them.  It  is  evident,
however, that the moderate evacuation of the
morbid secretions  and excretions is  not so
 much  dreaded by them as the disposition ex-
isting in most  cases  of the distemper to diar-
rhcea, and the difficulty  of  limiting the opera-
tion of purgatives to a moderate  evacuation,
and of preventing  inordinate and exhausting
discharges from  the exhibition of  them.  It
must be obvious  that the evacuation of accu-
mulated secretions and excretions from  the
bowels, and the prevention of any collection of
these, are most important objects in the treat-
ment ;  but they should be  attempted by such
mild agents as are most readily controlled, and
the least liable to excite irritation, in the weak-
ened and already  irritable  intestinal mucous
surface.  It  is extremely probable, that olive
oil, when used internally as well as externally,
 produces a mild demulcent, or soothing, as well
 as laxative effect on the  bowels, without occa-
 sioning an operation of an exhausting kind, or
 one which is not readily restrained by the other
 remedies usually employed against the malady.
 Although much employed as a popular remedy,
 it has not received that attention from the regu-
 lar members of the profession which I think that
 it deserves, from my knowledge of its  effects
 in several other diseases.  Judging by analogy,
 and guided  by other considerations, I would
 advise the occasional combination of the oleum
 tercbinthina with this oil, and the exhibition of
 it both  by the mouth and in enemata, according
 to the circumstances of the  case ; guarding, at
 the same time, their action  by means  of aro-
 matics, spices, and small  doses  of opium, or of
 camphor with opium.
   176.  E.  Stimulants, tonics,  and  antiseptics
 have been generally employed  against plague,
and are more applicable  to it than  to  any
other  malady.   Indeed,  I  much  doubt  the
propriety of  withholding them  in any state or
stage  of the distemper whatever, even where
vascular excitement appears the most violent.
The vascular reaction often occurring  at an
early period  of the malady is of that open  and
expansive kind which indicates greatly reduced
 vital power in connection with morbid action;
 and it will certainly be found that no more in 
258        PESTILENCE, SEPTIC OR GL^

this distemper than in other malignant diseases
similarly characterized, can this action be sub-
dued without restoring, as far as may be, vital
power, and enabling it to resist those changes
by which this action is  excited and perpetua-
ted.   In  fact, the same principles, upon which
I insisted when discussing the treatment of the
hamagastric pestilence  (y  178, et  seq.), should
also be adopted in this.  Even in cases of the
most violent vascular action, and when it may
be prudent to have  recourse to a moderate or
full blood-letting, the stimulating diaphoretics
already noticed, with full or even large  doses
of the sesquicarbonate  of ammonia,  or of cam-
phor, or of the sulphate of -quinine and camphor,
should be prescribed as  frequently as the ur-
gency of the case may require.   Sir A. Brooke
Faulkner states that in two instances a large
quantity  of  spirits of turpentine and of camphor
were  taken by mistake,  and that both recov-
ered.
  177. a. The remarkable loss of tone through-
out the vascular system, in this  as well as in
the preceding distemper, prevents the vessels
from  accommodating themselves to the  quan-
tity of blood in  the  system, and creates a de-
mand upon the heart to support the circulation
by means of greatly increased action ;  hence,
in the great majority of such  cases, even a
moderate blood-letting is often detrimental, in-
asmuch as it still further increases the loss of
that due correspondence  which should exist
between  the state of the blood-vessels and the
amount of blood circulating in them, unless,
indeed, the  depletion be immediately followed
by the exhibition of stimulants or tonics ; and
of those, the most to be  depended upon are
camphor,  quinine, ammonia, with or without the
liquor ammonia acetatis, the preparations ofser-
pentaria,  or of arnica, the hydrochloric ether, &c.
Of all these,  camphor  and ammonia are  the
most generally of service ;  and the former is
congruous with  any other remedy which may
be employed ; but it should  be  prescribed in
full or in frequent doses.   The sulphate of qui-
nine has been very favourably mentioned  by
most  recent writers ; but it has only taken the
place of  the cinchona bark, which  was formerly
much used in this distemper, with serpentaria.
ammonia,  and  other  stimulants.  It  will  be
found that the combination of the quinine with
camphor  and capsicum, and the exhibition  of all
three in full doses, will  prove most decidedly
beneficial, especially during the earlier stages
of the malady.
   178. b. When irritability of stomach prevents
the due  exhibition of stimulants or tonics, or
the retention of  them,  an epithem of warm
spirits of turpentine should be applied over the
epigastrium ;  and this will generally allay the
retchings, if it be properly applied, and remark-
ably aid  in bringing out  and promoting a most
copious perspiration.  In this state of the dis-
temper,  which J. Frank denominates the gas-
tric form, effervescing draughts  are  generally
grateful.   Dr. Russell is in favour of the use
of these, but those of the carbonate of ammo-
nia, with either the  citric or the acetic  acid,
the  ammonia  being considerably in excess,
should be preferred ; and such restoratives and
 antiseptics as the  circumstances of the case
may suggest be prescribed, from time to time,
 and chiefly in enemata when the stomach still
NDULAR—Treatment of Plague.

continues irritable.   About a drop of creasote
may be given with each dose of the medicines;
and several  drops of this  substance may be
added to the enemata, especially when diar-
rhoea is present.
   179.  c. At an advanced stage of the distem-
per, or from the  commencement of the  attack
in cases presenting much depression and other
signs of malignancy, the more energetic stim-
ulants  and tonics  recommended  for similar
states  of the hamagastric pestilence (y 179, et
seq.) may be resorted to, as being quite appro-
priate to these cases.  Indeed, whenever vital
depression is very remarkable, the stimulants
prescribed ought to be such in kind and quan-
tity as  will produce an immediate  effect;  and
the selection of  them should be guided by the
previous habits and  circumstances of the pa-
tient.   Several of the stimulants in more gen-
eral use are  also antiseptics, and these should
be  given in full, and even large doses, especial-
ly those mentioned above (Y 176, et seq.).   But
they ought  not to be deferred until a too far
advanced period of the disease,  but should be
prescribed early, especially in the more malig-
nant or septic  cases, and given in decided do-
ses and in efficient combinations.  It does not
appear, from the recent works on  plague, that
the chlorides  have been employed in it in such
a manner as fully to test their efficacy, and in
such  combinations as are most likely to prove
beneficial.  The most  appropriate of these is
probably the  chloride of lime,  conjoined with
camphor, aromatics, and opiates.   The chlorate
of potash also promises to be of  service, espe-
cially when prescribed in stimulating or tonic
infusions or decoctions, particularly the infu-
sion of cusparia,  or of serpentaria, or of cloves,
or  of valerian,  or the decoction of cinchona, or
of senega, or tormentilla, and with various other
restoratives and  aromatics.  The hydrochloride
of  ammonia was formerly much employed in
low fevers ;  it is equally suitable for this mal-
ady, and it may be taken with  any of the sub-
stances just mentioned, in as large doses aa
the stomach will tolerate, or from ten to twen-
ty grains.  Its good effects will generally be
promoted by the addition to each dose of from
half a drachm  to a drachm of the hydrochloric
ether.   Various formulae for the medicines rec-
ommended at  this place will be found in  the
Appendix, more especially Form. 385, 387, 388,
409, 416, 431, 437, 439, and 848, which may be
prescribed in quantity and frequency of dose
according to the  severity of the disease.
   180.  M. Aubert states that he gave phospho-
rus in  many cases  of this distemper; but it
does  not appear  that any decided  benefit was
derived from it.  The formula for it in the  Ap-
pendix (428) is  a  suitable mode of employing i*
in  this  disease.   This physician  mentions a
new medicine, called hachisch, which  he con-
siders of great efficacy in this malady.  He  fur-
nishes  no information as to the nature of  this
substance, but states that several cases recov-
ered by its aid, which he considered altogether
hopeless before it was administered.  He gave
it  in doses of one, two, or three  drachms in
coffee ; and  it appears to have had a stimula-
ting and exhilarating effect.
   181.  F. At the commencement of the pres-
ent century, the affusion of cold water over tht
surface was considered the most successful and 
PESTILENCE, SEPTIC OR GLANDULAR—Treatment of Plague.        259-
 most generally appropriate remedy in all fevers,
 especially those of a severe or malignant form.
 Experience has  shown  the  very exaggerated
 estimate then formed of this practice.   It was
 at that time recommended for  plague as well
 as for other pestilential maladies;  but  obser-
 vation and reflection have shown that,  unless
 where the vascular reaction  was high, and the
 heat of the surface was much increased, and
 at the early period of reaction, the  practice
 was sometimes injurious, and often of doubtful
 advantage.  I can find no evidence of its hav-
 ing proved  of service in  this distemper;  al-
 though it is probable that it may, in those cases
 which are characterized by more violent vas-
 cular reaction, and which have, from  this cir-
 cumstance, been  by some viewed as present-
 ing an inflammatory character, advantageously
 precede the frictions of the  surface with olive
 oil  (y  174) that have generally been found so
 beneficial in bringing out a copious perspiration.
  182.  G.  The very  general recourse  which
 was formerly had to mercurials in the cure of
 fevers by British physicians, more especially
 to calomel, was extended  also to the plague;
 but  the diarrhcea, which is so apt to come on
 in the  course of the malady, restricted their
 use; and their effects, in any form, appear to
 have been  equivocal.   The trials, however,
 made  of them by Mr. Stafford, as related by
 Sir B. Faulkner, seem to indicate that they
 deserve a farther and a more satisfactory trial.
 Calomel and  mercurial  inunction  were  the
 means employed, with the view of producing
 their specific effects.   They have been, also,
 recommended by Schreiber,  Formay, Schraud,
 and others ; but, as Olivier  has observed, the
 system resists the specific effects of all mercu-
 rials in the severe  cases, and the slight cases
 do not require a recourse to  them.   If calomel
 should be employed, it ought to be conjoined
 with opium and aromatics, to prevent it from
 disordering  the bowels ; and even when thus
 combined, this effect may nevertheless ensue.
  183  H. Diarrhoea is one of the worst  symp-
 toms which occur in the course of the distem-
 per, and is generally controlled with great dif-
 ficulty, especially when it appears  at  an ad-
 vanced stage.   At an early period, opium, con-
joined with  camphor, creasote,  and  aromatics,
 will  frequently restrain it; but the more active
astringents, conjoined with antiseptics, will oft-
en be  required, more especially the chloride  of
lime, the sulphate of zinc, conjoined with catechu
or kino, &c, and with opiates.  These substan-
ces  should also be administered in enemata.
  184.  J. The treatment which has been fully
described  as most beneficial in the haemagas-
tric pestilence is in most respects suitable to
this, the several means of  cure being  varied
according to the  form which  the malady as-
sumes.   Many  of the distinctions, however,
which  have  been pointed  out by writers will
hardly  be made out in practice ; and, though
they may be prominent  in  some cases, they
will hardly appear in others.   It will be suffi-
 cient for the physician to bear them in mind, to
adapt his measures to the features of each case
which  may come  before him, whether inflam-
matory, nervous, gastric, putrid, or septic, accord-
ing to the views of various writers ; to act upon
pathological principles; and to employ his  reme-
dies conformably with their ascertained effects.
   185. K. As to  the local treatment of the bu-
 boes  and carbuncles, little farther  is  required
 than the application of poultices, fomentations,
 or emollients,  as their  states  may require.
 When matter or other fluid accumulates, an
 exit  should  be  given to it, in order to prevent
 the contamination of the adjoining tissues, and
 a healthy suppuration  ought to be promoted.
I Subsequently the  healing  process  may be en-
 couraged by means  of such digestive  and gen-
 tly stimulating  applications  as the cases will
 suggest.   The  condition, however, of  these
 sores will be much  more efficaciously control-
 led by the internal or constitutional treatment
 than  by local applications ; and in  most  cases
 it will be necessary to support the powers of
 life, when the external lesions are considera-
 ble, in order that the  process of restoration
 may  go on satisfactorily.
   186. L. The diet and regimen of the patient
 should be the same in this as in other fevers.
 Indeed, the diet and regimen which are suited
 to this pestilence are also suitable for the oth-
 ers, especially the hamagastric.   At an  early
 period of the attack, especially when febrile re-
 action is considerable, and the disease assumes
 that  form which has improperly been denomi-
 nated the inflammatory,  owing to the vital re-
 sistance and vascular disturbance, simple dilu-
 ents, and refrigerant and diaphoretic drinks, are
 the most serviceable; but  in a more advanced
 stage, or in more  protracted cases, and where
 the vital powers are depressed, a more restora-
 tive diet may be  allowed, as chicken, veal, or
 mutton broths, beef tea,  &c, which may be ta-
 ken with sufficient  salt  and  spices to render
 them palatable; and as  the  distemper advan-
 ces, and vital depression increases, wine,  bran-
 dy, or liqueurs  may also be  taken, diluted in
 various  ways, or  in  arrow-root  or sago.  In
 this distemper, as well as in  the  haemagastric,
 hock or sherry, with Seltzer-water, Champagne,
 brandy in the warm infusion of black or green
 tea ;  the bitter Hungarian and Austrian wines ;
 milk or green tea punch;  the yolk of an egg
 beat  up in brandy and water or  sherry;  vari-
 ous kinds of jelley, &c, may be severally giv-
 en, according as the circumstances of the case
 will  suggest  to the  physician a  guarded re-
 course to them.   There is every reason to be-
 lieve that in this malady, as well  as  in other
 low fevers, the use of these and similar dietetic
 restoratives  is  often too  long  deferred, and
 that the cravings  of the  patient for them are
 very  improperly unheeded.  In the  diet and
 regimen, as  well as  in the medical treatment,
 of patients in low or malignant fevers, the phy-
 sician has been  too often guided by prevailing
 theories and doctrines, instead of proceeding
 warily in the path  of close  observation and
 sound common sense. With these as his guides,
 while he endeavours to fulfil  the intentions ra-
 tionally inferred from recognised states of mor-
 bid action or  of altered structure, the physician
 will generally act  safely and efficiently;   and
 will produce  as successful results in this as in
other distempers,  as can possibly be produced
by the limited amount of human means and of
human intellect*
  187. M.  The management  of  convalescence
should depend upon the circumstances in which
the patient is placed, and be  ordered  accord-
ingly.  The chief points which require attention. 
 260      PESTILENCE, SEPTIC OR GLANE

 are the enjoyment of a pure air  and due ven-
 tilation ; suitable diet ;  and the due  promotion
 of the several digestive and excreting functions.
 During this  period, care  should be  taken that
 the extent of the external sores, or the amount
 of the  discharges from them, should not ex-
 haust the patient, or cause a too protracted re-
 covery.   The  constitutional powers,  in  such
 circumstances, often  require  the aid  of  both
 medical and  dietetical restoratives ;   and  these
 should  not be timidly withheld, or too profuse-
 ly allowed.   At this time a healthy atmosphere
 is remarkably beneficial; and  as  soon as the
patient can bear removal  to  a different air, the
change will prove the  greater restorative ; but
this  must  be done with  due precautions  and
regard  to the health of  the uninfected.

  Bibliog. and Refer.—H. Stainhowel, Regiment der
Pestilenz, 4to.  TJlin,  1482.—A. Benedetti, Liber de Ob-
servatione in Pestilentia, 4to.  Venice, 1493, and folio, Bo-
logna, 1516.—P. de Bayrus, Questio nova  de  Peste,  12mo.
Taur., 1507.—/. Vochs, De Pestilentia Anni Presentis ejus-
que Cura,  8vo.  Magd , 1507.—F. Bernardus, Tract, de
Origine et Causis Morb. Pestilent., 4to.   Colon., 1518.—
J. Schillerus, De Peste Britannica Comment., 12mo.   Basil,
 1530.—/. B.  Gemma,  De Vera  Ratipne Curandi Bubonis
 Carbunculisque Pestilentia,  4to. Dant., 1549.—T. Gibson,
A Treatise behovefull to preserve  the People from  Pesti-
lence, 4to.  Lond., 1536.—iV.  Massa, De Febri Pestilenti-
ali, Petechiis, Variolis, et Aposlematibus  Pestilentialibus,
ac eorundem Curatione, <fec, 4to.  Venice, 1536, 1556.—G.
 Gratarolo, Pestis Discriptio,  8vo. Lyon., 1555, 12mo.  Paris,
 1561.—J. Dalechamps,  De  Peste, libri  tres; et R. Chalin
De  Vinario,  Liber de  Peste,  12ino.   Lyon.,  1553.—G.
Agricola, De Peste, Libri quinque, 8vo.  Bale, 1554.—B.
Landi, De  Origine et Causa  Pestis Patavinse, Ann. 1555,
Svo.   Ven., 1555.— V. de Bounagente,  Decern Problemata
de Peste, 8vo.  Ven.,  1556.—A. Gallus, Fasc. de  Peste et
 Peripneumonia  cum Sputo  Sang. Febri Pestilentiali, &c,
fol.  Brescia, 1565, et 12mo,  Francof., 1608.—J. Houllier,
De  Morb.  Curatione,  de Febribus, de Peste, <fec, 8vo.
Paris,  1565.— T. Beza, Tract,  de  Peste,  12mo.   l.udg.,
 1565.  Translated into English by J.  Stockwood, 8vo.  Lond.,
 1580.—L. Joubert, De Peste Liber,  &c, 12mo.  Lyon.,
 1566.—O. de Oddis, De Peste, et Pestiferorium Adfectuum
omnium  Causis, Signis, Pnecautione et Curatione,  Libri
 iv., 4to.  Veneta,  1570.—B.  Patinius, De Venenis, Sive
 Morbis Pestilentialibus, 8vo.   Biix.,  1572.—B. Pisanelli,
 Discorso  Sopra  la  Pes^e, 4to.  Roma, 1572.—J. P. Ingras-
 sias,  Informazione del Pestifero e Contagioso Morbo, il
 quale  afflige ed  ha afflitto la Citta de Palerme, e moltre ul-
 tre Citta e  terre del Regno de  Sicilia, nell' Anni 1575 et 76,
 4to.   Palerme,  1576.—/. Bokelius, De Peste Harnburgensi,
 I2mo.  Hurricop.,  1577.—C. Johnson, Counsell against the
 Plague, Svo.  Lond., 1577.—T. Brasbridge, The poor Mail's
 Jewel, a  Treatise on the Pestilence,  Svo.  Lond., 1578.—A.
 Perez, Tratado  de 1» Peste y sus Causas. 8vo.   Madr., 1598.
 —/. Bamford, A  short Dialogue concerning  the  Plague's
 Infection, 8vo.  Lond., 1600.—/. Mercuriali,  De Pestilen-
 tia in Universum,  priesertim  de Veneta et Pitavina, 4to.
 Venet., 1577, et 4to, Leyd., 1601.—G.  Potel,  Discours des
 Mai. epidemiques  ou  Contagieuses Advenues a  Paris en
 1596,  1597.,  1606, et 1607;  wmme aussi en 1619, 8vo.
 Paris, 1623.—J. Palmarius, De Morbis Contagiosis, Libri
 vij.  Paris, 1577.-4.  Massaria, De Peste, Libri ij., 4to.
 Venet., 1579.—/. Camerarius, Synopsis quorumdam  brevi-
 um, sed  perutiliem Comment, de Peste Clariss. Vir. Don-
 zellini, Ingrassice, C.  Rincii,  et post hoc sui ipsius eadem
 de lue Schpta in lucem retulit, &c, Svo. Nuremb., 1583.—
 F. Alexandri, Trattado della Peste  e Febbn Pestilenti, 4to.
 Torino,  1586. —P. Alpinus,  De  Medicina .iEgyptioruni,
 Libri  iv.   Veneta, 4to, 1591 ;  lib. i.,  cap. xiv.-xviij.—R.
 de Castro, Tract,  brevis de Natura et Causa Pestis qute,
 Anno 1596, Hamburgensem Civitatem afflixit, 4to.  Hamb.,
 1596.—T.  Lodge. A  Treatise of the  Plague, 4to.  Lond.,
 1603.—/. Godskall, King's  Medicine for  the  Plague, 8vo.
 Lond., 1604.—A  Gallus, Fascis Aureus  de  Peste,  12mo.
 Francof., 1606.—G. Garnevus, EntToun, &c, De Peste qua
 Grassata est Venetiis, Anno 1576, &c,  12mo.   Brunt.,
 1610.—F. Rondinelli,  Relazione nel Contagio Stato in Fi-
 renza l'Anno 1630  et  1633,  4to. Florence, 1634.— D. Sen-
 nert,  De Peste, Pestilentialibusque ac Malignis  febribus.
 In  Opp.  Omnia. T. V. Lib.  iv., 4to.  Francf., 1634.—M.
 A. Rota, De Peste Veneta,  Ann., 1630,Ato.  Veneta, 1634.
 —/. Ripumonti, Libri v. de Peste  qujeTuit Ann. 1630, in
 Urbi  Mediolanensi, 4to.  Milan, 1631.—/. Dt Lempriere,
 Traite de la Peste, de ses Causes, &c, 8vo.   Rouen, 1620.
 —Th. Thayne,  An excellent and best-approved Treatise of
 the Plague, 4to.  Lond., 1625.— W. Boraston, A Treatise
 of the Pestilence, 8vo.  Loud., 1630.—R. Lyonnet, Loimo-
ULAR—Bibliography and References.

 graphia  seu  Reconditnmm Pestis Cansarum Ouriosa Dis-
 quisitio, Svo.  Lion., 1639.—T. Woodfall, The whole Wurks
 of, containing a Treatise on the Plague, fol.  Lond.,  1039.
 —S. Bradwell, Physick for the Sicknesse cnlled the Plague,
 4to.  Lond.,  1636.—/. de Diemerbroeck, De Peste, Libri iv.,
 4to.  Arnh.,  1646,  et Amsterd., 1665.— Van Helmont, Tu-
 mulus Pestis, 4to.  Amsterd., 1648.—P.  de Castro, Penis
 Neapolitans, Romana, et Genuensis, Ann. 1656 et  1657,
 Fideli Narratione Delineata, 4c, 12mo.  Verona, 1657__
 L. Giesseler, Observat. Medicse de Peste Brusvicensi, Ann.
 1657, 4to.  Brunsw., 1665.—/. B. Bindt, Loimograjihi.i see
 Hist. Pestis Contagiosa, 4to.  Roma,  1658.—Anon.,  Certain
 necessary Directions concerning the Plague, 4to. T)xf., 1665.
 —Anon., Golgotha, or a Looking-glass for London, showing
 the Causes, <fec, of the Plague, 4lo.  Lond., 1665.—/. Gad-
 bury, London's Deliverance predicted, showing the Causes of
 the Plague, <fcc.,4to.  Lond., 1665.—T. Garencieres, A Dis-
 course concerning the Nature of  the Plague, 4to.  Lond.,
 1665.—T. Sydenham, Febr. Pestilent, et l'estis, Ann.  1665,
 1666 ; Opera  Medica, sect, ii., cap. 2.—N. Hodges, Aoi/ioAo-
 yia, sive Pestis nupene apud Populum Lnndinensem grassan-
 tis, Narratio  Historica, 8vo.   Lond.,  1672 ; transl.by Quin-
 cey, with additions, 8vo.   Loud., 1720—G. Harvey, A Dis-
 course of the Plague, 4to.   London, J665.—W. Kemp, A
 Treatise of the Nature, Cause, Signs, and Cure of the Pes-
 tilence,  4to.   Lond., 1665.— IV. Austin,  The Anatomy of
 the Pestilence, a Poem, 8vo.  Lond., 1666.— G. Thomson,
 Aoiuorouta, or the  Pest Anatomized, 12mo.  Lond., 1666.
 — P. Barbette,  Tract, de Peste, cum Notis, F. Dickeri,
 12mo.   Lond., 1667.—E. Gockel, Enchiridion de Peste, &c,
 Aug. Vin., 8vo.  1669.—L. J. Bimius, Peslis ad  Vivuni
 delineata et  Curata, Leod. Eb., 12mo.  1671.—/. /. Qua-
 troux, Traite de la Peste, de la Difference  de la Pourpre,
 la  Petite Verole, et la Peste,  Svo.  Paris, 1671.—C. La
 Font, Dissert,  duse de Veneno Pestilenti, l2mo.   Amst.,
 1671.—H. Brunswick, Liber Pestilentialis, Buch  der  Ver-
 gift der Pestilenz, fol.  Strasb., 1700.—L. Pereira de Bern-
 terna,  Loimologia, sive  Historia  Constitut.  Pestil. Ann.
 1708, 9,10, 11,  et 13, per Thraciam, Sarmatiam, Poloniam,
 Silesiam, Daciam, Hungariam, Livoniam, Daniam, Sueci-
 am, Saxoniani,  Austriam, variaque loca grassante, <fec. Vi-
 enna, 1714.—/.  B.  Werlosching a  Parenberg, Loimologia,
 seu Hist. Pestis quae ab Anno  1708 ad  1713  inclusive,
 Transylvaniani, Hungariam, Austriam, &c, aliasque Con-
 terminas Provincias et Urbes, pragrediendo depopulabatur
 per Epistolas ex Autopsia et Experientia propria medica ex-
 arata.   Styria,  1716.—/. C. Gottwald, Memoriale  Loimi-
 cum de  Peste  Dantiscana, Ann.  1709;  Dantzick, 1710.—
 M. Stoeckel,  Anmerkungen  bey der  Pest, die Ann. 1709,
 in Dantzick Grassante.   Hamb., 1710.—/. Browne, Practi-
 cal Treat, of the Plague and  all  Pestil. Affect, that have
 happened in  this Island for the last Century, 8vo.   Lond.,
 1720.—Anon., The  Causes of the Discontents in relation to
 Plague, 4to.  London, 1721.—R. Mead, A short Discourse
 concerning Pestilential  Contagion, 8vo.   Loudon,  1720.—
 Anon., Some Observat. on the Plague, occasioned by Dr.
 Mead's Discourse, 8vo.  Dubl., 1721.—Anon., Collection of
 valuable and scarce Pieces relating to the Plague of 1665,
 2d ed., 8vo.  Lond., 1721.—/. Browne, Antidotaria,  a Col-
 lection of Antidotes against the Plague and other  Malig.
 Diseases, 8vo.   London,  1721 ; Considerations on the  Na-
 ture, Causes, and Cure of Pestilences, by a Freethinker,
 8vo.  London,  1721.—R. Blackmore, A  Discourse on the
 Plague, with an Account of Malignant Fevers, Svo.  Lond.,
 1721.—Anon., A Succinct Account of the Plague at Mar-
 seilles, 8vo, 1721.—Anon., A brief Journal of what  passed
 in Marseilles, afflicted by the Plague  in 1720, 8vo.   Lond.,
 1721.—Peste de Marseilles et Provence ; Pieces Historiques
 sur la,  en 1720, 21, et  22, 8vo,  2 tomes ; repub.  Paris,
 1820.—/. Astruc, Sui l'Origiue des Maladies epidemiques,
 principalement de la Pesle, 8vo.  Montp., 1721.—/. B. her-
 trand, Relat.Histor.de la Peste de Marseilles, en 1720,
 12mo.   Col., 1721.—R. Boulton, A Treatise on the Plague,
 8vo.  Lond.,  1721.—R. Bradley, The  Plague at Marseilles
 considered, Svo.  London, 1721.—ii. Brookes, A History of
 the most remarkable Pestilential Distempers that have ap-
 peared in Europe for Three Hundred Years past, 8vo. Lon-
 don, 1721.—Chicoyneau,  Observat. et Reflex, touchant la
 Nature, les Eveneniens et le Traitement de la Peste de
 Marseilles, 12mo.   Lyons and Paris, 1721.—W. Henley,
 Loimologia Sacra ; A Discourse on the Plague, 8vo. Lon
 don, 1721.—B.  Ramazzini, De Peste  Viennensi, vide Ope-
 ra.—T. X Benza, Relatio Historica  Pestis Austriam  ali-
 quando Vastantis, 8vo.   Vien., 1717.—E. Timon, De Peste
 Constant!nopoli grassanti. In Philosop. Trans. Anno 1720,
 p. 14.—Chicoyneau, Vei-ney,  and Soulier, A Succinct  Ac-
 count of the Plague at Marseilles, translated by a Physi-
 cian,  8vo.  Lond., 1721.—G. Pye, Two Discourses  of the
 Plague,  8vo.   Lond., 1721.—Anon., A new Discovery of the
 Nature of the Plague, and the true Causes of its raging in
 European Cities, with  the Remedy,  8vo.  London, N. D.
 (about 1721.  Generated and propagated by minute insects).
 —/. Pringle, Rational Inquiry into the Nature of the Flag.,
 8vo.  Lond.,  1722.—C.  Scarborough, Practical Method for
 the Cure of  the Plague in 1665, 8vo. London, 1722.—R.
 Mead, De Peste Liber, 8vo.  Lond., 1733.—/. Astruc, Dis- 
PESTILENCES—Protection from.
261
  lerl. sur la Contagion de la Peste ; ou l'on prouve qui cette
  Maladie est veritablement Contagieuse, &c, 8vo.  Toulon,
  1724.—J". Boeder, Recueil des Observat. qui ont ete faites
  sur la Maladie de Marseilles, 4to.  Strasb., 1726.—D.  W.
  Triller, De  Carbone  Pestilenti EpistoUe,  4to.   Uratisl.,
  1736.—/. F.  Schreiber, De  Peste quae Annis 1738 et 9 in
  Ukrania Grassata est, 4to.   Petr., 1741.—W. U. Wald-
  schmidt, De Peste Holsatica.   In Halleri Disput. Med., vol.
  v., p. 547.—R. Goodwin An Historical Account of the PL,
  *c, 12mo.   Lond.,  1743.—Anon., The Plague no  Conta-
  gious Disease. Svo.   Lond., 1744.—T. Lobb, Letters con-
  cerning the Plague,  Svo.  Lond., 1745.—O.  Turriano, Me-
  moria Historica del Contagio della Citta di Messina dell'
  Anno 1743, 12mo.  Naples, 1744.—D'Autrechaux, Relation
  de la Peste de la Ville de Toulon.  Toulon, 1721, 12mo.
  Paris, 1756.—Af.  Mackenzie,  Several Letters  concerning
  the Plague at Constantinople; in the Philosophical  Trans-
  actions for the Year  1752, p. 384-514,  1764,  p.  69.— W.
  Hird, Remarks on  Pestilence and Pestilential Diseases,
  Svo.  London, 1753.—D. Ingram, An Historical  Account of
  the several  Plagues since  1346, 8vo.   London, 1755.—R.
  Manningham, A Discourse concerning the Plague and Pes-
  tilential Fevers, Svo.  Lond., 1758.—A. Bruce, Inquiry into
  the Cause of Pestilence, <fcc, 8vo.  Edinb., 1759.—F.  L.
  Meltzer, Beschreibung der Pest., 1770-72, in Moscau, 8vo,
  Moscow, 1776.—A. Chenot, Tract, de Peste,  8vo.  Vienna,
  1766 ;  et Historia Pestis Transylvania.  &c, Annis 1770,
  71, opus poslh. edict.  F. de Schraud, 8vo.  Bude, 1799.—
  De Hacu, In  Rut. Med., Part xiv., sect. 2, 1770—Samoilo-
  witz, Memoire sur la Peste qui, en 1771,  ravagie l'Empire
  de Russie, surtout Moscou, &c.  Paris, 1783.—C.  de Mar-
  tens, Observat. Mediae de Febribus Putridis, de Peste, Non-
  nullisque aliis Morbis, 8vo.  Vienna, 1778; Translated  by
  G. Pearson,  8vo.   London, 1799.—G. Orraus,  Descriptio
  Pestis  qu« Anno 1778 in Jassia, et 1771 in  Moscua gras-
  sata est, 8vo.  Peters., 1784.—G. Bajamonti, Storia della
  Peste che regno in Dalmazia, 1763-4, Svo.  Venez., 1785.—
  W- Henderson, A few  Observ. relative to the Things  which
  are probable  respecting the Plague, 8vo.  Lond., 1789.—/.
  M. Minderer, Comment, de  Peste, cique medendi Methodo
 in ratione et Experiments  fundata, 4to.   Riga, 1789.—P.
 Russrll, A Treatise  on the  Plague, containing an  Account
 of the Plague of Aleppo, 4to.  Lond., 1791.—/. Antes, Ob-
 servat. on the Manners, <fec, of the Egyptians, and on the
 Plague, 4to.  Lond., 1800.—/. Tytler, A Treatise on the
 Plague  and Yellow Fever, 8vo, 1799.—/. V. von  Hilden-
 brand, Ueber  die Pest,  &c, 8vo.  Wien., 1799.—/. P. Pa-
 pon, De la Peste, ou  Epoques memorables de ce Fleau., 2
 tomes, 8vo.   Paris, 1800.—N. Webster, A brief  History  of
 Epidemical and Pestilential Diseases, 2 vols., 8vo.  Lond.,
 1600.—W. Falconer, An Essay on the Plague, 8vo.  Bath,
 1600.—G. Sotira, Memoire sur la Peste Observee en Egypte,
 Svo.  Paris, 1802.—Savaresi, Memoire sur  la  Peste, <fcc.
 Dans son Recueil de Memoires Physiques et Medicaux sur
 PEgypte, 8vo. Paris,  1802.—/. Larrey, Mem. sur  la Peste,
 &c.; dans Mem. de  Chirurg. Mi lit., t. i., p.  316.—R. Wil-
 son, Hist, of the Brit. Exped.to Eicypt, 4to, 1803.—/. Afoc-
 Grigor, Medical Sketches of the Expedition  to Egypt from
 India, Svo.  Lond., 1804, p. 100.—R. Desgenettes,  Histoire
 Medicale de l'Arine  d'Orient., Svo.  Paris, 1802.—P. Assa-
 hni,  Observat. on the  Plague, 4c, of Egypt,  &c, 18mo.
 Lond., 1804—R. Pearson, A Brief Description of the PI.,
 8vo.  Lond.,  1813.—/. F. X. Pugnet, Mem. sur les Fievres
 de Mauvais Caractere du Levant et des Antilles, 8vo.  Paris,
 1804.—C. Maclean, The Plague  not Coutagious, or  a Dis-
 sertation on the Source of Epidemic and Pestilential Dis-
 eases, 2d ed., 8vo.  Lond., 1800; and Results of an  Inves-
 tigation respecting Epidemic and Pestilential Diseases, in-
 cluding Researches  in  the  Levant concerning the Plague
 2 vols , 8vo.   Lond. HI7.—V. Morea, Storia della Peste di
 No.ia, 8vo.  Naples,  1817.—G. M. de Richter, Geschichte
 der Medicin  in Russland, &c, 8vo.  Moscou,  1813, t. i.—
 R. Grohman,  Ueber  die in Jahre 1813, in Bucharest herr-
 schende Pest., 8vo.  Leipsic, 1816.—Report from the  Select
 Committee of the House of Commons appointed to  consider
 the Doctrine of Contagion in the  Plague, fol. Lond., 1819,
 —A. B.  Granville, A Letter, &c, on the  Plague and Con-
 tagion, etc., Svo.  Lond., 1819.—/. B. Faulkner, Treatise
 on the Plague, 8vo.    London, 1820.—ii. Calvert, Of the
 Plague of Malta in  1813, in Trans, of Med. and Chirurg
 Society of London, vol. vi., p. 1.—/. D. Tally, The History
 of the Plague  as it lately appeared in the Islands of Malta
 Gozzo, Corfu, <fec\, 8vo. London, 1821.—/  Hancock, Re-
 searches into  the Laws and Phenomena of Pestilence, in-
 cluding  a  Medical Sketch  and Review of the  Plague  of
 London in 1665, 8vo.   London,  1821.—C.  Balme, Observat.
 et Reflex, sur  les Causes, les  Symptoms, et  le Traitement
 de la  Contagion dans differentes Maladies, et specialement
 dans  la  Peste d'Orient. et la Fievre Jaune, 8vo.    Paris
 1822.-/. Frank, Doctrina Pestis, in Praxeos Med. Univers'
 Priecepta, pars i., vol. ii., sect. l.—Vaidy, Diet, de Scien-
 ces Medicales, Art. Peste, t. 41.—Lachaise, Sur la Peste en
 Egypte,  dans Bullet, de I'Acad. Roy. de Med., t. i., p. 354
—Ozanam, Historia Medicale de Mai. epidemiques. vol  v
—F. L.  Fodiri, Lecons sur les Epidemics,  et  l'Hygiene
 Publique. 5 tomes, 8vo.   Paris, 1824, t. iv., p. 167.—/. Hen-
 nen, Sketches of the Medical Topography of the Mediterra-
 nean,  &c, 8vo.  London, 1830, p. 501.—Brown,  Cyclop, of
 Pract. Med., vol. iii., p. 352.— D. Barry, On the  Gibraltar
 Epidemic, in Med. and Phys. Journ. of Lond., vol. lxiv., p.
 383 ; and vol. Ixvi., p. 476.—Chollet, Mem. sur la P. qui a
 regne epidemiquement a Constantinople en 1834, et sur sa
 Non-contagion, 8vo.   Paris, 1836.—A. Brayer,  Neuf An-
 nees a Constantinople, Observat. sur la Topogr. de cette
 Capitale; la Peste, les Causes, &c.; et la Non-contagion
 de cette Maladie, <fcc, 2 tomes, Svo. Paris.—Estiennes,
 Journ. des Connaissances Medico-Chirurg., Feb.,  1837.—
 Pariset, Mem. sur les Causes de la Peste, et sur les Moy-
 ens de la detruire, 12mo.  Paris, 1837.—/. F. C. Hecker,
 The Epidemics of the Middle Ages.  Trans, by B. G. Bab-
 ington.  (Published by the Sydenham Society.)  8vo. Lon-
 don, 1844.—L. A. Gosse, Relation de la Peste qui a regne
 en Grece en  1827 et 8, 8vo.  Paris, 1638.—A. F. Bulard,
 de la Peste  Orientale,  d'apres  les Materiaux recueilles a
 Alexandria, au Caire, a Smvrne, et a  Constantinople, pen-
 dant des Annees 1833 a  1838,  Svo.  Paris, 183'J.—L. Au-
 bert, De la Peste ou Typhus d'Orient. Documens et Obser-
 vations recueilles  pendant les  Annees  1834 a  1838, en
 Egypte, en Arable, sur la Mer Rouge, en Abyssinie, a Smyr-
 na et a Constantinople, Svo.  Pnris, 1840.—E. Littre, Art.
 Peste, dans Diet, de M6decine, 2d edit.  Paris,  1841.—A.
 B. Clot-Bey,  De la Peste Observee en Egypte ; Recher-
 ches et Considerations sur cette Maladie, 8vo.  Paris, 1840.
 —Prus. Rapport  a I'Acad. Roy. de Medecine sur la Peste
 el les  Quarantaities, fait  au  nom d'une Commission, &c,
 8vo.  Paris, 1846.—A. White, A Treatise  on the Plague,
 <fec; and on  Quarantine, Svo.  London, 1846.   This im-
 portant work, the result of much experience, appeared as
 this sheet was going to press.  It contains numerous addi-
 tional proofs of the truth of the doctrines for which  I have
 contended.
   PESTILENCES—Protection from.—Hav-
 ing considered the three destructive pestilences
 of modern  times, in respect of  their  causes,
 propagation, nature,  and treatment, as fully  as
 my limits have permitted me, I  now proceed
 to notice the measures which should be taken
 to protect the  community from them, and the
 prophylactic means which may be  used by in-
 dividuals against  them.  In order that the sub-
 ject may receive due  attention, I shall discuss
 it according to the  following arrangement :
 I.  Protection  op the  General  Community
   from  Pestilence.
   i. Prevention  or Warding off  Pestilence.
     A. By  sanatory  measures  having reference
        to the state of the locality, and to the com-
        munity.—Prevention of domestic causes.
     B. By  measures  intended to prevent  the  in-
        troduction of pestilence from abroad.—Pre-
        vention of foreign causes.
   ii. The Arrest of the Spread of Pestilence
     WHEN  INTRODUCED OR PREVAILING.
     A.  When introduced or prevailing in towns,
        cities, <5rc.
     B.  When introduced among troops, armies,
       or garrisons.
     C.  When introduced into ships.
 II.  Protection of Individuals, Families,  or
   Classes.
   i. Protection by Seclusion,  or strict Quar-
     antine, &c—Departure from the Sour-
     ces of Infection.
     A.  Estimate  of the means  answering this
       protection.—The avoidance of infection.
     B.  Restrictions  which should be imposed on
       those departing from  an  infected  locality,
       and when they should be imposed.
   ii. Protection  by  such  Means as may ena-
     ble  the  Constitution to resist  Infec-
     tion.
     A.  Medicinal Prophylactics.
     B.  Dietetic, Regimenal, and Moral Prophy-
       lactics.                                   y
   2. I. The Protection of the general Com-
munity from Pestilence.—The objects of gov- 
262                        PESTILENCES—Protection from.
ernment, m all civilized countries, are the pro-
tection  of the lives  and properties of the in-
habitants, the observance and advancement of
religion and  morals, and  protection from for-
eign aggression.  For the attainment of these
objects, laws  are  enacted and enforced.    In
most of the countries of Europe, however, the
last  of these objects have received the great-
est attention, and to it the wealth and resour-
ces of countries have been more especially de-
voted.   The  lives of the  inhabitants have al-
ways attracted the smallest amount of regard
from governments,  legislators, and  political
economists ;  and even from those who admin-
ister the laws, unless under  circumstances of
peculiar atrocity.   The  numerous  circumstan-
ces which influence the  health and longevity of
the community; the palpable causes which pro-
duce disease and pestilence ; the acts of indi-
viduals or of companies, affecting the health  or
lives of hundreds  or thousands of those with
whom they  have intercourse or  concerns,  or
who surround them; and the multifarious modes
in which avarice and the love of over-reaching
directly and indirectly sap the springs of life,
have never engaged the attention of most gov-
ernments, and least of all, those of this country,
until the magnitude of these evils, the fears of
a widely-spread pestilence, and the pressure
from without, diverted a very small portion of
that attention to  them which  had heretofore
been entirely absorbed by the interests of par-
ties and the advantages of a class.  Formerly,
and even now, although much less remarkably,
literature, in attempting to live upon the crumbs
which fell from the tables of placemen and aris-
tocratic partisans, like the parasite gull, so well
known to the naturalist, fed  only on the offal
and  filth ejected by those whom she worship-
ped.  The  sufferings of the  poor, the squalor
consequent on want and  misfortune, and the
garbs necessary to the satisfactory perform-
ance of important and requisite occupations,
were made the themes  of poetic derision and
prosaic  sarcasm by the statesmen and the pop-
ular writers  of the  day!  Yet, however foul
and  degraded  the  Georgian  era  of  literature
may have appeared  in  several of its  epochs,
science  continued to advance with due majes-
ty, and with a gracious  care  of the health and
lives of those who had become the least cared-
for parts of the machinery, invented for the ac-
quisition of wealth, and who were looked upon
by statesmen as  the  common herd, among
which pestilence and death might freely revel,
as " checks to an overgrown population."  Phi-
lanthropy went abroad ; but, in neglecting his
home, most signally destroyed or enslaved the
objects  of bis foreign care  His  very  enthu-
siasm blinded him to the effects of his actions,
and  diverted  him from his  domestic  duties ;
but hopes of his  return are  to be entertained
from certain  measures which public  opinion
has  enforced, and he may still promote some
of the numerous reforms  of our social condi-
tion that  are urgently  required, and  remove
many of the most influential  causes of disease
and of premature dissolution that degrade while
they afflict the community.
  3. i. The Prevention of,  or Warding  off,
Pestilence.—It is obviously the duty of gov-
ernments,  however  much they  may  neglect
it, to prevent  pestilence from  springing up  in
the countries they  profess to protect, and  to
ward off the invasion of pestilence from abroad.
These  are two grand sanatory intentions, the
fulfilment of which  the community has a right
to demand from those who govern and  enor-
mously tax it.  The second of these has been
as efficiently and satisfactorily accomplished as
circumstances allowed ; but the first has been
altogether neglected ; and not merely neglect-
ed, but sacrificed to class interests.   No ef-
forts have  been made  by those who  had the
power, but  neglected the  duties  which that
power  involved, to  prevent the  habitations of
the living,  the  depositories of the dead, and
the aggregations and conditions of the lower
animals, from becoming the sources of disease
or pestilence.   The ignorant builder,  who, in
many instances, could hardly write his name
was in  no way discouraged from building houses
and streets calculated to endanger not  only the
health  of their inmates, but that  also of the
whole  neighbourhood.   He might erect houses
and  streets in  any  form and position, at the
shortest possible distance, with the utmost dis-
regard  of ventilation, and without either drains,
cess-pools, or  sewers.  He might favour the
accumulation of animal exuviae as much as he
pleased, and in as detrimental a mode as pos-
sible to the health of all within many hundreds
of yards, and no one could interfere. He might
introduce disease and death among the whole
population of his district, and, instead of meet-
ing with reprehension from the authorities, ob-
tain the reputation  of being a spirited proprie-
tor, and accordingly receive  a portion of the
mammon-worship so generally and so assidu-
ously performed in  almost every street, man-
sion, and house in the kingdom.   The capital-
ist  economizes his  means by the neglect of
sanatory measures, which would necessarily in-
volve  expense, and the law protects him in
doing what he  pleases  with  his own ; but it
does not deign to  protect  the lives of those
around him from the certain  consequences of
his ignorance and avarice.  Thus London, and
most other cities and towns in the kingdom,
have increased in size without the least con-
trol, or the smallest endeavour  to protect the
public  health ;  but,  on the  contrary, with ev-
ery facility to accomplish the deterioration of
it, and  with the strongest inducements, in the
acquisition of wealth, and hence of considera-
tion, to generate disease.  These remarks may
be considered  overstrained;  but let the read-
er refer to  the evidence brought before the
" Health of Towns' Commission," and published
in its reports, and he will find them inadequate
to convey  the  opinions which the numerous
circumstances  and  occasions there described
must suggest.
  4. A very able and enlightened  member of
that commission, Mr. J. R. Martin, observes
with great justice in reference to this  subject,
that, "if it be the  business of government to
prevent and to  punish  crime—to secure the
public peace—to enforce industry instead of rap-
ine—and the settlement of disputes by appeal
to reason  instead of by fraud or violence;  if
the well-being of the subject be, in short, the
main object of legislation, then would  it ap-
pear the special duty of the  ruling power  to
secure  the health and the lives of those who,
of all others, stand most in  need of its protec- 
PESTILENCES—Protection from Domestic.                   263
 tion against the invasions of individual or cor-
 porate  caprice, ignorance,  or  stolid avarice.
 Here we perceive a moral and political duty of
 necessity.   On  this subject it  should  ever be
 borne in  mind  that, where  there  is disease,
 there also will be found the seat of poverty and
 crime.  Disease, poverty, and  crime in their
 worst forms are constantly and everywhere
 found together.   The truth then is, that misery
 and crime produce disease, and disease pro-
 duces misery and crime, in a circle which re-
 volves in the same calamitous  monotony from
 year to year,  of the brief existence of  the
 masses crowded in the worst  quarters of our
 manufacturing cities.  While  men are in  the
 lowest  state of physical destitution, surround-
 ed by filth, vermin, privation,  and  squalor of
 every conceivable kind—familiar with sickness
 and death, and strangers to every comfort—
 with the  mind  continually on  the rack, or ab-
 sorbed in striving against physical necessity—
 or with the animal spirits broken down by its
 pressure, how is it to  be expected that obedi-
 ence to the laws, and that  morals, education,
 or religion  should  find a place 1   How can a
 man whose mind is ruined even more  effectu-
 ally than  his body—the  man to  whom moral
 degradation and physical suffering  have done
 their worst—how can such  a man be expected
 to give a passing thought even to  such mat-
 ters]   The thing is impossible."
   5.  But, not to speak of these higher consid-
 erations, the benefits  of surrounding civiliza-
 tion, cleanliness and health,  are not for the oc-
 cupants only of lanes, courts, cellars, and hou-
 ses, teeming with exhalations from  the excre-
 tions and other  exuviae of the inhabitants, but
 extend  in various ways to the inmates of man-
 sions, and even palaces—to the houses of  the
 rich and the proud—to the dwellings, and even
 to the person's, of those who consider poverty
 and wretchedness  the worst  of crimes, and
 who cannot approach even the  one or the oth-
 er, even in the temples of the  Almighty, even
 in the houses of that God whom they profess
 to  worship, without  dreading  contamination,
 and derogation from their high positions.
   6.  A. The prevention of the generation of pes-
 tilence or disease in  a country has  been  already
 insisted upon as a duty which the government
 owes the  community.  The neglect of it is
 sure to become  the source of calamity, and  the
 extent of that calamity will  neither be readily
 controlled nor soon arrested, at least on all oc-
 casions of its occurrence.   In this climate  the
 calamities arising out of the sources to which
 attention is now to be directed are generally
 not so prominent as in warmer countries and
 places, where the progression  of the seasons
 is more regular; but if, owing to the nature of
 our seasons, they are less remarkably violent,
 they are more numerous and varied, and they
 can be shown to be  equally destructive in their
 silent, constant, and unobtrusive course.
  7.  It must not be supposed that, because the
 causes of disease to which particular reference
 is about to be made, and has been made, in va-
 rious parts of this  work, and  particularly in
 connection with the  pestilences  just  consid-
 ered, have not  been proved  to  be the origina-
 tors of any of these  pestilences in  this coun-
try, they are, therefore, entirely without influ-
ence as respects either the propagation of these
 pestilences when introduced, or tne production
 of other not less fatal, although more prolonged,
 maladies.   They are, in truth, among the most
 efficient causes of the diffusion  and propaga-
 tion of all infectious maladies; while they are
 the principal agents in the generation of chron-
 ic  and constitutional  diseases, in  contamina-
 ting the springs of life at their  very sources,
 and in producing decrepitude and mental weak-
 ness in the offspring, if,  indeed, the blighting
 influence of these agents during infancy  and
 childhood be survived.
   8. The prevention of domestic causes of pesti-
 lence is also the prevention of epidemic maladies,
 and of numerous chronic and constitutional  dis-
 eases.   The prevention of those causes has no
 farther relation to the three pestilences  above
 considered  than as respects the removal of
 some of the chief circumstances which favour
 and give activity to the infection of these pes-
 tilences, on the occasions of the introduction
 of the  infection from  abroad ;  but  it  has a
 much  more  certain, continued, and  manifest
 effect  upon the prevalence of the  numerous
 other maladies, which, in our climate, depend
 upon their domestic causes, especially as they
 exist in large towns and cities.  These causes
 are so evident  to  the  senses, so disgusting to
 the sight, so sickening and sensibly  injurious
 to all who come within their spheres, and so
 very prominently connected with their baneful
 effects, that it is a matter of the utmost sur-
 prise that a more enlightened  attention  to
 them, and attempts at their removal, have  not
 long since been enforced by the legislature.
  9. All sanatory measures which  should  be en-
forced  in a locality should have  for their  ob-
jects,  1st.  The removal of the excretions, as
 speedily as  possible, from the habitations  of
 the people, and  the prevention of their  accu-
 mulation ;  2d. The  means or method of their
 removal should be such as should, as efficient-
 ly as possible, prevent the escape of the gase-
 ous and putrid  emanations they  emit into  the
 atmosphere ; 3d. That a  sufficient  supply  of
 water  should be provided  for the rapid removal
 of putrid  exuviae  and excretions, and for oth-
 er purposes of cleanliness and ablution ; 4th.
 That animal remains and  excretions should as
 quickly as possible be conveyed to their natu-
 ral and intended destination, namely, to culti-
 vated fields and soils, with the intention of fer-
 tilizing them ; 5th. That the bodies of the dead
 should not  become, from  the mode  of sepul-
 ture, and the situation  and  crowded state of
 the places of burial, with reference  to the hab-
 itations, especially in cities and towns, a source
 of disease to the living ; 6th.  That ditches and
marshes should  be removed, especially in  the
vicinity of animal and  human habitations,  by
under-draining, &c.; 7th.  That while the sup-
ply of  water should be abundant, it should in
no way be contaminated by the vicinity of buri-
al-grounds, ditches, or marshes ; 8th.  The sup-
ply of pure air, and the requisite renewal of it
in all circumstances, with as little risk of con-
tamination as possible from  animal excretions
or remains—from  drains, sewers, cess-pools,
church-yards, ditches, marshes, &c.  In pro-
portion as attention is paid to these topics, so
will the health of cities and towns be improved.
But I cannot dismiss the consideration of them
without further and more particular notice. 
264
PESTILENCES—Protection from Domestic
   10. a. The prevention of animal excretions and
 remains from  accumulating, especially in large
 towns,  has always been attended with  some
 difficulty, but it is a difficulty which has rarely,
 until very  recently,  been attempted to be re-
 moved.  Indeed, much more frequently,  if not
 almost  universally, actual  provision has been
 made in large cities and towns for the accumu-
 lation of these excretions to a most astonishing
 amount, and without any intention of their re-
 moval for many years.  It was  proved before
 the  " Health  of Towns' Commission,"  that
 these accumulating sources of disease exist in
 respect  of most of the houses of all cities and
 towns, in the forms of privies attached to hou-
 ses unconnected with drains, and of cess-pools,
 into which  the soil from  water-closets and
 privies,  and the foul water used for domestic
 purposes, flow ; and that these cess-pools, priv-
 ies, and  drains exist under and around  most
 of the best residences, and in all the worst, in
 and  about  London,  and in other cities and
 towns, and  that they have  generally no  com-
 munication  with the   common  sewers  and
 drains, but actually are allowed to accumulate
 until their  overflowing contents compel a re-
 course to nightmen.
  [This  remark will apply particularly to the
 city  of  New-York,  which  has, undoubtedly,
 better natural advantages, and is more favour-
 ably located for health, than almost any city
 on  the  globe.   Though abundantly supplied
 with the purest water—the Croton—yet it has
 no extensive system of sewerage ; and, indeed,
 it is  but very recently that  sewers have begun
 to be constructed at all, and that  only in our
 principal streets ; while privies and cess-pools
 have  no communication with  those  already
 made, their contents being discharged by night-
 men, with  the  effect of contaminating whole
 neighbourhoods with the most horrible stench.
 When to this we add, that filth  of every kind
 is allowed  to  accumulate in our streets and
 gutters, which are rarely  washed,  although
 there is  ample water to accomplish it; that
 slaughter-houses and manufactories of various
kinds, deleterious to health, abound in  every
part of our city, it will be seen that reform is
loudly called for, if we mean to keep pace with
 other cities  in guarding the lives and health of
 our citizens.]
  11. The  inhabitants  who have for so many
years calmly submitted to a heavy sewer-rate,
from the notion  that  the  sewers formed  by
their contributions actually carried away the
 soil and foul water from their houses, now find
that they have been deluded, legally swindled ;
 and that, notwithstanding the vaunted  drains
and sewers of the metropolis, there is no ne-
cessary connection between them and the hou-
ses, close to which they pass, even where they
do pass; that the sewers  are few compared
with the number of streets, and that compara-
tively few  houses have any  communication
with them.  Thus the contents of privies or
necessaries,  water-closets,  cess-pools,  and
drains, are  allowed to sink  into  the soil  upon
 which the houses are built,  to poison it, and to
contaminate the  air within and around the
dwelling, the  more consistent remains being
pent up, and allowed  to accumulate without
any outlet whatever.  As  these  contents col-
lect and increase, the more fluid parts  filtrate
 through the upper layers of earth or clay, and
 contaminate the water supplying pumps and
 springs.  The gaseous parts, and those which
 are  carried off during evaporation by the air,
 more or  less infect the air, and destroy the
 health in various ways, of those especially who
 live in  the lower apartments, and particularly
 if they sleep in  them.   During warm seasons
 the emanations proceeding from these accumu-
 lations  of animal  excretions,  and  from the
 ground thus imbued with animal matters, upon
 and around which the dwelling stands, become
 almost  as  injurious as  those  generated  in
 warmer climates  and  countries,  to which ref-
 erence has been made above, in respect of the
 generation of the pestilences just now consid-
 ered ;  and would, equally with them, promote
 the  diffusion of the infection of those pesti-
 lences as soon as the  infection  should be im-
 ported.   Indeed, the accumulated emanations
 thus arising from the aggregation of individual
 sources, furnished by thousands of .residences,
 constitute that  contaminated state  of atmo-
 sphere which favours the propagation of the
 infection of these pestilences ; and the absence
 of these emanations, or at feast the  compara-
 tive absence of them in country places, partly
 accounts for the  much slighter prevalence of"
 pestilence in these localities.
  12. It is supposed that  the circumstance of
 cess-pools and drains, containing animal  mat-
 ters in a state of decay, being covered over, is
 a sufficient protection from their injurious in-
 fluence.   But they are not hermetically sealed.
 There is a constant generation and extrication
 of foul gases from them ; and these gases, and
 the air contaminated by them, are continually
 passing off between the boards and crevices of
 the stones which cover them.  In many places
 of this metropolis, as well as in manufacturing
 towns, large privies exist, used by the numer-
 ous workmen in large and crowded factories;
 and  cess-pools of immense  extent, which re-
 ceive the contributions of many nouses and
 work-shops.  It is well known that the former
 are often  not emptied for many years, but are
 allowed to diffuse their odours, and their bane-
 ful influence, for many hundreds of yards, in all
 directions ; and  it is stated  of the latter, that
 an attempt was made to empty one of them, sit-
 uated in a central and crowded neighbourhood;
 but after some scores of cart-loads of soil were
 removed,  the  rods which were employed to
 reach the bottom of the  depository were not
 sufficiently long  for the purpose, and the Her-
 culean task of emptying it—cleansing was out
 of the  question—was  relinquished.   It  was
 stated, also, before  this commission, that one
 of these immense reservoirs of filth and pu-
 trid  animal matter existed immediately under
 a school, so that, in addition to the contamina-
tion  of the air by the congregation of a great
 number of children in a confined and insuffi-
 ciently ventilated  space,  there was the addi-
tional evil of foul air constantly rising up from
the poisonous sources beneath them.
  13. Much has been said of the collections of
filth, of the superficial  uncovered drains, and
other disgusting  states of things in former
times ; and in numerous continental and east-
ern  cities  and towns  in modern times ; and of
their influence in originating and  perpetuating
pestilence.  But these sources of mischief are 
PESTILENCES—Protection from Domestic.
265
 readily swept away by rains ;  the emanations
 from them are  soon  dissipated by the winds;
 and the grosser materials are carried off and de-
 voured by birds of prey and the lower animals ;
 so  that they are actually less injurious than
 those accumulations  of filth and  faecal matters
 furnished by  almost every house in the  towns
 of this country.   These faecal collections are so
 carefully preserved from these natural  means
 of purification, that the emanations from them
 continue to be generated at all seasons,  and to
 be extricated within the very walls of the dwell-
 ing, in their areas, and  under the very win-
 dows which are intended to admit fresh air and
 light.  No cold in this climate is so great as to
 prevent the generation of noisome vapours and
 gases from these sources; while the warmth
 of summer and autumn increases the extrica-
 tion of them, and concentrates them in a more
 humid atmosphere.  But it may be  asked by
 utilitarians and political economists, where  is
 the mischief which  these  admitted nuisances
 and offences against the senses occasion 1  Do
 they produce pestilence 1   We see no sign of
 pestilence.   To these every well-informed phy-
 sician will answer, that there has been no pes-
 tilence—no plague—because the seminium or
 infection of plague has not been allowed to be
 imported.  But if it had been imported, or were
 even now to be imported, especially during sum-
 mer or autumn, all the conditions requisite to
 its devastating  spread exist in  the sources now
 pointed out.  Although protected from this for-
 eign scourge by quarantine laws, the existence
 of which is now threatened by persons ignorant
 of the subjects  to which they relate, let  it not
 be supposed that these nuisances, these sources
 of contamination, are unproductive of the most
 serious effects.   To the question, therefore, as
 to the mischief they  occasion,  another may be
 put, as to what mischief, evil, or disease afflict-
 ing the human frame may not be imputed more
 or  less to  these  very remarkable domestic
 sources.   I find it much more  difficult to point
 out a single  disorder or malady which cannot
 be imputed partly or altogether to these causes,
 than to enumerate the many  which acknowl-
 edge  them as  their  principal  sources.  Even
 where they are not the efficient agents, as in the
 pestilences above considered, they are predis-
 posing, aiding, and determining causes.  They
 more especially occasion sickness and  death
 during infancy  and childhood ;  and even when
 these epochs of human existence are struggled
 through,  and the various  affections of the di-
 gestive organs  and nervous system,  and the
 febrile diseases, and the varied  forms of debility
 which these causes produce, are either partially
 or altogether removed, there  frequently suc-
 ceed a sickly period of puberty, impaired man-
 hood and premature decay, scrofula, and tuber-
 cles in their numerous forms and seats, visceral
 diseases in countless variety, and mental weak-
 ness in endless  forms and grades.
  14.  During the present warm summer (1846),
 I have had numerous occasions  of remarking
 the very injurious consequences of frequenting
 those privies in which the faecal matters are
 allowed to accumulate.  Of three families, every
person was attacked with adynamic dysentery,
with a low or putrid form of tenesmus, and an
erysipelatous state of the anus,  extending to
the vulva  and vagina of the females.  In one
 family, nine  persons were thus attacked ; and
 in  several other families, and on other occa-
 sions, I have traced these affections, which have
 often been attended by great danger, to this par-
 ticular cause—to the influence of the foul and
 concentrated effluvia, from long-accumulated
 fascal  matters, upon the mucous surface of the
 anus and vagina.
   15.  It is obvious from  this that no such ac-
 cumulations  of noxious agents should be allow-
 ed to exist;  that drains and sewers should be
 so constructed as to convey from the dwellings,
 as rapidly  as possible, and without sinking into
 the soil, or evaporating into and contaminating
 the atmosphere, the foul materials and  animal
 exuviae into  the main sewers ; that the supply
 of water should be  sufficient to aid this object,
 and that the main  sewers  should be so con-
 structed, as respects their terminations, as to
 allow their contents to be removed by safe and
 suitable modes of conveyance,  to  cultivated
 grounds for the purposes of manure.
   [This is  a very important measure, which we
 trust will not be disregarded in the future sew-
 erage of our cities.  Wherever a proper system
 of house-drainage  prevails,  the  valuable  ex-
 creta  of the  human frame, containing the  de-
 bris of all the food consumed by the inhabitants,
 find their  way into the sewers.   Experience
 has proved that these excreta, but  especially
 the urine, are among the most effective of our
 manures ;  and that  they far exceed in value the
 products of the farm-yard and all solid manures,
 not even excepting guano.   In China, and those
 parts of continental Europe where agriculture
 is most skilfully practiced, this fertilizing liquid
 is highly valued.
  To this,  the most important constituent  of
 sewer  water, may  be added,  as  derived also
 from house-drainage, the  alkalies, potash, and
 soda, which  are so  largely used for household
 purposes in  the form of pearlash, soap, and
 common salt.  These alkalies form,  as  is well
 known, very  important  elements of the food
 and structure of plants.   Besides  all these,  we
 have the refuse of  slaughter-houses, markets,
 and manufactories, large quantities of soot, rich
 in ammonia and sulphurous acid.  So valuable
 are these debris of towns, that it is calculated
 that a  population of 100,000 in number would
 furnish sufficient nitrogen, phosphoric acid, and
 other substances to  manure no less than 93,440
 acres of wheat; and in  Flanders, we are  in-
 formed that the excreta of an adult are  valued
 at ten  dollars per annum.   Lands in England
 which were formerly a barren waste have been
 known to yield as  much  as £11 4s. per acre
 annually.]
  16. b.  The  burying of the  dead within, under,
 and around  chapels or churches, or in large bury-
 ing-grounds, situated within, or close  to cities or
 towns, is  among the most serious evils  of the
 present state of society, and of existing legisla-
 tion.   The emanations  from these places are
 equally injurious with those proceeding from the
 sources just  noticed, and are, on some occa-
 sions,  as I have often witnessed, even more
 strikingly injurious,  owing to the  greater con-
 centration  of the noxious vapours and  gases
especially as they emanate from the remarkably
crowded burying-grounds and vaults  around
and under chapels in the metropolis.   And,  al-
though numerous states of ill-health and forma 
266                   PESTILENCES—Protection from Domestic
of acute  disease actually proceed from this
cause, as well as from that above exposed, the
most malignant putrid or putro-adynamic fever,
as described under that article, have come be-
fore me, and been referred to this source by the
more  intelligent of those  who have been thus
attacked.   I have, moreover,  had demonstra-
tive evidence  that cases of this fever, caused
by the emanations from the vaults of chapels in
this city, and terminating fatally in eight days
from the period of exposure, these emanations
at the moment of their impression producing
most  marked  effects, have infected other per-
sons,  in the same house with them, with a sim-
ilar and equally dangerous and fatal fever.
   17. The congregation of many hundred per-
sons  in a building,  opened only once in the
week, warmed and ventilated but partially and
imperfectly on that occasion, and containing
immediately beneath its floors, and surrounded
by, thousands of human bodies undergoing pu-
trefaction  and decay,  must necessarily  prove
more or less injurious to health ; and still more
remarkably to the health of  those  who may
happen to inspire a portion  of those irruptions
of foul air which break forth at  intervals from
the  burying-places,  or which  flow from the
grated openings communicating with the  vaults
and other places of sepulture constructed under
the pews of these chapels.
   18. c.  It is  almost unnecessary for me to  in-
sist upon  the impropriety of  allowing ditches,
swamps, or marshes to  contaminate the air in the
vicinity  of towns,  or any human  habitation
whatever ; or to bring supplies of water from
places near to these sources of disease,  or to
burying-grounds.  Water loaded with  animal
matters in a state of decay, or abounding with
 animalculae, and the infusoria, is most remark-
 ably  productive of diarrhcea, dysentery, mucous
 and adynamic fevers, or of those typhoid forms
 of fever  which are attended  by ulceration of
 Peyer's  and  Brunner's  glands.  The  means
 of removing  these causes  are  too obvious to
 require notice at this place, and  ought never
 to be neglected, although no very remarkable
 mischief may result  from them, or  no very
 remarkable outbreak of disease may  occur.
 They, nevertheless, impair the constitutional
 powers of all within the  sphere of their influ-
 ence ; induce, gradually  and slowly, visceral
 obstruction, and  numerous chronic  maladies,
 and  favour the  prevalence by promoting the
 infection of malignant and  pestilential distem-
 pers.
   19. d.  Crowded apartments and assemblies, and
 neglect of due  ventilation of these, and of the dwell-
 ings  of the poorer classes, are among the most
 productive causes of disease, and of the diffu-
 sion  of pestilence, wherever pestilential  infec-
 tion  is introduced.  The  residences of the poor
 are not merely overcrowded,  but also ill-venti-
 lated, owing  both to the  prejudices of many of
 this class, and to the situation of them in courts,
 lanes, narrow streets, and cellars.   A free and
 thorough ventilation is often impossible in these
 situations ; and, in  addition  to this  cause of
 disease,  and  to the  evils resulting from large
 numbers residing and sleeping in  each of  the
 several apartments into  which the house may
 be divided, there are often superadded the foul
 air proceeding from privies, cess-pools, and
 drains, and the other sources above described
($ 9, et seq.).  Thus the air which is respired
by persons  thus circumstanced is contamina-
ted both by those who breathe it and by the scv.
eral causes just alluded to ;  and in this state of
contamination it is allowed, moreover, to stag-
nate, to  become  still  more foul,  and to  con-
centrate  more  fully the emanations  from the
bodies of those who respire it, and  from the
several sources above  indicated.   Among per-
sons thus placed, it must be expected that all
infectious maladies  will not only make  rapid
progress, and prevail extensively,  if not gener-
ally, but assume a more malignant character
than  in  other and  more favourable circum-
stances.
  20. It  is  not, however, merely by favouring
the extension and malignancy of infectious and
pestilential  maladies that these causes act in-
juriously on the classes of the community more
especially subjected to them, but also by ac-
tually generating infectious diseases,  and even
by imparting an infectious character to several
affections which  would not otherwise present
it.   In this  way fevers are  generated, and are
spread from these original sources to the abode8
of wealth and rank—to the very  families and
persons  of  those  by whom the wants of the
lower classes  were neglected,  for they could
not  have been unknown, and to whom  they
were an abomination ;  for, if they had been ob-
jects of compassion, they would have been long
since considered with  the intention of devising
a remedy for  such of them as  admitted of
remedy.
   21.  The want of due attention to ventilation
in  the construction of work-houses and  other
places for the reception and medical treatment
of the poor, aided by insufficient and  unwhole-
some food,  has been no mean cause of the pro-
duction  of low fevers, diarrhcea, and dysentery
among the  inmates of these places, but also of
the prevalence of these diseases in the vicinity.
 The crowded states of these abodes of poverty
 and disease, and the several other sources of
 disorder connected with them, certainly do not
 limit their baneful effects to the places in which
 they exist, but extend their malign  influence
 on many occasions by various modes of infec-
 tion, in  several  directions, and to more  than
 one class of the community.  If a rigid inquiry
 were made by competent persons into the states
 of work-houses, lunatic asylums, charitable in-
 stitutions, chartered and endowed schools, pen-
 itentiaries, and other  places where a constant
 residence or daily congregation of a number of
 persons or of children is  required,  how few
 would appear unexceptionable in every respect.
 In many, ventilation is imperfect or only par-
 tial ; in others, the sleeping as well as the sit-
 ting apartments  are  most  disgustingly  over-
 crowded ;  in most  of them imperfect ventila-
 tion is associated with over-crowding, and not
 infrequently, also, with foul emanations from
 privies, cess-pools, and drains; in some, one
 or more of these ills are conjoined with insuf-
 ficient and unwholesome food, and with want
 of due exercise in the open air; and in  not a
 few, all these evils are combined in various
 states, according as one or several of them as-
 sume more or less prominent characters, or
 are, moreover, associated with neglect of clean-
 liness of person and of residence, &c.  In what
 condition could the inmates of a lunatic asylum 
PESTILENCES—Protection from Foreign.                   267
have been in, as respects all the circumstances
which contribute to health, and especially those
to which  attention  has been  directed above,
when 112 out of 450 died in twelve months, as
proved by Mr. Wakley in the House  of Com-
mons 1
  22. e. There is nothing which tends more to
injure health, and to develop scrofulous and tu-
berculous  and other chronic diseases among
children and young persons than numbers sleep-
ing in the same apartment.  The evil is great in
proportion to the number relatively to the size
and imperfect ventilation of the chamber; but
when this is conjoined with others, as it often
is, more particularly with foul  emanations from
privies, cess-pools, and drains, with insufficient
or unsuitable  food,  and with insufficient  ex-
ercise  in the open air and in  sunshine, the in-
juries  thereby inflicted upon the constitution
in various forms of acute  as well as chronic
disease, and  the malignancy and danger  im-
parted to  infectious  and febrile distempers,
when they break out in these  circumstances or
places, become the  most  alarming, and often
the most hopeless, to which medical aid can be
called.  The circumstance of numbers being
compelled  to sleep  in the same chamber  has
been fraught  with  mischief,  not  only to  the
physical powers and the bodily health, but also,
and not less remarkably, to the moral feelings
and dispositions  through life; and although
most especially detrimental  to  children  and
young  persons, it is also very seriously injuri-
ous to  grown-up people.  What is the state of
health  in children in large  schools and institu-
tions,  where from five or six to fifty or sixty
children  sleep  in the  same  apartment;  the
smaller numbers in  boarding-schools,  and the
large number in public institutions, as Christ's
Hospital School at Hertford .   The data neces-
sary to a correct answer to this question  are
not before me ; but I will assert, from no small
experience of the bad effects  of this and other
conditions of these schools and institutions, as
favouring the development and spread of dis-
ease, that the extent of the mischief thus  pro-
duced  is not even suspected  by those who are
most actively concerned in their management.
The evils which result from causes connected
with the arrangements of these institutions are
even not  seen, and when they are seen, from
their prominence or extent, they are not refer-
red to  their actual sources.
  23. Nor are some of the evils which may be
traced  to the congregation of great numbers of
children during the  day in small school-rooms
much less remarkable than those above advert-
ed to ;  but when it  is known, as indeed it has
been proved  before  the "Health of Towns'
Commission," that these assemblages, of sever-
al hours' duration, actually take place in rooms
immediately over immense cess-pools, or in
chapels streaming with emanations  from the
dead bodies in  their vaults, or from those pu-
trefying around the walls, or from  both produc-
tive sources, it may,  without great Impropriety,
be assumed, that the wisdom  of man, even of
him who  thinks himself the most divinely in-
spired,  is but blindness, foolishness, and pre-
sumption ; and that, in his attempts  to accom-
plish what is laudable in itself, he is  actually
occasioning acute disease, or  contaminating
the constitution during  life, and occasioning,
moreover, that state  of contamination which
will be imparted to the offspring during many
generations.   The collection of numbers of per-
sons  in factories, the  imperfect ventilation of
many Of them, and the modes of warming and
lighting them, are not among the least of the
evils to which the health of the working class-
es  is exposed.   Science could not render a
greater service to the community than in ren-
dering her aid to  the reformation of these and
similar ills, which weigh upon the physical and
moral powers of the productive classes ; and af-
fect equally their health, happiness, and offspring.
  24. B. The Prevention of foreign Pestilence.—
The duty of government to prevent the intro-
duction of pestilence  from abroad  is as obvi-
ous as  that to prevent both the existing and
predisposing  causes of pestilence, and of dis-
tempers almost as fatal as pestilence, from be-
ing generated and allowed to exist at home.
While the former has been entirely neglected
in this country, the latter has received a very
proper attention.   Yet, although the neglect of
all  domestic  sanatory  measures has met with
little reprobation, the enforcement of the quar-
antine laws has experienced much opposition ;
and restrictions of every kind, calculated to
hamper commercial speculations,  have  been
condemned by those who consider a small pe-
cuniary loss  of greater importance to them
than the contingent occurrence of a great pub-
lic  calamity.   But, as Mr. M'Culloch justly
remarks, " quarantine is not a matter in which
innovations should be rashly introduced  ; when-
ever there is doubt, it is proper to incline to
the side of security."   In this country we have
to guard against the introduction  of the three
great pestilences above considered, and  the risk
from each, although remote, is probably almost
equal.   The frequent importation of plague into
this and other European and northern coun-
tries, before the institution of sanatory meas-
ures ; the increased risk occasioned  by the very
rapid communication between all parts of Eu-
rope and those places in the Levant and within
the tropics, where plague and haemagastric fe-
ver prevail, and our recent experience of the
pestilential cholera, are circumstances which
should  not be overlooked in  our estimate of
the probabilities of a visitation from either of
these distempers, and which ought to influence
those who are bound to protect the public, while
they give every facility in their power to trade,
in their deliberations and enactments.
  25. In the United States, more especially in
some of them, and in many of their  large com-
mercial cities, quarantine has been either im-
perfectly enforced, or not instituted at  all, un-
til recently.   The great distance between them
and the Levant, and the nature of their climate,
gave them little cause of alarm as to the intro-
duction of plague  ; and, until  lately, the hama-
gastric pestilence, so generally and destructive-
ly prevalent in the West Indies and on the coast
of Mexico, and so frequently epidemic in some
of their chief cities, was viewed entirely as a
domestic evil, against which quarantine and
other sanatory measures could not  possibly
prove of any avail.   From  1751  until 1791,
this pestilence made  its appearance in New-
York on several occasions;  but after the lat-
ter period it appeared more frequently and more
destructively, as might have been expected from 
268                      PESTILENCES—Protection from  Foreign.
the increased size of and population of the city
and the more frequent intercourse with  places
where it  prevailed.   It even occurred  during
two or three successive years, and was seldom
absent for a longer period than this, until 1822,
when it prevailed most fatally.  Since that year
quarantine  regulations  have been  strictly  en-
forced,  and  the distemper has  not appeared
again in  that city—now a  period  of  nearly a
quarter of a century—although it has  scarcely
been  a  year absent  from vessels detained in
quarantine, and in  the  quarantine  hospital.
(See the Report of a Committee of the House of
Assembly  of the State of New- York on the present
Quarantine Laws.   8vo.  Albany, 1846.)
  [It seems no more than proper to state that
the yellow  fever did not prevail in New-York
between the years 1805 and 1822, when, what-
ever quarantine regulations may have existed,
were by  no means  strictly enforced,  a fact
which may serve to  shake the soundness  of
the conclusion  arrived at by our  author.   It
seems to  us, moreover, that in  accounting for
the exemption  of the  city from this disease
since 1822, it is  hardly proper to  attribute  it
entirely to the observance of strict quarantine ;
for, during the same period, vessels have been
freely allowed to come to the wharves at Brook-
lyn, after two days' quarantine, and discharge
their cargoes, and yet no yellow fever has been
propagated in  that  city from this  source,  nor
has infection spread  from vessels  unladen at
the quarantine station, nor from yellow fever
patients received into  the  hospital at  Staten
Island from sickly ports.   It should be  borne
in mind that the general sanatory condition of
this  city  has materially improved  within  the
last twenty years, by  prohibiting the burial  of
the dead  in the crowded parts of the city ;  wi-
dening and cleaning streets ; and the introduc-
tion of the Croton water, &c., so that it  is now
the opinion of our most enlightened physicians
that, even were the yellow fever to be  intro-
duced, it would not spread, owing to the  ab-
sence of those atmospheric conditions on which
its extension seems to depend.]
  26. Can any stronger proof of the propriety
of enforcing these regulations be adduced than
that to  which I have  now referred, and which
may be perused with numerous other  valuable
documents in the official report just  named 1
It is well known  to most physicians  that  Dr.
Rush, celebrated not only as a medical writer,
but as a  statesman, at  an  early period  of  the
rising greatness of the United States of Amer-
ica, laboured with great zeal to  prove  that  the
pestilential yellow fever was of domestic ori-
gin.   But the authors of the report just refer-
red to state that " this opinion was neverthe-
less somewhat  modified before he ceased  ex-
erting a prodigious personal influence upon  the
mind of man; for he says, ' that it was even
produced in Philadelphia from the effluvia from
a chest of unwashed clothes which belonged to
one of our citizens who had  died of it in  Barba-
does.'*   This influence, says Dr. Monette,  has

  [* This statement is altogether erroneous. Dr. Rush,
during the latter years of his life, consistently and ably de-
feuded the doctrine of the domestic origin of yellow fever.
In a letter addressed to Ur. Mili.eR, of New-York,  he says :
•* You will perceive, from the facts and reasonings contain-
ed in this letter, that l have relinquished the opinion  pub-
lished in  my account of the yellow fever, in the years 1793,
1794, and 1797, respecting its contagious nature. I was
doubtless been  the destruction  of thousands;
and had it  not been  so great in the medical
community of the United States, our northern
seaports would not have  been so long subject
to the pestilential visitations of yellow fever.
The southern ports, still acknowledging a vas-
salage to his authority, and to his arbitrary dic-
tation, through his disciples, to this day immo-
late hundreds and thousands of victims annu-
ally upon the altar of a blind credulity."  (Re-
port, &c, p. 21.)
  27. Can  it  be possible  to  adduce a stronger
instance than  that to which this quotation re-
fers, of the baneful influence of authority upon
the minds of medical men .   Or is there more
satisfactory evidence required,  not merely of
the importation of the distemper to which it re-
fers, but also of the necessity of enforcing quar-
antine regulations for the  protection of the pub-
lic.  But the  instance thus adduced  by Dr.
Rush is one, not only proving the  importation
of this pestilence, but also showing  the facility
of such importation ;  and, when the nature of
the means  is  considered, the great difficulty,
however strict quarantine regulations may be,
of preventing  it through  the medium here in-
dicated.  Dr. Lind states that a trunk of clothes
was brought from the West Indies  into Phila-
delphia, in  1741,  containing the clothing of a
young man who died  of the  yellow fever; and
he  says  that all the persons present when the
trunk was opened contracted the disease, which
was afterward propagated to other persons in
the city.  The reporters to the House of Assem-
bly of New-York state that a vessel, which had
arrived  at  New-Haven from Martinico, "had
brought  home a chest of clothes which belong-
ed to a sailor who died of the yellow fever at
Martinico ;" that it was opened in the presence
of four persons named in the report; that three
of these four, in a short time afterward, died of
this fever; and that  the  pestilence  was propa-
gated from these to the town of New-Haven.
(See Report, &c, p. 17.)
  28. Now I have adduced  these facts, not be-
cause they  are strong proofs of the importation
and infectious nature of the pestilence to which
they refer,  for,  after what I have stated in the
preceding articles, no additional facts  are re-
quired, but because they  furnish the strongest
evidence of the necessity  of quarantine restric-
tions, and at the same time show the great dif-

misled by Lining and several West India writers. I am
aware of the influence which such changes in medical opin-
ions as I have  acknowledged have upon a physician's rep-
utation ; but small, indeed, should I consider the total sac-
rifice of mine  could it avert the evils which are connected
with a belief in the importation of pestilential diseases.
In the fourth volume of his "Medical Inquiries"  he says,
" I beg the forgiveness of the friends of science and human-
ity, if the  publication of that opinion" (alluding to conta-
gion) " has had any influence in increasing the misery and
mortality attendant upon that disease. Indeed, such is tbe
pain I feel in recollecting that I ever entertained or propa-
gated it, that it will long, and perhaps always, deprive roe
of the pleasure I might otherwise have derived from a re-
view of the attempts to fulfil the public duties of my iitut-
tion."  In  connexion  with  Dr. Rush, we may state, th»t
Dr. David Ramsay, in a letter to Dr. Miller,  of Mew-
York, in 1800, remarks, " The disputes about the  origin ol
yellow fever, which have agitated the Northern States,
have never existed in Charleston.  There is but one opio
ion among the physicians and inhabitants, and that is, tMt
the  disease was neither imported  nor contagious. This
was the uuanimous opinion of the Medical Society, who, in
pursuance of it, gave  their opinion to the government last
summer, that the rigid enforcement of the quarantine laws
was by no means necessary on accouut of yellow fever."] 
PESTILENCES—Protection from Foreign.
269
 ficulty of so enforcing them as to prevent the
 introduction of those articles and effects which
 are most likely to propagate not only this, but
 also the other pestilences.   I have not the least
 hesitation in maintaining, and I do so from per-
 sonal observation and knowledge of the fact as
 respects two out of the three pestilences  here
 considered, that there  is more risk of the im-
 portation of them from body and bed-clothes,
 and foul linen of those who have been affected
 with them, than from the persons of the infect-
 ed, or from  any other  source whatever.  Ev-
 ery person who has seen much of the commu-
 nications between  distant places by means of
 trading  vessels, who  has  travelled  much,  or
 who has voyaged frequently in those vessels,
 will admit the difficulty of preventing clothes
 and linen from being landed, and the frequent
 neglect of exposing infected articles of this de-
 scription to due ventilation and cleansing before
 they are landed.  Vessels are even not infre-
 quently, especially  in  countries where the re-
 strictions are loosely observed, allowed to con-
 tinue  in quarantine until the period is elapsed
 without the clothes or other personal effects of
 individuals  having been opened up or aired ;
 and not rarely are these articles, more especial-
 ly dirty linen, sent on shore or smuggled away,
 without the  guards either knowing the occur-
 rence or being able to prevent it.
   29.  My limits will not permit me to notice
 the several regulations requisite to the due en-
 forcement  of quarantine.   These regulations
 should be based upon the numerous ascertained
 facts mentioned in the course of the  preceding
 inquiries; and they should be enforced with a
 full knowledge of the deceptions so frequently
 practiced or  attempted, in order to  avoid the
 detentions  requisite to the observance of the
 law.   With highly qualified and duly remuner-
 ated health-officers, there can be little reason
 to  dread, either too  great  severity on the one
 hand,  or too  great laxity on the other, even
 should much be  left to their discretion.   My
 object at this place is merely to show the im-
 portance of, and necessity  for,  such restric-
 tions,  and to insist upon the strictest attention
 being given to the bed and body-clothes of all
 persons who may have been  infected, or sus-
 pected of being infected, with these pestilen-
 ces ; for, when the  numerous  ways by which
 these  and  other personal  articles and effects
 may pass, from infected places and vessels, to
 persons at a great distance, even before  they
 are opened up or exposed, are duly considered,
 it  cannot any longer be a matter of surprise
 that the distempers which they propagate are
 so  often traced with  difficulty,  or  even not
 traced  at all, to their several sources,  and
 through their several channels.*
  30. The  propriety of enforcing quarantine
 regulations does not rest  upon a few authori-
 ties  merely.  An outcry has  been raised, by
 persons interested in their abolition, that they
 are supported only by those who are  appointed
 to enfore them.  What possible interest can I
 have in contending for them ]  What other in-
 terest had most of the ablest writers who have
 advocated them  in this and in other civilized
 countries, than the cause of truth and the inter-
ests of humanity]   Dr. J. Bayley, in his cor-
respondence with the Mayor of New-York, af-
         [* See Appendix to this article,]
 ter adducing numerous proofs of the importa-
 tion of pestilential yellow fever into that city
 previously to 1822,  concludes  as  follows: " I
 cannot  suffer this opportunity to pass without
 expressing my firm conviction  that rigid quar-
 antine regulations are essentially necessary to
 guard the inhabitants of our commercial cities
 against  the introduction of pestilential and in-
 fectious diseases."  (Report, &c, p. 79.) What,
 also, say other eminent physicians of that city
 on this important topic . Dr. Townsend, whose
 experience of the haemagastric pestilence has
 been obtained  in  New-York, in  the Havana,
 in the Bahama Islands, in Charleston in South
 Carolina, and in the West Indies, thus remarks
 on the crude speculations and productions of
 some of those who  have recently written on
 the  subject now under consideration.  " The
 true character of  the pestilential yellow fever,
 commencing with the monographs of the ear-
 liest writers, as  Towne, Hillary,  Warren,
 Rouppe, &c, and the not less masterly descrip-
 tions of those who succeeded them,  as Chis-
 holm, Blane, Lining  (of Charleston, S. C),
 Hosack, and a crowd of others, together with
 the  more  recent  productions of Stroebel of
 Charleston, and Monette of Washington (Mis-
 sissippi), &c, have been entirely lost sight of to
 give place to the more  congenial and crude
 speculations and misrepresentations of empiri-
 cal adventurers, many of whom, with mercena-
 ry motives, designed to flatter the authorities
 of different governments with the delusive hope
 that commerce  might be disburdened of every
 such restriction, as a relic of barbarism, have
 not  hesitated to assert, and to disseminate on
 the subject of yellow fever, a tissue of heresies
 and  errors which every  practical physician,
 and every common citizen  acquainted with this
 disease, as it has prevailed in our seaports and
 in  the West  Indies, know to  be  without the
 shadow  of a foundation."
   31. Dr. Vache, of New-York, observes, "that
 yellow fever has  not appeared in  that city for
 nearly a quarter of a century, and not since the
 present health laws have been rigidly enforced ;
 therefore, let us not forget, in our zeal for in-
 novation and improvement, the good old max-
 im,  ' Let well enough alone.'  Admit they are,
 in a measure, restrictive to commerce and bur-
 densome to the merchant, will any calm ob-
 server deny they are alike protective of his life
 and conducive to his interest.   The pecuniary
 loss of a hundred years by the  quarantine es-
 tablishment cannot equal the ruin and desola-
 tion of a single season of the pestilence.  Who
 does not  shudder at the memory of closed
 dwellings, the  suspension of  business,  the
 shunned city, the  quarantine  abroad,  and the
 sepulchres of hundreds during the summer of
 1822 ."  (Report, &c, p. 97.)
  32. Similar opinions to these have been given
 by Dr. Francis, and other eminent physicians
 in the United  States, and  furnish the basis on
 which the Report is  founded, to which I have
 referred, and which reached me after the chief
 part of the above article was  put to press.
 These fully confirm the views which I have en-
 tertained, as well  as furnish most conclusive
evidence of the  necessity of enforcing quaran-
tine regulations.  Dr. Francis, as well as many
other eminent physicians, has shown that the
haemagastric pestilence  has been imported into 
270
PESTILENCES—Protection from Foreign.
 many places, and into the quarantine districts
 of the United  States, when the thermometer
 ranged  above 75°.  Now if the Eclair  steam-
 ship had arrived in this country when the tem-
 perature was at this elevation, or at any pe-
 riod during the summer of 1846, and quaran-
 tine regulations had either been neglected or
 imperfectly enforced,  what might  have  been
 the consequences 1 and what may still be the
 consequences if these regulations should be so
 far relaxed as to  allow of the admission of the
 foul bed or body-clothes of persons who  have
 died of  any of the pestilences just considered,
 especially during states of temperature and of
 the air  favouring the infection of these pesti-
 lences .  I fully believe that pestilential chol-
 era was introduced into various places, both in
 this and in other countries, by foul clothes, and
 that there  is more  risk in  either of these dis-
 tempers being  imported in this way than by
 personal communication—than by the infection
 having been imparted in some  place where the
 distemper prevailed,  and  remaining latent  in
 the infected person for a number of days, so as
 to break out only  shortly before, or soon after,
 arrival at the place of his destination.   Cer-
 tainly, all the contingencies of the malady—in-
 fection by close communication, by opening up
 the clothes of infected persons, and such  arti-
 cles of traffic as are calculated to imbibe infec-
 tious emanations, or are  likely to have been
 exposed to them ;  the period which has elapsed
 from the occasions of such  infection and of
 such exposures, and the several circumstances
 favouring or counteracting infection, even ad-
 mitting its presence, as temperature, humidity,
 or dryness  of the  air, cleanliness, ventilation,
 &c, ought severally  to be considered  when
 framing  regulations for warding off pestilence,
 and when carrying these  regulations into ef-
 fective operation.
   33. How far it may be prudent to relax these
 laws in respect  of merchandise, even still far-
 ther than they have been in this country, can-
 not  be stated absolutely and with confidence
 of perfect safety ;  for several articles of traffic
 belong to  the same category  as  apparel  and
 bed  and body-clothes, and  retain and convey
 the poison long and far; but caution should be
 used in such relaxations ; and the facts should
 not be overlooked, that the most  obvious  and
 important  advantages  have already  accrued
 from the recent institution  of quarantine laws
 in Constantinople and other places in the East,
 and from a more strict enforcement of them in
 the cities of the  United States.
   34. To the entire neglect of government meas-
 ures of prevention,  and to  insufficiently  strict
 quarantine regulations, the extension of  the
 choleric pestilence throughout the countries of
 the east, and through Europe and America, are
 entirely  to be imputed.  The difficulty,  how-
 ever, of  completely enforcing these measures,
 and the liability of evading them  in all  coun-
 tries, particularly those which are continental,
 and  have an  extended  boundary, which  are
 thickly inhabited,  particularly  on  their  fron-
 tiers, have large and populous  frontier towns
 and seaports, and enjoy a rapid  and extensive
commerce, either by sea or land, are  so  great
that  numerous  instances of their infraction
must  occur, and the chances of the introduc-
tion  of the pestilence  be  thereby increased.
  These circumstances fully account for the im-
  portation of the malady into the principal towns
  and seaports of Russia  and Prussia; its ap-
  pearance in Moldavia, Hungary, Austria, Vien>
  na, Dantzic, Hamburgh,  &c. ;  and the negli-
  gence with which quarantine regulations are
  usually resorted to, fully explains the introduc-
  tion of  this pestilence  into" Egypt,  into this
  country  at various ports, as well as  into nu-
  merous places in other countries, where strict-
  er precautions might have reasonably been sup-
  posed to prove successful.
   35. As intimately connected with all regula-
  tions of quarantine, the period which elapses
  from the impression of the morbid cause upon
  the frame,  and the full development of the dis-
  ease, requires some notice ;  but, unfortunately,
  sufficient facts have not been obtained, and those
  which have been observed are not sufficiently
  precise to  furnish us with exact data on this
  topic.  In respect of plague, eleven or twelve
  days have been assigned as the extreme period,
  while other observers have stated fourteen days
 to be the longest time.   Various  circumstan-
 ces, however, serve to  show that the full de-
  velopment  of the morbid actions  constituting
 these diseases may take place very soon, even
 a few hours, after exposure  to an intense de-
 gree of the exciting causes, or when the state
 of predisposition to become  affected  has been
 great;  while, on the other hand, several, per-
 haps many, days often elapse before a marked
 effect is  produced.  As to the exact length of
 time which may, in extreme cases of this kind,
 thus elapse, I have no means of stating, espe-
 cially as respects pestilential cholera and haem-
 agastric  fever ;  but even taking it for grant-
 ed that a few days merely will often form this
 period of latent or smouldering action, it be-
 comes obvious  that a person may  have  been
 exposed to a source of infection,  previous to
 leaving an  infected place; that  he may travel
 a long distance, especially  in these days of rapid
 locomotion, and  yet not experience the disease
 until some  time after his arrival in a healthy
 situation, when  he may be attacked, and thus
 he will introduce the pestilence.
   36. The  unknown duration of the  interval
 which may  elapse between the infection of the
 malady and its full development must render
 it doubtful what should be the prescribed pe-
 riod of quarantine; but there can be no doubt
 of the propriety of regulating it according to
 the length  of time during which persons or
 vessels have been on their passage from an in-
 fected place, provided  that no source of infec-
 tion existed in their  course.  I believe  that
 nothing can be objected to  the measures which
 have been resorted to  in this country respect-
 ing ships; but it remains  a question  in what
 point of view articles of merchandise are to be
 considered.
  37. That the chances of infection by  articles
 of this description are  much less than by per-
 sons, may, I think, be safely taken for granted;
 but I still consider those  articles  which are
 most likely to have imbibed a portion of the ef-
 fluvium of the affected, as  made clothes, arti-
cles  of bedding,  furs, cotton, woollen, silken,
and linen furniture, and rags, to be calculated
to transmit the infection.   In  all  cases, there-
fore, these should be subjected to precautiona-
ry measures, and particularly to  a  full expo- 
PESTILENCES—Protection  from.
271
sure to  the  open air.  It  is astonishing how |
very long woollen and silken  bed and  body-
clothes,  especially, will often retain animal ef-
fluvia, when  closely packed together, or exclu-
ded from ventilation.   This must be familiar to
every medical man who has been in the habit
of continuing for a considerable time, or to be
frequently in dissecting-rooms ; for the animal
miasm which his clothes  have there  imbibed
will be sensibly felt months  afterward  if they
have been put in a close place immediately after
they were saturated with the foul air.
  38. That sanatory  measures will succeed in
averting  a visitation  of this  pestilence, will
much depend upon the nature of the frontier of
a country, upon its extent, the number of popu-
lous places in its vicinity, and the nature of the
intercourse between  it and the infected parts.
In respect of this last-named source of infec-
tion, illicit intercourse, or smuggling, is one of
the most probable channels through which the
disease  will  be communicated ; and when the
population is thick, and the towns large and
numerous, the chances of pestilence being in-
troduced in this way are much greater than by
regular  commercial  intercourse, inasmuch  as
the  latter is more or less  under the  control
of  sanatory regulations, whereas the  former
avoids them altogether.  Besides, bed and body-
clothes, foul  linen, and similar infected articles,
are more likely to be conveyed clandestinely
than by  ordinary commercial channels.
  39. ii. Of  the Arrest of Pestilence when
Introduced  or Prevailing.—When pestilence
is introduced, the measures which should  be
taken to arrest its progress must necessarily
depend upon the  extent of its diffusion, upon
the number and situation of the places in which
it has appeared, and upon the nature of the pes-
tilence itself.  As regards the last of these, it
may be  premised, 1st. That the hamagastric
pestilence can be introduced into a country only
where the temperature is above 70° ; and when
the air  is close  and humid,  and the elevation
not greatly above the level of  the sea ;  that it
is rarely  disseminated when  the situation  is
well ventilated, and not thickly inhabited ; that
frost destroys its infection, and that it attacks
the human frame only once.   2d.  That the sep-
tic or glandular pestilence maybe introduced into
a country at all  ranges of  temperature, from
35° to 75°;  that it may remain dormant in fa-
vourable circumstances at a temperature either
below 35° or above  75°, although these  more
extreme ranges are  more likely to destroy its
infectious power; that  a  close, humid atmo-
sphere, with the  other circumstances  already
noticed  (§ 9-23), favour its spread ;  and that a
previous attack generally protects the  system
from a second, although not so fully as observed
in respect of the  haemagastric distemper.  3d.
That the choleric pestilence may be introduced
and  prevail  in any range of temperature ob-
served  in temperate  countries, although it is
most rapidly and  generally  diffused in warm,
humid, still,  and  sultry states  of the  air;  in
crowded situations,  or  where  intercourse is
most frequent, as in camps, barracks, trans-
ports, and ships of war ; where, also, the oth-
er pestilences are  more rapidly and universally
propagated.
  4(»  It has always been observed that, when
either of the  pestilences has appeared in a coun-
| try, the places nearest the frontier or coast, or
 in most intimate and frequent communication
 with  a previously infected  part, are the first
 attacked.  It is obvious that, when once intro-
 duced into a populous and  commercial  town,
 surrounded either by other towns or by a dense
 population, the difficulty of preventing its ex-
 tension is greatly increased beyond what ob-
 tains when it appears in  a walled city or in an
 isolated locality.   For in all places depending
 chiefly upon manufactures, and upon commerce
 with  distant or  foreign parts, measures suffi-
 ciently restrictive to confine the malady there
 until it shall have subsided or exhausted itself,
 will be productive of so much distress, by throw-
 ing many persons out of employment, and by
 abridging the means of subsistence, and  so in-
 jure the health of the community, and predis-
 pose to the extension of the  distemper, as to in-
 duce all classes to combine to evade them, until
 the pestilence will spread, notwithstanding these
 restrictions.   The  failure,  however, of such
 measures is not to be viewed, as it has been by
 the anti-infectionists, as  a proof of the justice
 of their cause, but of the impossibility of pre-
 venting communications, indirect or direct, be-
 tween the sick and  the  healthy, in these  cir-
 cumstances.
   41. A.  When pestilence  first appears in a popu-
 lous  city or town  thus circumstanced, the  chief
 measures of prevention ought to be directed to
 the infected habitations,  as will be pointed out
 hereafter,  and to the  infected  persons  and
 things which introduced the distemper.  Those
 attacked  should  be  immediately removed, in
 conveyances constructed for the purpose, to an
 isolated  hospital, devoted to them only ;  and
 suspected persons, or those  in close communi-
 cation with the infected, but not yet attacked,
 ought to be  removed to another  hospital or
 place of observation near to, but not connected
 with the former, to  which all should be con-
 veyed as soon as they are  seized.  All inter-
 course between the inmates of infected houses
 and of  those adjoining should be prevented, or
 placed  under  rigorous restrictions; and thus
 the  pestilence may  be  strangled  at  its birth.
 In all outbreaks  of pestilence, the  attendants,
 and those employed in removing the infected,
 ought to be selected  from those who have been
 attacked on some former occasion ; and they
 should be provided with linen, canvas, or other
 suitable dresses; and  the medical attendants
 ought not to leave persons  infected by eitheT
 of these  pestilences  and proceed abroad, or
 to visit other persons, without changing the
 clothes,  in which patients in pestilence were
 seen, for other garments.
   42. If  pestilence  spread notwithstanding
 these restrictions and precautions,  more espe-
 cially in large towns, and a thickly inhabited
 surrounding country, more advantage will ac-
 crue from the  individual means of prevention
 hereafter to be  noticed  than from measures
 which aim at that which cannot be enforced or
 accomplished,  namely, the maintaining a strict
 non-intercourse   with  the  vicinity.  Where,
 however, this object may be attained with rea-
 sonable hopes of success, it should not be neg-
 lected.   But  in  a place  where, besides a fre-
 quent  intercourse with  other  parts  by ship-
 ping,  an hourly  communication by means of
 stage-coaches, wagons, canals, and railroads is 
272
PESTILENCES—Pprotection from.
  kept up with other towns  in  all directions, I
  cannot see that quarantine  or sanatory cordons
  can be strictly maintained, or regulations be
  enforced  in  such a manner as to prevent the
  extension of the  malady.  How can various
  effects and  articles, even those most likely to
  transmit the pestilence, be sequestered for the
  purpose of purification, and yet avoid all chan-
  ces of conveying it.  And how, especially, are
  the  hundreds, or  even thousands of persons
  whom their  avocations daily call to adjoining
  parts, many of whom may have  been exposed to
  infection previous to their departure, to be placed
  in quarantine, or in observation, for a sufficient
  time  to avoid all  chances of their conveying
  the disease to the  places of their destination .
   43. I conclude, therefore,  that where a strict
  quarantine, or sanatory measures calculated to
  confine the pestilence to the place of its intro-
  duction, cannot be maintained, the mischief
 resulting from the attempt will be greater than
 the benefits which will arise to the community.
 But that, where they may be enforced, owing
 to the nature of the locality, the employments
 of the  population, the distance from other
 towns or populous places,  and the thinly inhab-
 ited  state of the  surrounding  country, they
 should be  adopted, notwithstanding the tempo-
 rary losses, or even distresses, of the place thus
 sequestered,  for the good of the few should
 give place to  the safety of the many.
   44.  B. When pestilence  is introduced among
 troops in armies or in garrisons, the very best
 results will  be generally  obtained if decided
 measures  be  early resorted to, as  shown  by
 those  devised  by  Sir  W. Pym at  Gibraltar.
 Notwithstanding  the  existence of  medical
 boards in this country and  in each of the presi-
 dencies in  the East Indies, there does not ap-
 pear to exist  any code of regulations by which
 either the young and  inexperienced  medical
 officer, or the  more responsible and experi-
 enced army physician may be guided wholly or
 in part, or  which he may mould  to circumstan-
 ces.   In 1831 Sir David Barry, whose talents
 were great, and sphere of observation exten-
 sive, published several suggestions on this sub-
 ject, with  reference especially  to the  haema-
 gastric pestilence of Gibraltar,  but applicable
 to all outbreaks of pestilence in  armies or gar-
 risons.  How far they have been adopted  in
 garrisons or among troops  liable to be infected
 by either pestilence, I am unable to state ; but
 there was  formerly, and I believe that  there
 still is, in all  departments  of the army, more
 especially in the East Indies, a most remarka-
 ble neglect of sanatory or precautionary meas-
 ures.  Those which I have  now to offer are
 in several  respects  the same as were  recom-
 mended by Sir D. Barry.
  45. a. When pestilence  shall have  been
 proved to exist within a fortress, garrison, or
 encampment, let the sick and the suspected be
 immediately  removed without  the  walls, or
placed in tents in dry, airy, and open places, or
in hospitals, or places fitted up as hospitals,
when  these are  more favourably situated or
circumstanced, and there kept effectually sep-
 arated from the healthy, unsuspected, suscep-
 tible part of the inhabitants.
  46. b.  Let the infected houses and goods be
kept in strict  quarantine, and purified  by wa-
ter, air, fumigations, and  every  other means \
  that may be thought advisable ;  great care be-
  ing taken that these expurgatory measures be
  executed by non-susceptible persons, or those
  who have been attacked by the pestilence on
  former occasions of its prevalence.
    47.  Let no time  nor labour be thrown away,
  at this  most  important crisis,  on  cleansing
  drains  or privies,  Experience has already
  proved, most fully, both in Cadiz, in the great
  epidemic of  1800, and in Gibraltar in 1828, the
  perfect inutility, nay, the absolute mischievous
  tendency of  this measure, when adopted after
  the pestilence has commenced, with the view
  of arresting its propagation.
    48. c. Should  the infection appear to spread
  within  the territory or fortress,  notwithstand-
  ing the removal of the  first sick, all theories
  must be abandoned, and one  established fact
  must alone guide  all our measures, viz., that
  the disease will stop as soon as the  susceptible are
  separated from  contaminated places, persons, and
  things.
    49. d. Since, however, it would be obviously
  impracticable to remove  all  the susceptible
  from a fortified  town, or garrison, at  once,
  when an  epidemic breaks out  after a long in-
  terval  of public  health,  and when,  besides  a
  large portion of the civil population, the whole
  garrison may belong to this class, as was the
  case in  Gibraltar  in  1828, all the  moveable
  sources of infection and fomites should be sent
  beyond  the walls, and as many as possible of
 those capable of being affected by such sources
 as cannot be  removed.   The civil hospital of
 a fortified town should also be transferred, with
 its whole establishment, to the open ground or
 any situation  as above (a) directed, to serve as
 a nucleus of a civil lazaretto, on  the very first
 breaking out of  pestilence.  The regimental
 hospital, also, should be sent out, as the corps
 to which they belong happen to  be  attacked.
 No family or person, after having been  once
 contaminated, should  be allowed to remain an
 hour in a fortress or fortified town, particularly
 at the  commencement  of  an  epidemic,  but
 should be removed to the places above indica-
 ted, where they should be strictly secluded or
 placed in rigorous quarantine.
   50. e. Temporary emigration should be en-
 couraged among the healthy, uncontaminated,
 and unsuspected civilians ;  and the whole sus-
 ceptible  population, civil  and military, should
 be scattered over the open  ground and adjoin-
 ing  country, as widely as  circumstances will
 admit, due care being taken that the places or
 ground  occupied  by the  sick,  suspected, and
 the  hospitals  should  not be too nearly ap-
 proached (a)   Whenever  a regiment  becomes
 infected, it should be immediately encamped
 outside the town, city, or fortress, if it can be
 spared ;  but if it cannot, it should be removed
 to as open and as well-ventilated a place as can
 be obtained, and the infected instantly carried
 to the hospital.
  51. /.  The sanatory division of the healthy
 into the susceptible,  and the non-susceptible or
 those previously  attacked,  naturally dictates
the classification of the sick into the decidedly
infected, the suspected, and the unsuspected.
There should,  therefore, be three distinct hos-
 pital establishments, viz.:  1. The foul lazaretto
for pronounced cases.  2.  The lazaretto of ob-
servation, for those cases which may, or may 
PESTILENCES—Protection from.
273
not, turn out to be infected.  3. The  free or
clean hospital, for accidents or non-susceptible
»ick.  All the attendants of the  first and sec-
ond establishments, medical, clerical, and oth-
ers, should be kept, if possible, in quarantine.
  62. g.  The bed, bedding, and every thing
personal  to the sick  soldier, sent to either of
the two first hospitals, should follow the for-
tunes of their owner.  If the sick man should
happen  to die, his  effects  will  thus  remain
where they can do no further mischief, viz., in
the foul hospital;  should he survive, they  ac-
company him to the convalescent depot,, and
thence, after having undergone the most care-
ful ablutions, fumigations, &c., to the suspect-
ed quarter within the fortress, on his return to
duty.
  53.  Hospital bedding, properly  so called,
should be used, as in time of public health, in
the clean hospital only.  This, of course, im-
plies that the bed  and  bedding of the unsus-
pected sick  need  not  be removed  from the
tents or quarters of the healthy.
  54. A. There should  be three descriptions of
camps and quarters, corresponding to the hos-
pital establishments ; the foul, the suspected,
and the  clean, or free.   These should be kept
distinct during the epidemic.
   55. Convalescents from the foul and sus-
pected hospitals should be returned to the for-
tress, after their recovery, placed in suspected
quarters, and  appointed  to the lightest duties
at first, distinct  from the uninfected, until the
return of public health.
  56.  i.  The guards, and all other duties with-
in the  town and in the sheltered  situations,
should be reduced to the mininum consistent
with the  safety of the fortress ;  and,  as soon
as the original and convalescent non-suscepti-
ble soldiers  are sufficiently numerous to per-
form these duties, the susceptible should no
longer be permitted to participate in them.
   57. k. The  epidemic  sick should, as far as
practicable, be treated in detached tents, huts,
or sheds, so placed  and constructed as to  ad-
mit of the most perfect ventilation.  It will  not
be enough for the protection  of the  suscepti-
ble, nor for  the benefit of the  sick, that  the
latter be sent outside the gates.  They must be
so  placed as  not  to be sheltered  by the out-
works from currents of cool air.
  58. I.  Should  it so happen that troops in gar-
rison, or otherwise in service, cannot furnish
a sufficient number of  non-susceptible (former-
ly attacked) orderlies  for attending upon  the
infected, civil attendants of that class should
be employed from the commencement.
  59.  m. In the pitching of tents, and particular-
ly in the erection of  boarded sheds,  as tem-
porary hospitals, places  of seclusion, observa-
tion, &c, care ought to  be taken that they be
not huddled too closely together, and that they
be so placed in regard to each other as to al-
low a free passage for currents  of  air;  for
nothing tends  more  effectually to prevent and
to  destroy the propagation of infection than
open space and perfect ventilation.
   60. n. The  first and most  important steps
towards the saving of human life, on the break-
ing out of pestilence, being the early detection
of it, and the firm, unhesitating announcement
of its existence  to the proper authorities,  the
chief medical officers, or those best acquainted
    III.             18
with  its characters, should carefully  observe
and  report  upon all cases of sudden attacks
and of malignant features.
  61. o. When corps, detachments, re-enforce-
ments,  or  armies are marching or changing
quarters, care ought to be taken by command-
ing officers to cause all quarters, barracks, and
encampments to be inspected by trustworthy
and experienced medical officers,  in order to
ascertain their cleanliness, salubrity, &c.; and,
as far as possible, the state of health of the
previous occupants, and  the existence or non-
existence  among them  of any malignant, in-
fectious, or febrile disease.  The  three pesti-
lences above  considered have severally been
often  propagated in this way to both troops and
civilians ;  those departing carrying with them
and imparting on their route the  infection to
others ; while healthy  troops have rapidly been
infected upon  arriving  in  the contaminated
quarters which had been  relinquished to them.
This shows the necessity of using the  most ef-
ficacious disinfecting means to all quarters and
barracks that are in the least suspected, before
healthy troops approach them.
  62.  p. When troops or detachments are upon
march, care should  be taken not to allow any
of the men, or  even of  the officers, to enter
towns or villages before  the state  of health of
such  town or village  is  inquired after by the
principal and most experienced medical officer;
and this inquiry should be  made  at the chief
authorities and medical  practitioners  of the
place.   Want of attention to  this, and to the
immediately preceding precaution, has been the
cause of the  infection  of healthy corps, on nu-
merous occasions in  the East and West Indies,
with the pestilential cholera and yellow fever.
  63.  C. When pestilence is introduced into ships,
especially transports, ships of war, and emigrant
vessels, it will be most difficult, if not impossi-
ble, to prevent its extension to all susceptible
persons in such vessel.   Hence the necessity
of the utmost precaution in preventing commu-
nication with  ports in which even the suspicion
of the existence of pestilence may be entertain-
ed.  Trading vessels are, however,  often bound
to ports where one or  other of the pestilences
above considered is more or less prevalent, or
where it sometimes breaks out during the con-
tinuance of the vessel  in the port;  and in such
circumstances the infection of one or more of
the crew generally  occurs; for sailors usually
frequent those places in which a pestilential
malady generally makes its first appearancel or
most commonly lurks, awaiting susceptible sub-
jects, especially in regard of plague and haema-
gastric pestilence, for its outbreak.   Besides
the infection introduced  in the persons of sail-
ors infected on  shore, infection may be intro-
duced in clothes, especially such as may have
been previously worn, purchased by them and
brought on board.  Vessels, also, may be infect-
ed by  incautious communication with other ves-
sels, especially  in the Mediterranean, and on
the coasts wf Africa and  .America, and more
particularly with slave-ships.
  64.  When a pestilential malady thus appears
in a vessel in  port, the circumstance should be
dealt with as follows:  If the vessel have been
infected in the port, the  distemper existing at
the time in the port or its vicinity, the person
or persons attacked ought to be instantly land- 
274
PESTILENCES—Protection  from.
ed and taken, with all the precautions against
the diffusion of the infection, to the hospital or
place provided for pestilential cases, unsuscep-
tible or formerly attacked individuals being em-
ployed for the removal, if they can be obtained.
The vessel should be removed to some dis-
tance from others, and ventilation and purifica-
tion resorted to.   If the vessel have conveyed
the disease from an infected place to a healthy
port, especially during seasons and temperature
which favour the  propagation of the distemper,
communications of all kinds ought to be strictly
prevented with the infected vessel.  She should
be instantly placed in quarantine, in a suitable
place, and health guards sent on board.  The
persons already infected ought to he sent to the
quarantine hospital, and the susceptible non-in-
fected removed to an observation hospital, ship,
or place, and  their clothes be carefully venti-
lated, cleansed, or fumigated.  The Vessel and
articles in her capable of imbibing  infectious
emanations should be purified by  non-suscep-
tible persons.
  65. The greatest risk of the introduction  of
pestilence, and of the diffusion of it among the
crew, arises from  the concealment, on the part
of the captain of a trading vessel, of the illness
or death of any of his passengers and crew, and
from the preservation of the bedding and clothes
of the infected, which are often concealed and
smuggled on shore, or even openly preserved
and sent home to the relatives of the deceased.
It has been frequently found, in the quarantine
ground at New-York, that the haemagastric pes-
tilence has reappeared in vessels after purifica-
tion had been, as was supposed, sufficiently re-
sorted to.  This failure of the usual means of
disinfection, in respect of these vessels,  may
have arisen from  some articles  of clothing or
bedding having escaped notice or sufficient pu-
rification, or from  the return of such articles to
the vessel without due ventilation and cleans-
ing ; or from the circumstance of the infection
having remained longer latent in the system
before it developed its effects than is generally
believed to be possible.
  66. When the haemagastric pestilence breaks
out in a vessel within the tropics, it has usually
been  recommended, and practiced, to proceed
forthwith to a colder climate, or to latitudes in
which the range of temperature is below 60° ;
all  the usual  means of  ventilation and disin-
fection being at  the same time employed.   In
some circumstances this measure may be ju-
dicjous.   But it should not be depended upon
when the vessel,  especially  a  ship of war or
transport, is so circumstanced as to admit of
the instant removal of the infected into a quar-
antine or other appropriate hospital, and of the
susceptible  non-infected into an  observation
hospital  or ship, and of the immediate disin-
fection of the  ship.  The great errors, in many
instances of the outbreak of this pestilence in
war-ships within  the  tropics, have  been, 1st.
The non-recognition of  the  distemper  by the
medical  officers;  2d. The  too frequent denial
of its infectious character, and the proceeding
upon that supposition ; and, 3d. The neglect of
measures based upon  its infectious character,
and especially of the immediate  separation of
the  infected, and  the removal of  them to the
pestilential hospital, even  when such removal
could have been carried into effect.
  67. The  sending of a vessel to sea  ought
never to be unforced where the means of imme-
diate separation of the sick and suspected, and
of purification, can be  carried out in  the place
or port where the vessel lies ; for, by  doing so,
the  infection of the whole  susceptible persons
in the crew, or among the passengers, is there-
by ensured before she can possibly reach a tem-
perature so low as to  put a stop to its exten-
sion.   In cases  of ships of war or transports,
the  captain should be advised to proceed to the
nearest port where these measures can be en-
forced with all the precautions of quarantine,
and without endangering the inhabitants of the
port; and a recourse to a colder climate should
not  be entertained unless  it may  be  certainly
reached in  a much shorter time.   But the dis-
temper may  appear in vessels  in  such places
and circumstances as  preclude the possibility
of reaching either a suitable port or  a colder
climate, within a period likely to save the crew,
or at least  a large proportion of them.  In this
dilemma, and even while the attempt to reach
either of these destinations is being made, the
resources of the medical officer, as well as of
the  captain, become of the greatest importance,
and, if wisely directed, are  always  most advan-
tageous.
  68. In the circumstances now  adverted to,
every means of ventilation consistent  with the
safety  of the ship should  be enforced.  The
hatches and  gun-ports ought to be constantly
open, and wind sails carried down  to the lower
decks and  hold.   The infected should be re-
moved instantly upon being  attacked  from
among the crew to a well-ventilated place upon
the  upper or gun-deck, and be excluded as much
as possible from all persons but the unsuscep-
tible or those who have been formerly attacked,
and these latter  should be  made attendants on
the  sick.  The sick-berth should be separated
by a bulkhead or partition, and be in  the best
ventilated part of the ship.  A number of the
crew of a  ship in which  I was  a passenger
many years ago, had been exposed to the in-
fection of pestilential yellow fever; and as they
were attacked I advised them to remain on
deck under an  awning, a free perflation of air
existing  around them.  The accumulation of
infectious emanations'was  thus prevented, and
the  distemper extended no farther  than to one
only of the crew who was not exposed to in-
fection in the first  instance.  The  seclusion of
the  infected and ventilation should be rendered
as perfect as possible ; and all the  evacuations
ought to  be instantly removed in covered ves-
sels and immersed in the sea,  without un-
covering them until actually immersed.  Vari-
ous  disinfecting agents, especially the solu-
tions of the chlorides, the vapour  of creasote,
&c, may be employed, but they should never
interfere with  a recourse  to  every  possible
means of  ventilation, to  which   they should
always be subordinate in importance, as  they
are in efficacy.
  69. II. Protection of Individuals, Families,
or  Classes from  a prevailing Pestilence.—
When  pestilence exists in a city  or  place, or
when measures  have not prevented the intro-
duction of it, much may be accomplished by
cautiously devised means either of avoiding it,
or of enabling the frame to resist it. The most
certain way of escape is, 
PESTILENCES—Protection from.
275
  70.  i. Departure from the Sphere of In-
fection, or strict Seclusion or Quarantine.
—Departure from the infected city or place is
protective to all such as have not been exposed
to the emanations from the sick, and from fo-
mites, previously  to  their departure.  In the
Levant, European consuls and merchants gen-
erally observe strict seclusion during the prev-
alence of plague, but the seclusion is enforced
with great difficulty in respect both of persons
and effects,  more especially body-clothes, &c.
Moreover, when  seclusion is attempted  in  a
house or mansion forming  part of a street, or
within the walls or limits of a town,  the atmo-
sphere around the place of seclusion may be so
contaminated by the numbers of sick and  dead
as to become more or less infectious to the in-
mates of the secluded residence; and the winds
or currents of air may convey the infection into
the very apartments of such residence.  This
circumstance fully explains the failure of seclu-
sion in affording protection in the comparatively
few instances in which seclusion has failed.
   71.  A.  In order, therefore, that protection may
le with great certainty procured, departure  from
an infected  town or  place should be immediate
upon the ascertainment of the existence of pes-
tilence, and before the pestilence has extended
itself to many of the inhabitants ; for, if it have
spread far, or if cases of it have  occurred  in
most of the quarters of a city, it is impossible
to determine who is, or who is not, already in-
fected, although not yet attacked,  and the dis-
temper may be conveyed to healthy localities
in the persons or effects of those who may then
depart. Indeed, this contingency has been often
observed  as regards each  of the  three pesti-
lences in question.   The same remark equally
applies to seclusion or  quarantine  within or
near an infected city or place ; for, if the seclu-
sion be too long delayed, some one of the per-
sons about to be secluded  may  have been ex-
posed to the infectious effluvium, and be attack-
ed several days after this precaution has  been
adopted,  and  thus  introduce  the  distemper
among the  secluded party.  In this case, the
farther extension of the malady  may be pre-
vented by the immediate removal of the person
attacked, with his  personal effects, from the
place of quarantine ; but the removal should be
effected, if possible, by non-susceptible persons.
   72. Those who may be unable to depart from
an infected place,  or to seclude themselves,
should carefully  avoid a too near approach to
any person either in a street or in  a  house, and
more especially  to  those  who are strangers.
Above all, they ought to avoid the breath or the
expired  air  from another  person;  and  they
should not  enter the houses  or apartments of
any one  unless  there is the fullest evidence
of immunity from  infection.   But even  when
no risk may be anticipated, persons or articles
may be in these houses at the time which may
 endanger those who approach  them. If any
 danger exist as regards the reception-rooms of
 a house, the danger  is greater in respect  of the
 sleeping  apartments.  Great caution should,
 also, be exercised as respects articles of cloth-
 ing, beds, and bed-clothes.   During seasons of
 pestilence, the  linen of a family ought not  to
 be sent out of the house; it should be cleaned
 at home ; and care ought to  be  taken that this
 precaution extends to the servants more espe-
cially ; and no beds, bedding, or clothes, more
especially such as may have been previously
used, ought to be  admitted.   Strangers, and
particularly those with effects,  ought to be ex-
cluded as much as possible, unless they come
direct from healthy and uninfected places.
  73. B. Restrictions should be imposed on those
departing from an infected locality, in order that
they  may not convey  the pestilence to the
places of their destination, and that they may
be  received in these places in such a way as
may least endanger the safety of the inhabi-
tants.—a. Persons  who appear to be already
attacked, or those who  have members of their
families attacked, or who have  recently lost
any of their family, either should not depart for
a healthy locality, unless the departure be to a
country residence or house, secluded from other
houses, or should be subjected to strict quar-
antine before being admitted into towns, cities,
or ports.
  74. b. All  persons leaving  infected  places
ought to obtain  from  the Medical  Board, or
Board of Health, which  should exist in all cities
and large towns, certificates  of the  probable
degree of immunity from infection existing in
their individual cases, to be produced to the au-
thorities of the places to which they are about
to proceed.  The information supplied by per-
sons requiring these certificates may be verified
by  the messengers  of the board.
  75. c. Persons already infected, and suspect-
ed  cases, instead of being allowed to depart for
healthy towns, should  be removed to quaran-
tine, infected, or observation hospitals, accord-
ing to the circumstances of each case, and not
be  permitted to endanger the inhabitants of an
uninfected place until  due precautions have
been strictly enforced.
  76. d.  It is obvious that, if certain restric-
tions are requisite on  persons departing from
 an infected place, they are still more  necessa-
 ry  for those who arrive at an uninfected city
 or  port; and  more  especially for those who
 come from an infected  part.  On these latter, a
 due period of observation and quarantine should
 be imposed, when the circumstances of the lo-
 cality or town are such as admit of the restric-
 tion being duly enforced.   The chief difficulty
 is the determination of the period of observa-
 tion or quarantine in each of the pestilences in
 question.  When persons  have already passed
 some time  from leaving an infected place be-
 fore  arriving at their  destinations,  a propor-
 tionate abridgment  of the period  of quaran-
 tine may be allowed, especially if no sources
 of  infection existed at any place in their routes.
 Tn  the case  of a person arriving directly from
 an infected place not far distant, there is every
 reason to believe that a quarantine of fourteen
 days would afford sufficient protection, in re-
 spect of any of the pestilences now considered.
 But the clothes and personal effects of this per-
 son should be immediately opened up and ven-
 tilated.
   77.  e. In all cases, where the clothes, linen,
 and bedding are infected, or  even suspected,
 disinfecting agents  should be  applied to  them.
 Of all disinfectants, high ranges of temperature
 are the most  efficacious ; and  the best method
 of  employing a high temperature, with the view
 of  decomposing the morbid effluvium retained
 by the bedding or clothes of persons who have 
276
PESTILENCES—Protection from.
laboured under pestilential and infectious mala- |
dies, is that invented by Mr. Davison and  Mr.
Symington, who recommend the transmission
of heated air through a chamber in which these
articles are suspended, the temperature of the
air being raised  to  grades varying  from 200°
to 250° of Fahrenheit.  The great advantage
of this method  is  its  easy applicability to  all
kinds, and to any number,  of objects and arti-
cles,* without injury to their textures or fabrics.
  78. ii. Protection by such  Means  as may
ENABLE THE CONSTITUTION TO RESIST  INFECTION.
—A. There are four facts which should be kept
in recollection, as  being intimately connected
with the adoption  of  preservative measures
against pestilence :  1st. That a specific princi-
ple or effluvium, probably of a  parasitic or or-
ganic nature (Pestilence,  Septic, 9 137), pro-
ceeding from the diseased,  is necessary to  the
communication  of  the  malady.   2d. That this
specific effluvium is inhaled with the  air into
the  lungs when a person sick  of either pesti-
lence is too nearly approached ; and that  the
infecting effluvium  invades  the  susceptible
frame chiefly through the respiratory passages
and organs.  3d. That a predisposition to be-
come affected by this effluvium is requisite to
infection by it, or a susceptibility of infection.
In what this susceptibility  consists can hardly
be  determined with  precision  in many cases,
and as respects each of the kinds of pestilence,
although  there is sufficient reason to believe
that  the causes of predisposition described
above, with reference to each of these  distem-
pers, are more especially concerned in produ-
cing it; and,  4th.  As  regards  two of these
maladies, at least, a  previous attack destroys
this susceptibility.   Upon these facts  all pro-
phylactic measures should chiefly be based.
  * Messrs. Davison and Symington, civil engineers,
have employed heated air, in various modes, both in cur-
rents and otherwise, and in various grades from 60° to 600°,
and for numerous purposes—for the drying and seasoning of
timber, for the prevention of dry-rot,  for the drying and
preserving of animal and vegetable substances, for cleansing
casks, and for  preventing mouldiness, and the formation of
fungi, and other parasitic productions ;  for disinfecting foul
clothing, feather and wool beds, mattresses, <fcc.; and have
obtained  patents for  the application of heated air to all
these, ami various other purposes.  Their experiments prove
that  currents  of  heated air, of 250° and upward, may be
passed through linen and cotton articles, for the purpose of
disinfection, without injury to their textures, and that wool-
len and other animal productions, as feathers, feather beds,
wool beds, hair mattresses, cloths, flannels,  &c, will  not
be injured by a temperature of 240°.  It is obvious that the
application of this method to the purification or disinfection
of all kinds of bedding, and bed and body-clothes, used in
hospitals, ships, prisons, <fcc, will  be of the utmost advan-
tage.  Even to private  families it will often prove most
beneficial, especially in arresting the progress of infectious
diseases,  to transmit the contaminated beds, bed-rlothes,
&c, to a place where this mode of purification and disin-
fection is employed.  On the occasion of smallpox, scarlet
fever, typhus, or measles having infected one or more mem-
bers  of a family, the infection being, possibly, limited to
one chamber or floor of the house, and due precaution being
taken so to limit it, the properly-constructed and carefully-
closed cart of the establishment might remove the contam-
inated articles to the place of disinfection, and return them
in a very short time, thereby preventing the extension of
the malady to  the rest of the family, or  to other persons by
that medium which is most likely to transmit the infection.
In these maladies, and still more remarkably in pestilential
distempers, this method of disinfection deserves a general
adoption, in respect both of its great efficiency and of its
universal applicability.  When feather beds, or woollen and
hair mattresses, have become foul  or impure, as they must
necessarily become when in long  use, especially  in hospi-
tals, prisons, ships, <fec, this method of purification is par-
ticularly necessary.   The beds used in lying-in-hospitals
ought frequently to be subjected  to this process, la order
to prevent puerperal fevers and diseases.
|    79. As respects the first and second of these,
 the measures above recommended, in order to
 prevent exposure to infection, are the most ef-
 ficient, the great object  being to avoid inter-
 course with such persons as are most likely to
 have been among the  infected, and a  near ap-
 proach to  contaminated articles.  The predis-
 posing and concurring causes of the distemper,
 as far as they are known, ought to be avoided.
 There is much reason to  believe that whatever
 tends, directly or indirectly, to exhaust  the vi-
 tal energy, especially  excesses of every kind ;
 low and unwholesome diet; exposure to cold
 chills, wet,  night-dew, &c.; the use of cold
 fluids, of cold, flatulent, and unripe fruits, will
 favour the invasion  of  pestilential infection.
 On the  other hand, whatever supports the en-
 ergy and preserves, in their due regularity, the
 several functions of the frame, will render the
 body less susceptible of infection.
    80. If at any time exposure to the night air,
 or to cold and moisture,  is inevitable, the sys-
 tem should be fortified against them, but not,
 unless when better means are not within reach,
 by wines or spirits ; for  these  should be used
 in very moderate quantity, otherwise they will
 leave the system, as soon as their stimulating
 effects have passed off, more predisposed than
 before  to  the  invasion of  the infectious efflu-
 vium.  Medicinal tonics, however, and those
 more especially  which determine the circula-
 tion to  the  surface of the body, at the same
 time that they improve the tone of the digest-
 ive organs, and promote  the regular functions
 of the bowels and  biliary system, may be re-
 sorted to on such occasions.  For this purpose,
 the infusions  or  decoctions of bark, of casca-
 rilla, of columba, &c, with the spirits of Min-
 derer, or  any warm  stomachic  medicine;  or
 the powdered bark, or the sulphate  of quinine,
 or the  balsams, may be  taken  either alone  or
 with camphor, or with the aloes and myrrh pill,
 and any one of the  spicy  aromatics.
    81.  B. Olive oil  has been much employed,
 both  in Spanish America and  in the  Levant,
 not merely for the cure, but as a prophylactic,
 of pestilential distempers:  in the former coun-
 tries, with lime-juice,  in  the haemagastric pes-
 tilence ; in the latter, both internally and  ex-
 ternally, for the plague.   It is usually given in
 full  and frequent  doses  in both distempers;
 and, from  the information I have derived from
 various quarters, it appears to be deserving of
 a much more extensive trial in these pestilen-
 ces than it has hitherto  received from  Euro-
 pean physicians.   As a prophylactic, it has usu-
 ally been employed externally with slight fric-
 tion, after  coming out of the warm bath.   It is
 much  employed in both hemispheres by the
 native practitioners of medicine.
   82. C. The diet should be regular, moderate,
 nutritious, and easy of digestion.  While  ev-
 ery approach to low living  should be shunned,
 its  opposite ought  never  to be  indulged in.
 The stomach should have no more  to do than
 what it  can perfectly  accomplish,'without fa-
 tigue to itself, but to the promotion  of its own
 energies.  It must never be roused to a state
 of injurious excitement by  means of palatable
 excitants, nor weakened by over-distention, 01
 too copious draughts of cold, relaxing diluents.
   83. Care should be taken never to be  expo-
 sed to the  morning  or  night air with an empty 
PESTILENCES—Protection  from.
277
 stomach.  A cup of coffee previous to such ex-
 posures will be serviceable.   The state of the
 bowels should be always attended to, and their
 functions regulated and carefully assisted ; but
 in no case should this be attempted by cold, de-
 bilitating medicines, such as salts.   The warm
 stomachic laxatives,  or those combined with
 tonics, may be adopted with  advantage as oc-
 casion may require.*
   84. Particular attention ought to be paid to
 personal and domestic cleanliness.  The sur-
 face of  the  body should be kept in its natural
 and perspirable  state.  The  constant use of
 flannel  nearest the skin will be serviceable for
 this purpose.   Excessive perspirations ought
 to be avoided.
   85. During the existence of either of the pes-
 tilential  diseases  in  our  vicinity, or  family,
 these precautions  are  still more imperatively
 required.  A free ventilation of every apartment
 ought to be constantly observed; in  conjunc-
 tion with fumigations, by means of  aromatic
 substances  kept slowly burning, or by the va-
 pour of the chloride  of soda  or  of lime.  If a
 quantity of a very weak solution of the chloride
 of lime be put in  a vessel, and some  muriatic
 acid poured on it,  and placed  in the hall, or the
 very lowest parts in a house, the  disengaged
 gas will soon find its way in sufficient quan-
 tity to  the higher apartments.t  The  attend-

  * Any of the following recipes may be employed for the
 purposes here recommended:
  No. 319. ft  Decocti cinchonae, fivss.; liq. ammon. ace-
 tat., fiss.; spirit, ammon. arom.,  3ij.; tinct. capsici annui,
 Jltxx.; spirit, piments, Jij.   Misce. Fiat mist, cujus capiat
 coch. j. vel ij. vel iij. pro re nata.
  No. 320. ft  Infusi Cascanllie, fvjss.; potassie subcar-
 bon., 3j.; tinct. aurantii comp., Jiij.; spirit, lavaudul. comp.,
 T,jss.  M.  Fiat mist, cujus capiat cochlear., ij. vel iij. larga,
 mane nocteque.
  No. 321.  ft Quinins sulphatis, 3j.; masss piluls aloes
 et myrrhx, 35s.; Extr. Aulhemidis, 3j.  M.  Fiant pilulae
 XX. quaruin sumatur una mane nocteque.
  No. 322.  ft Camphorae  rase,  3j. ; extr. gentians:; pi-
 lul. aloSs cum myrrha, aa, 3ss.; pulv. capsici, gr. xv., siru-
 pi simp., q. s.  M.  Fiant pilule xxiv. quarum capiat binas
 Diane nocteque.
  No. 323. ft Camphors rasa, 3j.;  piluls galbani comp.,
 3«s.; quinins sulphatis, gr. xii.; pulv. capsici annui, gr.
 xx.; balsami  Peruviensis, 3j.  Fiant piluls xxx. secun-
 dum artem, quarum capiat binas primo mane ac nocte.
  Shortly before the sailing of the Niger Expedition, sent
 oat by government, a physician, one  of the naturalists to
 the expedition, called upon me, he having heard that I had
 been in or near that part of Africa to which he was about
 to proceed. During our interview, I advised him to take
 three grains each of camphor, sulphate of quinine, and cap-
 sicum, night and morning, during the period of his expo-
 sure to the malaria proceeding from the low grounds near
 the banks of the river, and to increase the dose to five
 grains of each when the exposure was greater than usual,
 or the malaria more concentrated. This gentleman called
 upon me, upon the return of the expedition, to  thank me
for my advice, which he had followed, and he informed me
that he had not experienced a single day's illness.
  t Dilute oue part of the concentrated solution of the
 chloride of lime with fifteen parts of cold water, and stir
 the mixture for a few minutes.
  Place an open earthen vessel, containing a quart of the
diluted solution, in the  current of air entering the room or
place to be disinfected, and pour into it a wineglassful of
the hydrochloric acid : perfect purification will very speedi-
 ly take place.  In about an hour fresh air shonld be admit-
 ted as freely as possible. If clothes supposed to be infected
 are suspended in the room during this process, they will be
 readily purified.
  To disinfect  rooms in which sick persons are confined
 (who would be incommoded by the above rapid mode of
 purification), wet a linen cloth with  the diluted solution,
and suspend it in the place to be disinfected: it will re-
quire renewal two or three times a day.  Night-chairs, or
any vessels in  which putrid animal or vegetable matter
has been kept, will be  immediately disinfected by rinsing
them with the diluted solution ; a small quantity of which
may afterward be allowed to remain in them while in use.
ants  on the sick should  particularly observe
the measures now prescribed, and ought never
to bestow  their  attentions on the affected so
near their  persons as  to  inhale  the  effluvium
emanating from them,  without at least fortify-
ing the vital energies in the way pointed  out;
and they should  carefully avoid entering upon
those duties with an empty stomach, or when
fatigued.                                     '
   86. Besides burning warm aromatic substan-
ces, and  odoriferous gum-resins,  in the apart-
ments, and in those adjoining them, in which
affected persons  are or have  been confined, a
saturated solution of camphor in aromatic  vin-
egar, or in  the pyroligneous acid, should be oc-
casionally sprinkled on the floors, furniture, and
bed-clothes.   These means, with a thorough
ventilation, and a due attention to cleanliness,
will not only counteract  the  influence  of the
effluvium  proceeding  from the  affected,  and
ward  off its action even on  the predisposed,
but will also  prevent the clothes, bedding, or
furniture of the  apartments of the sick from
becoming imbued with it so as to communicate
the malady.  They are within the reach nearly
of all; and, in the event of the extension of
pestilence  to any considerable town  or city, if
care  were  taken  to see them put in practice,
under  the   direction of medical councils  of
health, one of which should be formed in each
district, or quarter, much good would result
from them.   Keeping in recollection the princi-
ple with which I  set out, namely, that the ex-
citing cause of the disease undoubtedly makes
its first impression on the lungs, the advanta-
ges of those measures, from the circumstances
of their being applied especially to this organ,
must be obvious.
  87. D. The state of the mind also requires ju-
dicious regulation.   It ought never to be exci-
ted much above, nor lowered beneath its usual
tenor.  The imagination must not be allowed
for a moment to dwell upon the painful consid-
erations which pestilence  is calculated to bring
before  the  mind; and  least  of  all ought the
dread of it  to be encouraged.  There is a mor-
al courage  sometimes possessed by individuals
who are the weakest, perhaps, as respects phys-
ical powers, enabling them to  resist more effi-
ciently the  causes of infectious  and epidemic
diseases, than the bodily powers  of the strong-
est, who are not endowed with this mental en-
ergy.   Those who dread not attacks  of diseas-
es, and who yet exercise sufficient prudence in
avoiding unnecessary exposure to their predis-
posing and  exciting causes, may justly be con-
sidered as  subject to comparatively little  risk
from  them.  This, I am persuaded, is particu-
larly the case as respects  the  pestilential chol-
era, and I wish to impress it upon the minds of
those whom the observation concerns.  On all
occasions a fool-hardy contempt  or neglect of
ailments,  especially  those affecting the stom-
ach and bowels, ought  to be guarded against,
and the best  medical  advice  be immediately
procured upon the first manifestation of disorder.

                [APPENDIX.]

  Professor Charles Caldwell, of Louisville,
Ky.,  has  written  a  very  able  treatise on  the
  To disinfect drains, sewers, and water-closets, a quan-
tity of clean water should first be thrown down them, and
afterward one or two  gallons of the above diluted solution. 
278
PESTILENCES—:
•Protection  from.
contagiousness of plague, yellow fever, and
cholera, which was crowned with the Boylston
medical prize of Harvard University for 1834
To this essay the reader is referred for a vast
amount of  information  in  opposition  to the
contagiousness of these diseases.  Dr. C. is,
accordingly,  opposed to  all quarantines,  re-
garding them as founded in error and supersti-
tion, and  a relic of barbarous  times.   " No-
thing," he remarks, " in  the  history of despo-
tism can surpass them.   Though professedly
intended for the benefit of man, they are stran-
gers, within their sphere, to human right and
human sympathy.   To  say they make sport
and food of the sufferings and misfortunes of
man,  would  scarcely be  extravagant.   They
may, and often do, prohibit at pleasure, during
indefinite periods, and under heavy penalties,
all forms of business, and, as far as they can,
of social intercourse, whether public  or pri-
vate ; invade personal freedom, by  confining
those who become obnoxious to them  to their
own dwellings, or  in  places worse  than com-
mon prisons ; assume the right to destroy prop-
erty, to the ruin of its owners, on mere suppo-
sititious  grounds,  and have been  frequently
carried to the taking away of life. The modi-
fications  that have been made  in them have
been  far from  keeping pace with the progress
of that branch of science by which they should
be  regulated.   They  manifest,  therefore, no
practical wisdom, and have done no apprecia-
ble good.  I speak of the evil they constitute,
as  it  prevails  throughout  the world.   In the
United States,  and a few other places, it  is
somewhat mitigated, but is still sufficiently an-
noying in its operations and grievous in its ef-
fects.  Quarantine  establishments, then, are
still the  product of the fourteenth, with but
little affinity to any of the institutions  of the
nineteenth century.  That consideration alone
renders them objects of well-founded suspicion,
the date of their origin being, in so high a de-
gree, unfriendly to truth and usefulness in all
that depends on physical science."
  With respect  to  the contagiousness  of
plague, we are  not  so particularly interested,
perhaps ; but it is nevertheless well to reflect,
that the  British government has long main-
tained quarantines in London, Liverpool, Bris-
tol, Portsmouth, Falmouth,  Milford,  and all
other ports between which and the  whole
country of the  Levant, and, indeed, every Ori-
ental  place  of  business visited  by plague, an
extensive  intercourse by commerce has been
constantly maintained ;  and yet, although sus-
pected cargoes that have entered them have
been opened, examined, and familiarly handled
in innumerable cases, for nearly two hundred
years, no opener, inspector, or cleanser of re-
putedly infected goods  in them  has ever sick-
ened of plague; nor  has a single patient  af-
fecteftl with  that disease been  received  into
their lazarettoes.   The same remark will apply
to vessels  from the Levant arriving  in  this
country.   With respect  to  the  yellow fever,
there can  be no doubt, as stated  by Dr. Cald-
well, that when the disease first broke out  in
Philadelphia, in 1793, the views of the physi-
cians of our country respecting it were direct-
ly the reverse of what they are  now.   The be-
lief in its contagiousness was universal; hence
the wide-spread panic produced, and  the nu-
merous barriers that were erected to prevent it
from overrunning the land.  From that time to
this, quarantines, more or less rigid, have ex-
isted in nearly all our Atlantic ports, but with
a gradual relaxation, until, at the  present time,
when some of them, as New-Orleans and Mo-
bile, have no quarantine whatever.  There can
be no doubt whatever that the port regulations
of this city, for example, have been needlessly
oppressive  and vexatious, previous to their re-
cent modification (1846), and that they are still
unnecessarily stringent.   We have seen, that
although vessels have been allowed to come to,
and unload at the wharves of Brooklyn for the
last  thirty  years, where the population is  as
compact as in New-York, there has not been a
single  case of yellow fever  communicated  to
the inhabitants, nor has there been the slight-
est fear of  such a result.  Quarantine regula-
tions should  form a  part of a general code of
sanatory discipline, and  the  quarantine  board
should be but a branch of a general board of
health.
  We are not aware that there is a particle of
evidence to show that the yellow has ever been
imported by the sounds cargoes of  vessels com-
ing from infected ports ; and, even with respect
to the  bed  or body clothes of passengers, the
risk  of its  introduction  in  this  way is  very
small indeed ; though it will always be prudent
to avoid  this risk, especially as it can be done
with so little trouble and expense.  More at-
tention ought to be paid to the  condition of
ships' holds than is usually the case.  It is uni-
versally agreed that a foul hold is a not unfre-
quent cause of bad fever on board—afeverthat
may eventually acquire an infectious character.
If the duration of quarantine was made to de-
pend on the state of the vessel, rather than the
port from which it came, or the time of year it
may arrive, much expense and delay might be
saved, and the  public health be equally pro-
tected.
  The great object of sanatory establishments
should be to keep the atmosphere in a  pure
condition, for even infectious diseases cannot
spread under such circumstances;  foul  ships
and damaged cargoes should, therefore, be ex-
cluded until rendered innocent by purification,
because they tend powerfully to vitiate the air
of the place.  The mode  of effecting this must
be adapted  to the nature of  the articles to be
purified, and the depth of their contamination.
" In all cases and kinds of cleansing," says Dr.
Caldwell, " the only means to be confidently
relied on are pure air,  pure water, soap, sand,
brushes and  sponges, or cloths, to wipe with.
These  agents, skilfully applied, are competent
to the  cleansing of all articles worth preserv-
ing ; and fire alone can purify the rest."  We
believe, however, that  fumigation with the
acids and chlorides, perhaps sulphur, is impor-
tant, where fomilcs  are  suspected.  But the
process of purification should  depend on the
circumstances of the case, as well as the peri-
od of detention.   For this reason, they cannot
be specified, but should, in all cases, be left to
the judgment of the health officer.  " Vessels
may accomplish all that is required." says Dr.
Smith, the quarantine physician of Boston, "in
three hours as  well as three days, unless the
circumstances are of a  very marked character,
requiring time  for some anticipated develop- 
PHLEGMASIA ALBA  DOLENS—History of.
279
ment of disease supposed to exist on  board."
In Baltimore no vessel has been detained over
four days, for the last twenty years, except in
cases of smallpox.   In the  port  of Boston no
vessel  is required to stop  at  the quarantine
ground at all,  but  is  piloted  directly before
the city,  where it is inspected.   If the crew
are well, and have been so  during the  voyage,
and the bill of health speaks favourably of the
public health at the port of  departure, the ves-
sel is allowed to approach the wharf and  dis-
charge, without any reference to  the  kind of
cargo on board, although the inspectors are not
allowed to permit any thing to leave the ship in
a  damaged  condition.  The sick  are  sent to
the different hospitals, according to the nature
of their complaints, if they have neither friends
nor homes ; if they have either, they are per-
mitted at once  to  leave the vessel and go to
them.  Infectious cases  only are  subject to
quarantine detention, as smallpox, ship  fever,
&c.    Damaged goods are sent to the  quaran-
tine to be aired, dried,  washed, cleansed, &c.,
as circumstances require.   Vessels are sent
there when there is a prospective danger from
them, if permitted to remain in the city, but not
without.   Hides, skins,  hair, wool,  rags, car-
pets, feathers, &c, are landed freely at all times
of the year, and with perfect immunity.   Un-
der  this  system, which is  based on common
sense principles, there has not been a  case of
yellow fever in  Boston in the last twenty years.
We  regret  that the  quarantine  regulations of
our own port (New-York) are not equally judi-
cious.  For example, according  to the recent
revision of our health laws, " Vessels arriving
at the port of New-York shall be  subject to
quarantine as follows : Ail vessels direct from
any place where yellow, bilious  malignant, or
other pestilential or infectious fever existed at
the time of their departure, or which shall have
existed at any place, and proceeded thence to
New-York, or on board of which, during the
voyage, any case of such fever shall have oc-
curred, arriving between  the first day of May
and  the first day of October,  shall remain at
quarantine for at least thirty days after their
arrival, and at  least twenty days  after their
cargo shall have been discharged, and shall
perform such  farther quarantine as the health
officer shall prescribe."   We doubt whether a
physician  can  be  found in the United States
who will say that such a regulation as this is
necessary.
   In all our other Atlantic ports detentions of
more than four days are rarely required.   We
have yet  to learn what evils have arisen from
the practice.  The  Board of Health of Phila-
delphia have power to detain a vessel at the
lazaretto  not exceeding twenty days, if it ap-
pear that it has come from a port at which  a
malignant disease prevailed ;  but this is rarely
done.   In  Baltimore the whole subject is  left
to the discretion of  the health officer, and so,
also, in Charleston and Savannah.  Our limits
do not allow us to go into  greater detail.  In
conclusion, we say,  with Prof. Caldwell, "in
every sanatory establishment a hospital should
be included,  as well  as  suitable  buildings,
grounds, and apparatus  for  cleansing and sto-
ring goods and merchandise.  Into the former
should be received all sick persons arriving on
board of ships, and  sailors who may sicken in
port;  not because they would endanger  the
health of the city by being lodged and attend-
ed elsewhere, but  because their accommoda-
tions and chance of recovery might not be so
good.   The healthy portions of the  crews  and
passengers of sickly ships may go on shore im-
mediately,  free  from  all restraint, care being
taken that their persons and  clothes are clean.
No filth, however small in quantity, should be
conveyed  into the city  from without.   Under
the best-regulated police, every crowded place
of commerce has filth  enough of its own.   Let
ships, cargoes,  bedding, persons, and wearing
apparel be thus  purified, and  all other  neces-
sary measures be pursued to enforce domestic
cleanliness and  prevent the  formation of  ma-
laria, AND THE DREAD  OF IMPORTED  PESTILENCE
MAY BE SAFELY DISMISSED."]
  Bibliog. and Refer.—T. Gibson, A Treatise behove-
full to  preserve the People  from  Pestilence, <fcc, 4to.
Lond., 1536.—L. Fioravanti, Regimento della Peste, 8vn.
Ven., 1565.—F. Hering, Certain Rules, &c, for the  Pre-
vention of the Plague, 4to.  Lond.,  1625.—/. du Chesne,
La Peste recognue et eombatue ;  ensemble la Reformation
des Theriaques et Antidotes opiatiques, dec, 12roo.  Paris,
1631.—Anon., Certain necessary Directions as well for the
Cure of the Plague  as for  preventing the Infection, 4to.
Lond., 1636.—/ Guastaldi, Tractat. de Avertenda et Profli-
ganda Peste urbem  iiivadente, dec, fnl. Bologna, 1684.—
L. A. Muratori, Del Governo  della Peste, e della Maniera
di guardarsene, trattato Politico, Medico, ed Ecclesiastico,
Svo.  Milan, 1721.—J. Browne, Antidotaria, or a Collection
of Antidotes against the Plague, 8vo.  Lond.,  1721.—Af.
Pestalossi, Avis de  Precaution contre la Maladie Conta-
gieuse de  Marseilles, <fcc, 12mo.  Lyons, 1721.—J.  Col-
batch, A Scheme for  proper Methods to be taken, should it
please God to visit us with  the Plague, 8vo.  Lond., 1721.
— T. Lobb, Letters relating  to the Plague and other Conta-
gious Diseases, containing  Rules for a suitable Manage-
ment when that Sickness  shall be brought into a City,
Army, or Navy, and proper Preservatives from it, dec, 8vo.
Loud., 1765.  (A singular, somewhat curious, and yet a good
book.)—E. Langier,  L'Art de  faire cesser la Peste,  &c,
8vo.  Paris, 1784.—/. P. Papon, De  la Peste ; ou Epoques
memorable de ce Fleau, et  des Moyens de s'en preserver,
2 tomes, 8vo.  Paris, 1797.—A. B. Granville,  A Letter,
&c, on the Plague  and Contagion, with reference to tha
Quarantine Laws, 8vo. Lond.,  1819.—L. J. M. Thomas,
Guide Sanitaire des Gouvennens Europeens, ou Nouvelles
Recherches sur la Fievre Jaune et le Cholera Morbus, dsc,
2 tomes, 8vo.  Paris, 1826.—F. E. Foderi, Lecons sur les
Epidemies et 1'Hygiene Publique, t. iv., p. 167.—Pariset,
Annales d'Hygieae  Publiq., t. vi., p. 243, Paris, 1831.—D.
Barry, in Lond. Med. and Phys. Journ., vol. lxiv., p. 476.—
J. Copland, Of Pestilential Cholera, its Nature, Prevention,
and Curative Treatment, 8vo.  Lond., 1832, p. 95.—Lagas-
quie, Recherches sur l'Origine de la Peste, et les Moyens
d'en prevenir la Developpement, 8vo.   Paris, 1833.—Segur
—Dupeyron, Recherches Historiques et Statistiques sur les
Causes  de la  Peste,  8vo.   Paris, 1837.—/.  Bowring, Ob-
servat. on the Oriental Plague,  and on Quarantines  as a
Means of arresting them, Svo.  Edin., 1838.—A. Holroyd,
The Quarantine Laws, their Abuses and Inconsistencies,
Svo.  Lond., 1839.—E. Lefevre, Essai Critique contre les
Adversaires de la Contagion  par Infection  applique i. la
Peste, Alexandria, 8vo, 1838 ;  et Propositions sur la Cause
et la Contagion de la Peste, 8vo.  Alexand., 1839.—Reports
of the Commissioners for inquiring into the State of large
Towns, <fcc, 4 vols., 8vo. London, 1845.—G. Milroy, Quar-
antine and the Plague, <fec, Svo.  Lond., 1846; and Med.
and Chirurg. Review, No. 90, p. 286.—jl. White, On Plague
and Quarantine, &c, 8vo.  Lond.,  1846.  See, also, the
Bibliography to the several Articles on Pestilence.
PHARYNGITIS.  See Throat, Diseases  of.
PHLEBITIS.   See Veins, Inflammation  of
PHLEGMASIA  ALBA  DOLENS.—Synon.—
  Phlegmasia Dolens, Hull.  Phlegmasia Lacte,a,
  Levret.   Ecchymoma Lymphatica, Parr.  An-
  asarca Serosa,  Cullen.  Ecphyma GUdemati-
  cum, Young. Sparganosis Puerperarum, Good.
  Phlebitis Cruralis, Davis, Lee.  Cruritis, Ho-
  sack.   CEdema  Lacteum,  Metastasis Lactis
  Auct. Var.  QHdeme  des Nouvelles Accouchees,
  Depdt laiteux, French.   Milchstreichen, Germ.
   Crural Phlebitis, swelled leg of Lying-in Wom-
  en ;  Puerperal tumid leg. 
280                   PHLEGMASIA ALBA DOLENS—History of.
     Classif.—III. Class, I. Order (Author).
   Defin. — i.  Nosoloo.  Defin.—Painful and
 tense swelling of one or both legs, attended by fe-
 ver, and running an acute and definite course, oc-
 curring most frequently after delivery.
   2. ii. Patholog. Defin—Inflammation or ob-
 struction, or both, of the veins, lymphatics, and
 lymphatic glands, sometimes attended by inflam-
 mation  of the adjoining nerves, most frequently
 occurring after delivery; but sometimes appearing
 independently of the puerperal states, and consec-
 utively of other diseases, mechanically or otherwise
 implicating the veins, absorbents, and nerves of a
 limb.
   3. Having sometimes met with this disease
 in various circumstances as the sequela of other
 maladies, independently of the puerperal states,
 I have not considered  it under the head of Pu-
 erperal Diseases.  Whether occurring  after
 delivery, or in other circumstances, it evident-
 ly does not present the 6ame  appearances and
 symptoms in all instances; and in fatal cases
 the morbid changes are  also  not  always the
 same.  Owing to these  causes, opinions  have
 lately differed widely as to its nature, and to
 these opinions  I shall more particularly refer.
   4. I.  History.—This affection was  first no-
 ticed by Roderic a Castro and Wiseman ; but
 Mauriceau  first  described its  symptoms,  and
 referred them  to  pathological states.  He ap-
 pears to refer many of the symptoms to the
 femoral  nerve; but Dr. Lee supposes him to
 have mistaken the femoral vein for the nerve.
 Puzos and Levret subsequently described the
 disease, and considered it to proceed from me-
 tastasis of the  secretion of milk.  The former
 states that it is a  painful  and  sometimes  fatal
 malady,  occurring frequently about  the twelfth
 day after delivery, although sometimes as late
 as the sixth week.  The description of Levret
 coincides with that of Puzos, and both refer
 the disease to the crural vessels ; especially in
 their accounts of the symptoms, although they
 view it as proceeding from a " dep6t de lait."
 -According to Mr. Cruickshanks, Dr. William
 Hunter did not subscribe to the opinion of Pu-
 zos, and did not view it either as a metastasis
 of the milk, or as a cold of the limb, as it was
 considered by some.   Mr. Trye published, in
 1782, an essay on the disease, in which he re-
 ferred the symptoms to rupture of the lymphat-
 ics as they cross  the brim of the pelvis under
 Poupart's  ligament.   Mr. White soon after-
 ward published  on this affection, and suggested
 the opinion that it depends on obstruction, de-
 tention, and accumulation of lymph in the limb,
 or some  other morbid condition of the lymphat-
 ic glands and vessels of the part.  Mr. White
 saw fourteen cases, but they all recovered   Dr.
 Ferriar next maintained that the disease pro-
ceeded  from inflammation of the absorbents.
 In 1800,  Dr. Hull published an essay on phleg-
masia dolens, in which he showed that all the
phenomena could not be explained by referring
them to inflammation of the  lymphatics only ;
he therefore viewed them as the results of an in-
flammatory state  of all the textures of the limb
—.of blood-vessels, lymphatics, glands, nerves,
 oellular and muscular tissues, causing an effu-
sion of serum and coagulating lymph; but he
 furnished no case in which the appearances ob-
served on dissection supported  this  view.
  S. It  is a remarkable  circumstance, as Dr.
 R. Leb has remarked, that nearly a century and
 a half should have elapsed since the time when
 this disease was pointed out by Mauriceac, be-
 fore the precise nature of it was attempted to
 be ascertained by dissection.   There had been
 opportunities to determine the accuracy of the
 different opinions advanced as to its nature and
 origin, but these were neglected until 1817,
 when Dr. Davis examined the body of a patient
 who died of it;  and the appearances were de-
 scribed by Mr. Lawrence.  The left lower ex-
 tremity was oedematous, without  external  dis-
 coloration from  the hip to the foot, owing to
 effusion into the cellular tissue.   The inguinal
 glands were a little enlarged, but pale-coloured.
 The  femoral vein,  from the ham upward, the
 external iliac,  and  the common iliac veins, as
 far as the junction  of the latter with the cor-
 responding trunk of the  right side, were dis-
 tended and firmly plugged with what appeared
 externally a coagulum of blood.  The femoral
 portion of the vein, slightly thickened, and of a
 deep-red colour, was filled with a firm bloody
 coagulum, adhering to the sides of the tube, so
 that  it could  not be drawn out.  As the  red
 colour of the vein  might have been caused by
 the red  clot everywhere in contact with  the
 vein, it cannot be deemed a proof of inflamma-
 tion.  The trunk of the vena profunda was dis-
 tended in the same  way as the femoral vein;
 but the saphaena and its branches were empty
 and healthy.  The substance filling the exter-
 nal iliac and common iliac portions of the vein
 was like the laminated coagulum of an aneu-
 rismal sac.  The tube was completely obstruct-
 ed by this matter,  more intimately  connected
 to  its surface than  in the femoral vein ;  adhe-
 ring, indeed, as firmly as the coagulum does to
 any part of an old aneurismal sac; but in its
 centre there was a cavity containing about a
 teaspoonful of a thick fluid of the consistence
 of pus, of a lightish-brown tint, and pultaceou9
 appearance.  " The uterus, which had contract-
 ed to the usnal degree, at such a distance of
 time from delivery, its appendages and blood-
 vessels,  and the vagina,  were  in a perfectly
 natural state.   There was not the least appear-
 ance of vascular congestion about the organ,
 nor the slightest distention of any of its ves-
 sels.   Its whole  substance was pale, and the
 vessels everywhere  contracted and empty."
 (Transact,  of Med.  and Chirurg.  Society, vol.
 xii., p. 427.)
   6. An essay  was read by Dr. Davis, on the
 6th of May, 1823, to the Medical and Chirurgi-
 cal Society, with  the object of proving that the
 proximate  cause of the disease, called phleg-
 masia dolens, is an inflammation of one  or
 more of the principal veins within, and in the
 immediate vicinity of the  pelvis, producing  an
 increased thickness  of their coats, the forma-
 tion of false membranes on their internal sur-
 face, a gradual coagulation of their contents,
 and occasionally  a destructive suppuration  of
 their whole texture ; in consequence of which
 the canals of these vessels are so much dimin-
 ished, or so totally obstructed, as to  be incom-
 petent to the circulation of blood through them.
 He first notices a case by J. G. Zinn (Comment.
 Soc. Reg.  Gdlting., t. ii., p. 364,1753), in which
dissection disclosed  an enlarged and  indurated
state of the inguinal glands of the affected limb,
surrounding the crural  vein, and  diminishing 
PHLEGMASIA ALBA DOLENS—Description—Symptoms*
281
the diameter of this vessel; and next adduces
the case, the post-mortem appearances of which
I have noticed as described by Mr. Lawrence ;
and, in addition to the cases which he had him-
self observed, he mentions a case communica-
ted to him by Mr. Oldknow, in which inflam-
mation of the iliac veins was present; and " the
absorbent vessels and glands were slightly en-
larged as  high as the lumbar regions, but not
otherwise  affected."  (P. 436.)
  7.  During the  commencement of 1823, M.
Bouillaud published several cases and dissec-
tions, in which the crural veins were oblitera-
ted in  women who  had been  affected with
swelling of the lower extremities after deliv-
ery ; but Dr.  Davis hajl been promulgating his
views since the occurrence of his first case  in
1817.  Dr. Bouillaud distinctly  states, in his
instructive memoir on this subject, that he con-
siders obstruction of the crural veins to be the
cause not only of the oedema of lying-in women,
but of many  partial dropsies; and he  adduces
instances  of" this obstruction being caused both
by disease of the vessel itself, and by tumours
pressing upon the vessel.  (Archives Generales
de Medicine, t. ii., 1823.)
   8. Soon afterward, M. Velpeau  published
some observations on this disease, and conclu-
ded as follows : 1st. The acute swelling of ab-
dominal extremities of  women after  delivery
has  for its cause, at least in some  cases, in-
flammation of the pelvic articulations, or of the
veins.   2d. On the other hand, the symptoms
observed in the living patients are referable as
much to severe lesion of the deep-seated veins,
as to that  of the lymphatics.  3d. At  present
it  remains to be shown whether  or not these
latter parts are really the cause of  the phleg-
masia alba dolens.  4th. Affections  altogether
different are  ranged  under the  same  name,
causing confusion,  and giving rise to obscurity
in  the writings of several  physicians on the
subject.  Those cases adduced by M. Velpeau,
and which occurred in the Parisian hospitals,
are very interesting.  In all of them there were
marks of inflammation, with collections of pus,
in the pelvic articulations or symphyses, in the
uterine  canals and veins (see case 2d), in the
iliac and femoral veins, and in the lymphatics
and glands.   The whole of the memoir, and the
observations appended to it by M. Andral, have
not received, from more recent writers on the
subject, the attention which they deserve.   It
should be added, that M. Velpeau  considers
the inflammatory appearances, and the puru-
lent  matters  found in the veins  and lymphat-
ics, to be  the  consequences of the inflamma-
tion commenced in the pelvic articulations and
uterine organs.  (Archives Gener.  de Med., t. vi.,
p.  220.)
  9.  MM.  Gardien and  Capuron,  somewhat
earlier writers than those now referred to, re-
garded the disease as an inflammation of the
lymphatic vessels and glands ;  and Dr. Dewees
considered it to be inflammation occupying "ex-
clusively the white lymphatic vessels (1) of the
cellular membrane of the several textures of
the limb."   (Dis. of Women, p. 489.)
   10. Dr.  Burns believed, and with much jus-
tice, judging  from  some  cases which I have
seen, " the nerves to be  implicated in  the dis-
ease as much as the veins ; and that while both
may contribute, we shall find, in different cases,
one or other predominate."  (Midwifery, page
611)
   II. In April,  1824, I attended a case, with
my friend Dr.  Davies, now  of Hertford,  in
which the symptoms indicated  at the  com-
mencement considerable affection of the nerves
of the limb;  but those of vascular obstruction
afterward predominated.  (Lond. Med. Reposi-
tory, vol. xxiii.. p. 452.)
   12. Dr. Davis, to whom the honour of origi-
nating the phlebitic pathology of phlegmasia
dolens belongs, considered the inflammation to
commence in the iliac veins.  But Dr. Lee re-
marks, that Mr.  Guthrie suggested to him the
idea of tracing the affected veins to their origin
in the uterus ; and that, acting upon this  sug-
gestion, he ascertained  that crural phlebitis is
"but an extension of uterine phlebitis.   That the
disease thus originates, in many cases, cannot
be doubted.  I have  myself seen such cases,
and Dr. Lee has observed many others.   One
of my cases,  not, however, occurring in  the
puerperal state, was seen also by him.   But,
judging from the few I have seen, and from the
descriptions of cases which have been publish-
ed, I cannot come to the conclusions, either
that the affection is a pure and uncomplicated
phlebitis in all  cases, although it may be  in
some, or that it always originates in the uterus,
although it often does so originate.  My views
as to the pathology of this affection will appear
more precisely in the sequel.
   13. II. Description.—This  disease  attacks
much more frequently the  left lower extremity
than the right.  It very rarely commences  in
both limbs at the same time ; but it sometimes
passes over to  the other limb, when it leaves
the one first attacked.  It  generally appears
within six weeks from delivery—most frequent-
ly between the fourth and  fifteenth day ; but it
is not confined to the puerperal state.   Dr. Lee
states, that in eight  of twenty-three  cases of
puerperal crural phlebitis seen  by  him, the
disease  commenced  between  the fourth  and
twelfth day after delivery, and  in the remain-
ing fifteen it appeared subsequently to the lat-
ter of these days.
   14. i. Symptoms.—The pathognomonic symp-
toms  of phlegmasia dolens are  preceded,  in
some cases, by general febrile disturbance, and
in others the local symptoms are the first to
appear.   In the  former case the patient com-
plains, from the period of delivery, of fever,
which continues without a  manifest cause; and
in the course of a few days the swelling of the
limb  appears.  In other instances, the swelling
is preceded by severe rigours, which recur sev-
eral times.  In many cases, signs of peritonitis,
or of inflammatory action  of the pelvic viscera
or parietes, are  present before the symptoms
of this affection are remarked, especially in the
same  side of the pelvis with the affected limb;
and there is often a severe pain complained of
in the iliac fossa of that side.  In a few cases,
however, the symptoms of phlegmasia alba do-
lens occor suddenly in one  of the limbs, without
pain or any other symptom in  the abdomen  or
correspondent iliac region.  In addition to un-
easiness and pain in  the lower  part of the ab-
domen, or extending along the brim of the pel-
vis, the  patient  is  weak,  irritable,  and de-
pressed.
   15.  a. When the disease begins in the pelvis, 
232                   PHLEGMASIA ALBA DOLENS—Symptoms.
the pain soon extends below Poupart's  liga- I
ment along the  thigh to  the ham, calf of the ]
leg, and instep of the foot.  Shortly afterward
the inguinal region is tumefied  and tense, and,
in a day or two, the thigh becomes swollen,
tense,  white,  and  shining.  When  the  pain
commences in the calf of the leg, the swelling
is first observed  there, or at the ankles, gradu-
ally extending itself up the leg and thigh.   In
some cases, the pain ascends from the leg along
the thigh to the  groin, or even to the iliac re-
gion.   In rarer instances, a considerable space
intervenes  between the situation of the pain,
which, in this case, is usually felt in the inguinal
region and in  the leg, the thigh being exempt
from pain.
  16. The  character of the pain varies greatly.
In some it is  merely a sense of numbness or
stiffness, or a  sort of cramp, or a painful  feel-
ing of tension.  In others the  pain is severe,
burning, or shooting; and in several it is dart-
ing or  lancinating, and so violent  as to cause
the patient to  scream aloud.  The slighter or
duller pains are usually constant, but the vio-
lent shooting pains are remitting.  The pains
follow  exactly the course of the femoral  ves-
sels, the darting violent pain being especially
referable to the femoral nerve.   In some cases
the pain extends all the way from the iliac fossa
along the thigh to the ham and calf of the leg.
The whole  surface of the limb is tender. Pres-
sure at any part, but especially on the femoral
vessels and nerves, remarkably aggravates the
pain.   The least motion of the extremity, more
especially extension, greatly increases the pain;
the easiest  position  is that of partial flexion.
Aggravation of the pain on pressure is some-
times only  felt in a limited portion  or spot, as
in the groin, or popliteal spot, or calf of the leg.
  17. b. The swelling generally occurs after the
pain has existed a short time—usually after a
period varying from twelve to thirty-six hours.
In some instances the swelling appears nearly
contemporaneously with the pain, and it usually
commences in the same situation as that in
which the pain is at first felt.   In the majority
of cases it  proceeds from above downward, im-
plicating successively the hip, nates, and labium
pudendae ;  the thigh  and leg.   Casper, Calli-
sen, Fraser, and Raige-Delorme mention in-
stances in  which the swelling extended  also
upward to the flank and trunk, so as to reach
the upper extremity of the  same side.  In some
cases it begins in the foot,  and rises more or
less rapidly until it invades the whole extrem-
ity, the  nates,  vulva, and iliac region;   but
Puzos, Levret,  White,  Gardien, and other
writers consider the descending character of
the swelling as pathognomonic  of the disease.
The swelling is sometimes so great that the af-
fected limb is  double the healthy size.  When
it is advanced it is generally uniform, but  it is
sometimes  more remarkable on the  inside of
the thigh,  and near  the  knee.  In  the early
stage of the disease, and while the acute symp-
toms continue, the swelling is tense, and does
not pit after pressure ; it is generally at a later
period that pitting from pressure is observed.
  18. c. The colour of the limb is commonly a
pearly  white.  In some,  reddish lines are ob-
served chiefly in the course of the vessels ;
and  in others only small  red  spots or points.
In cases observed by Dr. Lee and M. Salgues,
[ dark vesicles  and phlyctenae  were observed;
| and in  a case  terminating in  gangrene, under
 the care of Dr. Da vies, and also seen by me,
 the usual discoloration of the  skin in  such cir-
 cumstances was observed.  In most instances
 the temperature of the affected limb is increased,
 especially on the inner aspect, and at the earlier
 periods ; but sometimes, as Dr. Burns has re-
 marked, it  is diminished, particularly at an ad-
 vanced stage.   Gangrene, in the  case just ad-
 verted  to,  was preceded  for  several days  by
 great coldness of the limb.  Most writers have
 remarked  the  existence of a  nodulated chord,
 very painful on pressure, descending from the
 crural arch more or less down  the thigh.  This
 chord may be  only barely perceptible, or very
 remarkable, from the thickening and infiltration
 of the cellular tissue surrounding the vessels.
 In some cases it descends considerably down
 the thigh, and may even be detected in the pop-
 liteal space.   It is not easily detected when
 the swelling and pain_are great, and  it is chiefly
 when the  more violent symptoms have subsi-
 ded that it  can be best ascertained.   The pain
 and  tenderness are  always  greatest in  the
 course  of this chord, or in its immediate vicinity.
   19. d. Enlargement of the glands in the groin,
 and even of those of the ham, is often observed
 during  life, and found after death.  In some
 cases,  as  observed by  Casper, red lines are
 traced  along the surface in the direction of the
 tumefied and  tender  glands.  The nodosities
 frequently  found in the course of the vessels
 are attributable, in some situations and cases,
 to enlargement of  the  glands;  and, in other
 places  and  instances, to the induration and in-
 flammation of portions of the cellular tissue
 surrounding the inflamed vessels ; or to thick-
 ening of the coats of the vessels, and to coagu-
 lation of the blood below the  seat of obstruc-
 tion.  As  observed, also, in the  first case, in
 which  a dissection  was made  after death, the
 tumours may  arise both from enlarged lym-
 phatic  glands, and  from the distention of the
 vein below the seat either of compression by
 these glands, or of obstruction by disease of the
 vessel itself.
   20. e. The constitutional symptoms are often
 very remarkable, even before the local mischief
 is much complained of.  In most  cases, weak-
 ness, depression, irritability of the pulse, di-
 minished or disordered lochia, diminution of
 the secretion of milk,  want of sleep, and disor-
 der of the digestive and excreting functions im-
 mediately  precede and accompany  the acces-
 sion  of the  local disease.  As this becomes de-
 veloped, the pulse, hitherto weak, quick, or
 sharp,  becomes rapid, often 130  or 140  in a
 minute, and small  and feeble; the appetite is
 lost,  the tongue is white or loaded, the thirst is
 increased;  the bowels  are confined, and the
 stools unhealthy, but they are sometimes loose,
 fetid, or bilious; the  urine is  turbid,  and the
 lochia is often  diminished or suppressed, or of-
 fensive.  The patient is restless, sleepless, and
 irritable, or morbidly sensible.  The counte-
 nance is generally pale, and sometimes evincing
 marked anaemia.  There are frequently indica-
 tions of disorder of the uterine organs, or of
 disease of the pelvic viscera or parietes.  The
 vulva and  vagina  are tender; and pressure
 above the pubis is  seldom made without pain.
 The  os-uteri is sometimes partially open and 
RMINATIONS--APPEARANCES AFTER DEATH.    283
        PHLEGMASIA ALBA DOLENS—Tei

soft.  At the commencement  of the disease,
the skin is generally hot and dry ; but it some-
times becomes moist, or  perspirations  break
out.  The secretion of milk is  often altogether
suppressed or much  diminished.  In very se-
vere cases, the febrile disturbance is not only
attended by sleeplessness, but followed by de-
lirium.  In some instances, in.which the dis-
ease supervened in the other limb, as it subsi-
ded in the first affected, the cerebral symptoms
were very urgent.  In two cases which were
under my care, one of which was attended also
by Dr. Lee,  constant low delirium, followed by
coma, came on ; but the patient ultimately re-
covered.
  21. ii. Terminations.— The  disease  may
terminate variously :  1st, by resolution.  When
it  terminates in this  way, the acute symptoms
subside in the course  of from twelve to twenty
days, generally  in the order  of their appear-
ance ; the pain ceases, the swelling disappears,
and the use of the limb returns.  As the swell-
ing  begins to subside, it pits  more readily on
pressure;  and,  in many  cases, the tumours
and chord, in the situations already mentioned,
are more distinctly felt, and in some the super-
ficial veins are dilated, or irregularly enlarged,
not only in the limb, but also, as stated  by M.
Raige-Delorme, in the flank  and parts adjoin-
ing.  As the resolution proceeds, the constitu-
tional  symptoms  subside.   Resolution  takes
place much  more  gradually  and slowly  when
obstruction  of the femoral is present.   The
swelling then continues sometimes for months,
in  a less degree, and thus becomes chronic, the
patient being hardly able to use the limb.  In
these cases,  thickening of the cellular tissue
surrounding the vessel often exists, and a vari-
cose state of the veins takes place and remains.
2d. Suppuration, according to Petit, Capuron,
and Churchill, takes place in rare instances,
generally in the tract of the large vessels, or
situation of the lymphatic glands.   This result
obviously proceeds from the  inflammation of
those vessels having extended to the surround-
ing  cellular tissue and passed on to  abscess.
3d. The disease still more rarely terminates in
gangrene.  M. Gerhard has adduced a case in
which this occurred ;  and Dr.  Da vies has pub-
lished the details  of  another, which was also
seen by me  on several occasions.   In this case
gangrene of the leg and foot was followed by
sloughing, and the parts were amputated by Dr.
Da vies above the  knee, the thigh being  at the
time about double  the thickness of the opposite
one.  As soon as the vessels were divided, the
blood in the veins was observed quite coagula-
ted.   A  considerable quantity of serum was
discharged from the  surface  of the stump as
soon as the leg was  removed.  (London Med.
Repos., vol. xxiii.,  p. 454.)
  22. 4th. Death sometimes takes place, gen-
erally owing to the   severity  of the several
changes which supervene in the course of the
disease.  It  may occur suddenly, as remarked
by Denman, Burns, and Blundell, owing chief-
ly  to exhaustion  consequent upon previous
losses of blood,  and upon the violence of the
constitutional  and nervous  symptoms,  espe-
cially if the patient makes any exertion in this
state, or raises herself up too quickly in bed.
It  most  commonly, however,  takes  place con-
sequently upon the organic lesions found  in the
pelvic viscera and parietes; such as inflamma-
tion  and purulent formations  in  the uterus,
ovaria,  and pelvic articulations, with similar
changes and coagulations of blood in the iliac
veins.  In these  cases, death is the  result of
contamination of the circulating fluids, and is
generally preceded by a very rapid, small, and
feeble pulse, by distressing feelings of sinking,
by delirium, sometimes coma, and various ner-
vous  phenomena.
  23. iii. Appearances after Death.—On dis-
section, the limb is seen infiltrated with serum
and lymph.  Several  small  abscesses are dis-
seminated through the cellular tissue, between
the muscles, or one  or two considerable ab-
scesses are formed in the vicinity of the large
vessels,  especially in the iliac, inguinal, and
popliteal regions.   The  sub-peritoneal cellular
tissue, particularly that of the meso-rectum and
iliac fossae, is sometimes infiltrated with a sero-
purulent matter.   The articulations of the af-
fected limb, and even the joints at a distance
from  the seat  of the  affection,  although much
more rarely, are occasionally the seats of sup-
puration.  Purulent collections  have also been
found in the liver and lungs.  A sero-puriform
effusion  has sometimes taken place in the pel-
vic cavity, and  in the  cavity  of the pleura.
These lesions are secondary, and the conse-
quences  of the phlebitis, constituting the chief
pathological condition of the malady.
  24. A.  The researches of Dr. Davis, Dr. R.
Lee, Dr. Da vies, and  others, have fully shown
the great extent to which the veins of the limb,
and very frequently also those of the uterus,
are affected in this malady.  The femoral vein
is always more or less  diseased.   It is inflamed,
its parietes are thickened, and its canal is ob-
structed  by fibrinous coagula, in the centres of
which puriform, or a brownish grumous, matter
is often found.  In rarer cases a fibrinous false
membrane is  observed  adhering to  the inte-
rior of  the  vessel.  The  same changes  may
be  traced along   the profunda  and  popliteal
vein, to  most of the veins  of  the extremity.
The phlebitis  may be so general in  the  limb,
that a puriform  matter escapes from all the
small veins upon  dividing them.  In many ca-
ses, however, the  saphena remains unaffected.
The same lesions  as exist in the femoral vein
are also generally observed in the external iliac
of the same side, and  often extend to the hypo-
gastric or internal  iliac.  In this  latter case the
veins of the vagina, of the  neck and body of
the uterus, and of the ovaria and tubes, and,
indeed, most of the branches which contribute
to the hypogastric, present  the  usual appear-
ances of inflammation, on the same  side with
that affected.  In many cases the same lesions
are found in the veins of both sides of the uter-
ine  organs, but they extend not so far as the
internal iliac of the unaffected side.   In  some
instances the inflammation extends not only to
the  common  iliac, but also  to the vena  cava,
and in rare instances as far as the  emulgent
veins.  M. Raige-Delorme  remarks, that the
alteration may even be traced to the right side
of the heart;  but  this can be possible only in
rare instances.
  25.  When the disease has existed in both
extremities, the  phlebitis  in the pelvic and
uterine organs extends along both hypogastric
veins to  the external  iliacs and  femoral veins 
284
PHLEGMASIA ALBA DOLENS—Causes.
&c. ;  it has even been  observed in the lower
portion  of the vena  cava.   It  has been sup-
posed that  the supervention of the disease in
the other limb, as that in the first attacked sub-
sides, is produced by the extension of the in-
flammation from the common iliac of the one
side to the vena cava, and to the common iliac
of the other side ; but the inflammation of the
uterine  veins may  extend to  both limbs, al-
though not at the same time, without passing
to and from the vena cava.   M. Raige-Delorme
refers to two cases  in which  phlebitis  super-
vened  in  the  brachial, cephalic,  and cubital
veins in the course of this disease.
  26.  B. The lymphatic  glands  and vessels  are
frequently also found inflamed ; but where this
lesion coexists with phlebitis,  it is difficult to
determine which of the two 13 primary.   They
are probably contemporaneous  in  their  devel-
opment  and course.   In  the account of the first
post-mortem examination of the disease on rec-
ord, Zinn states, that the inguinal glands were
greatly enlarged and indurated, and that they
surrounded and very much diminished the di-
ameter of the crural vein.  The glands  of  the
groin  and ham are often enlarged, injected, and
sometimes  in a state of suppuration ; but  pu-
rulent matter is more frequently found  in  the
cellular  tissue surrounding them than  in  the
glands  themselves.   Raige-Delorme  states
that the glands in the  iliac fossae sometimes
present  various degrees of inflammation, which
has also extended to the mesenteric glands.
  27.  C. The lymphatic vessels  have been fre-
quently  overlooked in dissections of the  affect-
ed limb.  Bouillaud states that inflammation
of these vessels has been ascertained in  a con-
siderable number of cases of this disease.  MM.
Tonnelle, Duplay, and Nonat have also con-
firmed  this view.   M. Albonneau  (Journ.
Comp. du  Diet, des Scien. Med., t. xxxviii., p.
10) has  recorded a case in which " the  super-
ficial lymphatics of the thigh presented a deep
red colour,  were enlarged  and tortuous,  the
veins being also inflamed on the same side as
high as the vena cava."   Dr.  Churchill  re-
marks, that pus and evidences of inflammation
are sometimes met with in the  absorbents.
  28.  D. The nerves  are  probably also  more
frequently  implicated  than they  have  lately
been supposed to be, particularly since  atten-
tion was more especially directed to the  veins.
In the  interesting case published by Dr. Da-
vies, the symptoms, which were very violent
in their accession, were referable to the femo-
ral  nerve ;  and  M. Duges has adduced several
cases showing  that  neuritis actually  forms a
part of the  lesions observed in this disease.
  29.  E. Alterations of the uterus, and  espe-
cially of the veins of the organ, have been much
insisted upon by Dr. Lee as the points of  depar-
ture in  the  succession  of morbid  phenomena
constituting this  complex  malady. Although
M. Velpeau appears to have been among  the
first to describe  lesions of the uterus and its
veins,  in  examinations of  this disease after
death, still  Dr. Lee first insisted upon the con-
nection, and upon  the circumstance of  the
phlebitis being  propagated from the uterus or
its  appendages to the  hypogastric,  iliac, and
femoral veins.  Inflammation of the veins and
canals of the uterus, puriform matter in them,
or in the walls of the uterus ; softening of the j
organ ;  membranous exudations on its internal
surface;  softening, dark  discoloration, and
marks of inflammatory action, more especially
at the part where the  placenta  was attached;
puriform collections in the ovaria, &c, have been
very frequently observed.   Dr. Burns, howev-
er, remarks that the uterus is sometimes found
quite healthy.  Besides these lesions, M. Vel-
peau has shown  that the  adjoining pelvic vis-
cera may be also more or less implicated, es-
pecially the sacro-iliac and pubic symphyses, the
cartilages and ligaments of which are loosened,
softened, and bathed in pus ; but these lesions
are not  so frequent as  those of the uterus and
its appendages.
   30. II.  Causes.—.4. This  disease  has not
been  observed with due precision  in  respect
of its remote causes,  and particularly as to
those which  predispose to  the origination and
extension of the several  lesions recognisable
during life and found after death.  The much
more frequent occurrence of the affection du-
ring the six weeks  immediately  following par-
turition  evidently proves that the changes more
especially connected with that period are more
or less concerned in producing  it.  The pres-
sure which the gravid  uterus exerts upon the
nerves, blood-vessels, and other parts within the
pelvis during the latter months  of pregnancy,
the violence  which these parts often  sustain
during parturition, the  sudden removal of the
pressure, and the changes in  the  state  of ner-
vous function and of circulation consequent on
the removal,  altogether remarkably predispose
to the supervention of  the affection, especially
when aided by other circumstances.  But the
disease  may  occur  during  pregnancy.  Puzos
treated three cases before the period of partu-
rition ; and in these, as well  as  in others met
with  at this period, it is reasonable to infer
that the pressure was chiefly concerned in pro-
ducing it  in these instances, and that  uterine
phlebitis was not its point of departure.
  31. As far as my own  observation enables
me to judge, aided by the histories of many
recorded cases, constitutional debility and del-
icacy of" frame ; the  exhaustion consequent
upon  protracted, difficult, or  instrumental la-
bours ;  haemorrhage during  or  after parturi-
tion ; and anaemia! and cachectic states of the
system, are among the most influential predis-
posing causes of this affection.  Females sub-
ject to leucorrhcea, especially during pregnan-
cy, appear also to be more liablt than others to
an attack.
  32. B. The exciting causes are, in  the great
majority of instances, those of uterine phlebi-
tis.  The use of instruments  during labour, in-
jury of the organ, the retention of portions of
the placenta, the means taken to remove it;
the retention of coagula, or of the lochial dis-
charge in the uterine  cavity  or vagina, owing
to deficient contractile power ; imperfect con-
traction of the uterine  canals and veins admit-
ting of  the retention,  and  consequent altera-
tion, of their contents ; the passage of the re-
tained and altered lochia from the cavity of the
uterus into the uterine  veins ; inflammation of,
and purulent collections in, the parietes of the
uterus or in  the ovaria, giving rise to  inflam-
mation of the veins of these  organs;  inflam-
mation of the vagina, or of any of the pelvic
articulations, are the most frequent exciting 
PHLEGMASIA ALBA DOLENS—Causes.
285
causes of phlegmasia dolens.  These local con-
ditions and changes, in the great  majority of
cases in which they  take place, either proceed
no farther, or give rise to other secondary mal-
adies than this; but, when the predisposition is
marked,  and when other  causes re-enforce
these, the affection  will be induced, and  may
occur, although in rare cases, even when the
uterine lesions are not present.
  33. There can be no doubt that, when the
lochial discharge is not  freely  thrown off, in
weak or exhausted females, or after  copious
losses of blood, and when morbid secretions
form in  the uterus or ovaria, in these states of
the system absorption of these matters, either
by the lymphatics or veins, or by both, will then
take place more readily and abundantly than in
other circumstances, the matters thus absorbed
inflaming the  vessels  and  contaminating the
fluids.  Causes producing a suppression of the
lochia,  or of the secretion  of milk, may also
occasion the supervention of crural phlebitis,
and even of inflammation of the absorbents, by
favouring the absorption of excrementitial mat-
ters ; and thus the  old doctrine of the metas-
tasis of these  secretions, although not strictly
applicable to  these cases, is not, in some re-
spects,  very wide of the truth.
   34. Exposures to cold, wet, and to currents
of air, insufficient clothing, and unwholesome,
heating food and beverages, especially spiritu-
ous liquors, are evidently concurring, if not ex-
citing causes.   Probably more importance has
sometimes been attached to the  influence of
cold than it deserves ; but where  the cold is
applied  directly to the  limb—where the lower
extremities are not  sufficiently protected from
it, or where the patient wears damp shoes, &c,
particularly  upon getting about soon after par-
turition, the injurious influence may not be lo-
cal only, but extended to several of the excre-
ting functions; and, although it  may not be
sufficient of itself to  produce the disease, it
may powerfully aid  the operation of other cau-
ses, or favour  the extension of morbid changes
existing in the uterine organs, or parts in the
vicinity, to the iliac and femoral veins, or also
to the nerves  and absorbent vessels.
   35. iii. Phlegmasia  Alba  Dolens, uncon-
nected with the Puerperal States.—An af-
fection, or rather a complex disease, in every
respect similar to that now described in connex-
ion with the puerperal states, may occur in wom-
en independently of these states, and even in the
male sex; but  in every instance which I have
seen of this description, amounting in all to
nine, of which I have taken notes, it has  been
contingent upon some other dangerous disease,
and has presented  the  same changes of struc-
ture in the limb as those which I have described
above (v 24, et  seq).  The diseases upon which
it has supervened  in  my practice are the fol-
lowing : Inflammation of the uterus; hysterilis
complicated with  dysentery;  cancer of the
mamma (two cases); tubercular consumption ;
typhoid fever; iliac abscess (two cases);  ma-
lignant ulceration of the mouth and neck of the
uterus,  and injury of one of the upper extrem-
ities.  The injury in this last instance of the
affection was soon followed by inflammation of
the lymphatics and  veins ; the patient, howev-
er, recovered.
   30. The case of  the disease  following hys-
teritis occurred in 1831, in a lady who had not
been pregnant in three or four years.  The af-
fection commenced in the right thigh, and ex-
tended to the left as it began to subside in the
right.  The patient had shortly  before expe-
rienced a smart dysenteric attack, which was
followed by inflammation of the uterus, and for
each of these she had been moderately blooded.
The disease  of the extremities was most  se-
vere, and was attended  by dangerous constitu-
tional symptoms.   As the case well illustrated
Dr. R. Lee's views of the pathology of the dis-
ease, I  requested  him to see her.   Delirium,
sopor,  and great  nervous exhaustion  super-
vened, but followed the very rapid subsidence
of the swelling of both extremities, which had
reached  as high as the flanks.  She was very
remarkably benefited by nervous and restora-
tive remedies, and recovered  very rapidly.   I
have seen her very frequently since, and as re-
cently as the day  of my writing this ; but there
was never any evidence of enlarged  veins  or
swelling about the ankles subsequent to the at-
tack ; the appearances of the limbs, up to this
time, now fifteen  years, being in every respect
the same as before.
   37. In the other case there were both hys-
teritis and dysentery; indeed, the whole pel-
vic viscera appeared simultaneously attacked.
This person, the wife of a publican, had never
been pregnant; only one extremity was affect-
ed ;  but low fever, with muttering delirium,
coma, and destructive inflammation of one eye,
supervened, and she died, the other eye  also
becoming affected shortly before death.
  38. In both the cases of carcinoma mammae,
the arm on the affected side was enormously
swollen, painful,  and tender, but not discol-
oured.   One of the cases was that of a lady at-
tended  by Dr.  Young  and myself.  She  was
only thirty-five years of age, had borne several
children, and was then pregnant.  Great  en-
largement of the  lymphatic glands had taken
place, and  obstruction both of the lymphatic
and of the venous circulation obviously exist-
ed.  This lady, who was far advanced in preg-
nancy  when  the  affection of the arm  super-
vened, was delivered nearly at  her full time
of a child about one fourth  the usual weight;
she died, as  was  expected, shortly afterward.
The other case occurred in a person advanced
in age, and was in all respects similar as re-
garded the local disease.  In  neither instance
was an examination after death allowed.
  39. The case  contingent upon tubercular con-
sumption, of which I  have notes, and which
was a remarkable instance of the affection, pre-
sented,  upon dissection, tubercular deposites in
the inguinal glands, with great enlargement;
obstruction of,  and coagulation of blood in the
femoral and iliac  veins, the centres of the  co-
agula consisting  of a grumous, soft, or pulta-
ceous brown matter.  There had been, also,
diarrhoea and ulceration of the bowels ; but the
veins were not traced from  the iliac  to  the
ramifications to the pelvic viscera; and it was
hence not manifest whether or not the disease
of the veins was  caused  by ulceration  in  the
lower bowels, or  by the morbid state  of  the
blood consequent upon the absorption of puru-
lent and tubercular matters.   I have seen oth-
er cases of great  swelling of one or both lower
extremities,  consequent upon phthisis; but I 
286
PHLEGMASIA ALBA DOLENS—Nature of the Disease.
have had an  opportunity of examining after |
death only the one now mentioned.  My rec-
ollections of the others are such as to lead me
to infer that the obstruction in the veins of the
lower extremities was the consequence chiefly
of the  morbid states of the blood, aided by the
physical  conditions of  the  limb—the sitting
posture,  and  the remora of the  blood in  the
veins, owing to this posture, and to the  influ-
ence of gravitation; and that these states fa-
voured coagulation  of blood in the veins, or in-
flammation of their internal surface.
  40. Instances of phlebitis, in  the course of
low or typhoid fevers, are  not rare.  I have,
however, met with  only one in my own  prac-
tice.  In this  case there was certainly no evi-
dence of ulceration of the lower bowels.   The
disease of the veins is to be referred chiefly to
the state of the blood, and to some local physi-
cal conditions, or causes acting locally.   Drs.
Graves  and Stokes have related instances of
this  contingent form of the affection.  They
remarked that the  oedema was unattended by
redness,  but accompanied with pain, tenderness,
increased heat, and  impaired motion of the limb.
   41. The first case of the disease contingent
npon iliac abscess occurred to me in 1821, in a
groom, a patient of the  South London Dispen-
sary, when physician to that institution, and
was attributed to the pressure of the collected
matter upon the iliac nerves and veins, and
probably, also, upon the lymphatics.  A more
recent case was entirely similar,  and both ter-
minated  fatally soon afterward, but inspections
were not permitted.  There can be no doubt
of the occasional occurrence of this malady du-
ring organic changes in the uterus and ovaria,
occurring independently of  parturition,  and
more especially if these changes are attended
by the absorption  of morbid secretions  from
these organs.  Dr  R. Lee has adduced several
instances of this source of the disease.  SirH.
Halford has recorded  two cases, which con-
sisted chiefly of inflammation of the veins ari-
sing apparently from exposure to currents of
cold air  ; and, in one case, from such exposure
being in  the  standing posture. Many years ago
I met with  a case which  originated in  this
cause ; but the patient was of a cachectic habit
of body  ; recovery, however, took place with-
out any unfavourable occurrence.   It is not im-
probable that, during an impure or morbid state
of the blood, connected with debility and a lan-
guid state of the circulation, the  remora of the
blood  in the  veins of the lower extremities, fa-
voured  by position or  other  physical causes,
will occasion either partial spontaneous coagu-
lation, or an inflammatory state of the coats of
the vessel, more especially if pressure have ex-
 isted on the  trunk of the veins.   Hence the oc-
 casional appearance of this affection in the ad-
 vanced  progress of many other diseases,  espe-
 cially of those in the course of  which morbid
 secretions are apt  to pass  into the circulation,
 or to be absorbed by the lymphatics, and when
 pressure has existed upon, or has been sudden-
 ly removed  from, large veins.   (Veins, Dis-
 eases of)
   42  IV. Nature  of the Disease.—A. I have
  already noticed ($  4, et seq.) some of the opin-
  ions formerly entertained respecting the nature
  of this complex affection, and stated enough to
  show that most of these were more or less er-
roneous, but  chiefly in their limitation  to one
only of the several morbid conditions generally
present in the fully-developed cases of the dis-
ease.   Since the days of White, who attribu-
ted the malady to rupture of the lymphatics,
most writers up to the end of the last century
believed it to be an inflammation of the lym-
phatics.   Boyer, Trye, Denman, Ferriar, and
Gardien  adopted  this opinion, with certain
shades  of difference.  Thus Trye  considered
that the inflammation of these vessels proceed-
ed sometimes from pressure of the gravid uter-
us, sometimes from an acrid matter secreted
by this organ ; while Denman supposed that it
originated in  the lymphatic glands of the groin;
and Ferriar that it  commenced in  the lym-
phatics of the thigh.  Many of the symptoms
observed  during life, and even part of the
changes detected after death, evince that these
views  were  not entirely without foundation.
They wanted the  support derived  from post-
mortem research ; and they constituted only a
part of the morbid changes ; they were merely
a substitution of a part, and often only a small
part, of the malady for the whole.
  43. Much more  recently, certain  symptoms,
attracting the notice of pathologists, and more
than ordinary attention being directed to these
symptoms, and to their origins, a different opin-
ion of the nature of phlegmasia dolens was sug-
gested, and  former views were  thrown in the
shade.   Thus Albers (Hufeland's Journal,
&c, Feb., 1807, p. 16) considered the disease
as merely a form of neuralgia.  He believed
that it  commenced in the nerves of the limb,
and that the swelling was a consecutive lesion.
That this is actually the case, at least in some
cases, as in that  recorded by  Dr. Davies, in
two or three cases seen by myself,  and in oth-
ers recorded by Duges, Kruger, and other phy-
sicians,  cannot be doubted.   Duges (Revue
Medicale, t. iii., 1824); Siebold, Lokwknhard
(in Siebold's  Journal, t. x , p. 352), Hansel
(Rust's Magazin, t. xxiv.), and Kruger (Horn's
Archiv., t. iv., 1831)  attributed  the malady to
inflammation of the  nerves of the pelvis and
thigh, or, at  least, to a morbid state of the sen-
sibility of these nerves, admitting, however,
consecutive  changes in the veins, lymphatics,
and arteries of the limb.
   44.  Newmann and Treviranus  (Siebold's
Journal, t. xi., p. 253), on the other hand, con-
sidered this affection as an inflammation of the
aponeurosis, or fascia lata, giving rise to an ef-
fusion of serum and lymph; while others even
supposed it to be a form of rheumatism occur-
ring in the puerperal state, and  modified by the
circumstances of this state.  This opinion, sup-
ported by Himly and Reuter, is equally vision-
ary with that of Newmann.
   45.  The  researches of Dr. Davis first  es-
tablished inflammation and obstruction of the
 veins as the principal lesion of severe cases of
this malady; and the investigations of Bouil-
 laud, Velpeau, J. Davies, Boudaut, and R.
 Lee farther  illustrated this doctrine.   Dr. Lee
 first demonstrated the origination, of at least
 many of the cases of the disease, in lesions of
 the uterus and the veins of this organ, in uter-
 ine phlebitis.   So that  the prevailing opinion
 in the present day is, that phlegmasia alba do-
 lens is inflammation of the  iliac and femoral
I veins, originating in the veins  of the  uterus, 
PHLEGMASIA  ALBA DOLENS—Treatment.
287
and often extending, on the one hand, to the
common  iliac veins, or even to the vena cava;
and, on the other, to most of the  veins in the
extremity.
  46  I  believe, however,  from  considerable
experience of the disease in different circum-
stances, that phlegmasia dolens is  a more com-
plex affection than it is  generally now consid-
ered to be;  that it is not  always, at  least, a
simple crural phlebitis ; that it does not always,
although  very frequently it does, originate in
uterine phlebitis; that it is not uniform in char-
acter, phenomena, and progress ;  and that it is
a much more complex disease  than  it is gen-
erally viewed to be.
  47.  B.  Pathological Inferences.—a.  The dis-
ease certainly consists chiefly of inflammation
or obstruction, or of both lesions, of the femoral
and iliac  veins; hut these, although the chief,
or occasionally almost the only lesions, are not
always  such.—b. The crural phlebitis,  even
when manifestly existing,  cannot always be
referred  to the  uterus for its origin, although it
very frequently does so originate, especially in
cases occurring after delivery.—c. The lesions
observed in the veins appear, in some instan-
ces, as consequences of prolonged pressure, or
of this cause  and the sudden removal of that
pressure, the disease originating in  the  iliac
and femoral veins.—d. The  affection appears to
commence, in some cases, in the nerves, owing
to the causes just assigned, the veins becom-
ing consecutively affected, or being contempo-
raneously attacked.—e.  Cases occur in which
it is difficult to  determine whether the veins or
the lymphatic vessels and glands are  primarily
or mainly implicated, the symptoms and the le-
sions  observed after death being referable to
both systems of vessels.—/. The  disease may
originate in lesion  of any of the pelvic viscera,
or of the articulations or parietes of the pelvis;
and in such cases it may not be limited to ei-
ther the  veins  or absorbents, but may  affect the
one or the other, and extend to both.—g. The
disease may be unconnected with lesion of the
pelvic viscera, and may commence in  the veins,
or in the lymphatics or veins, or even in the
nerves, and extend more or less to these ves-
sels, especially when the patient has had  the
extremity exposed to pressure or injury, or to
cold or currents of cold  air, or to other inju-
rious  physical agents.—h. The precursory, ear-
ly, and advanced symptoms, the constitutional
phenomena, and the terminations  or conse-
quences of the  affection, vary according as ei-
ther of the parts just pointed out  as  being im-
plicated more or less, or any two or more of
them, are prominently affected ; the pain and
nervous symptoms are more severe, the more
the nerves are affected ; the swelling, the gen-
eral oedema of the limb, and the pitting on pres-
sure, and the low or typhoid character of the
accompanying fever, are more remarkable the
more the disease is confined to the veins; and
especially when it  is preceded or attended by
disease of the  uterus, or of any other pelvic
viscus or part; the hardness, tenseness, and
heat of the limb ; the tenderness of the sur-
face, and its indisposition to pit  on  pressure,
are more manifest the more the lymphatics and
glands are concerned in the malady.—i. I have
never met with a case of the disease in which
the arteries were implicated.
  48. V. Prognosis.—Although a  small pro-
portion  only  of those who are  attacked with
phlegmasia dolens terminates unfavourably, es-
pecially when the affection appears after partu-
rition, still it should be viewed as a serious dis-
ease, and more particularly when it occurs in
the course of other  maladies which contami-
nate the circulating fluids.  But the amount of
danger should be inferred chiefly from the se-
verity of the  symptoms,  from what  is  made
apparent as to the cause and origin of the at-
tack, and from the pathological condition man-
ifested at the commencement and progress of
the case.  Pre-existing disease of the pelvic
viscera  or parietes ;  evidence of inflammation
of the iliac and femoral veins ;  the extension
of the malady to both extremities ;  low fever
and  delirium;  a very  rapid, soft,  and  small
pulse, are severally indications of great danger.
  49. The nature and amount of disease of the
pelvic viscera, preceding and  attending the at-
tack, should always be duly estimated, as well
as the nature and relations of it.  When dis-
ease of the veins is detected,  the extension of
it to the common iliac and vena cava, and con-
sequent contamination  of the blood, are  to be
dreaded—changes which may be often prevent-
ed by judicious practice, but which, when once
induced, can rarely be removed.  The passage
of the affection to the other  limb indicates, at
least, a  severe lesion of the uterine or pelvic
viscera, possibly even the  extension of the ve-
nous disease to the vena cava.  Low fever, de-
lirium, sopor,  and a  rapid, soft pulse, evince
contamination of the blood, and the injurious
influence of this change  upon  the brain and ner-
vous system, and constitution.  The contingent
occurrence of the affection  in  the course of
other maladies is always a very grave, or even
most dangerous circumstance ; but the amount
of that  danger depends upon  the nature of the
primary  disease.  In malignant or cancerous
maladies, in tubercular  consumption, and even
in some other constitutional diseases, the hope-
less state of the patient  depends more upon
these than upon this super-induced affection,
which, however, hastens the unfavourable  issue.
  50. VI. Treatment.—It is  of the utmost im-
portance to ascertain the predisposing and ex-
citing causes of this  affection ;  and the pre-ex-
isting pathological conditions, especially those
so frequently implicating the pelvic viscera and
parietes, before  the  indications and means of
cure are adopted.  Of the  considerable number
of cases in which I have been consulted, I have
not met with  one which did  not occur conse-
quently  either upon large losses of blood from
the uterus, or  upon blood-letting, large in rela-
tion  to the state and constitution of the patient.
There have frequently been marked disorders
of the secreting and excreting  functions,  and
sometimes, also, a cachectic habit of body.   In
no instance have the previous health  and ex-
isting state of the patient  been such as to ad-
mit of venesection, or even of local depletions
to  a  great amount.   I  have  never prescribed
the  former for the complaint, and  I have or-
dered the latter only in  a moderate  degree.
The  uterine or other lesions  in which the dis-
ease often originates, the pre-existing state of
the  parts which are  the seats of this disease,
the antecedent and existing state of the patient'
and the  character of the pulse and other symp- 
288
PHLEGMASIA ALBA DOLENS—Treatment.
toms, not merely forbid the employment of gen-
eral  or  large local  blood-lettings, but  warrant
the adoption of restorative, and often  even of
tonic remedies.  But the facts, first, that the
disease generally originates in states of rapid-
ly-induced anaemia, of vital exhaustion, or of
vascular contamination ; and, secondly, that both
the morbid changes in which it originates, and
the pathological conditions of which it consists,
become more extended, and more rapidly con-
taminate the circulation,  after vascular deple-
tions and depressing agents, have been either
altogether unknown to, or very remarkably over-
looked by, the numerous  writers on this com-
plaint.
  51. The chief indications are, therefore, first,
to enable the powers of life to resist  the exten-
sion  of the changes constituting the malady, and,
secondly, to palliate, reduce, and ultimately re-
move, the symptoms and lesions which already
exist.  These intentions should not  be carried
out altogether in succession, but in great meas-
ure simultaneously ; and they are most appro-
priate in the cases of the  disease occurring af-
ter parturition.  My observation warrants me
in stating that the  most dangerous  symptoms
have occurred in those who had been most ex-
hausted, or lost  the largest quantities of blood
either before or during the disease ; while those
cases proceeded most favourably for which the
above indications were prescribed.  I have  cer-
tainly seen cases proceed favourably after the
application of leeches in the course of  the cru-
ral vessels; but I doubt any actual  advantage
having been derived from  them.   Dr. Church-
ill remarks that,  "generally speaking,  vene-
section  will not be required ;  but if the patient
be of a plethoric habit—if she have in some de-
gree recovered her  confinement, and if the  dis-
ease  set in with great violence, it may be ad-
visable."  (P. 426.)  Now, without denying the
occurrence of the complaint in these  circum-
stances, it certainly takes place  very rarely;
but most commonly in opposite conditions of
the patient.   Dr. R. Lee states that, in all the
cases he has witnessed,  "there  has  been so
much feebleness of pulse and prostration of
strength,"  that  he  has not ventured  to draw
blood from the arm ;  yet  he  trusts for the re-
lief of the inflammation " to the repeated appli-
cation of leeches above and below  Poupart's
ligament;"  and recommends  " from  two to
three dozen of leeches to be applied  immedi-
ately after the commencement of the  disease,
and the bleeding to be encouraged by warm fo-
mentations."  " Should the relief of the local
pain  not be complete, it is requisite soon to re-
apply the leeches  in  numbers  proportioned to
the severity of the  attack, and to repeat them
a third, or even a fourth, time at no very dis-
tant  intervals, should the disease not yield."
(Cyclop, of Pract. Med., vol. iii., p 349.)
  52. Now I believe that " the feebleness of
pulse and  prostration of strength,"  so  very
justly insisted upon by Dr. R. Lee,  as forbid-
ding a  recourse to venesection, equally forbid
the  application  of  leeches in the numbers, at
least, here recommended  by  him.  He consid-
ers the disease exclusively to consist of inflam-
mation of the veins, and,  according  to  his own
showing, it should  be treated as such.  But I
am  confident that neither bleeding from the
arm, nor applications of large r.umbers  of leech-
es  are beneficial either in phlebitis, or in lynj-
phangeitis, or even in the association of both.
I state this from a very sufficient experience;
and I am supported in  this by John Hunter,
who has insisted upon the necessity of having
recourse to such remedies as will prevent the
extension of the disease along the vessels, and
the contamination of the blood; neither of which
objects can  be accomplished  by venesection,
nor by the application of numbers of leeches.
If,  therefore, leeches be applied at all in the vi-
cinity of the pain, or near the groin, they should
be  few.
  53. I have shown, when  treating of inflam-
mations of the lymphatics, of the nerves, and
of the veins, that blood-letting aggravates them,
and that  even moderate local depletions pro-
duce  but  little benefit;  and,  granting that in-
flammation of these vessels exists in phlegma-
sia dolens, and even that it  originates in the
pelvic viscera or parts, it is to be presumed, ir-
respective of the  results  of experience, that
vascular  depletions cannot be more servicea-
ble in this malady than in the uncomplicated
states of either of these inflammations.   The
very  circumstance of the inflammation having
commenced in some one of these viscera, es-
pecially in the uterus, and extended to the in-
ternal iliac veins, is a  sufficient proof of the
impropriety of having recourse to depletions of
every kind ;  for, whether the complaint  origi-
nates in the absorption of morbid matter from
the uterus, or whether it arises in the lymphat-
ics or veins themselves, extending along theii
internal surfaces, both the  absorption and the
disposition  of the disease to extend itself will
be  very remarkably increased  by depletions and
other depressing  agents.  Indeed, I have no
doubt of the extension of the disease to the op-
posite limb being caused chiefly by blood-letting
and a lowering treatment.   Instead, therefore,
of  approving  the  treatment usually mentioned
in the works of writers upon midwifery and the
diseases of women, I would advise that which
my experience, since 1820, has shown  to be
most efficacious,  not only in  this disease, but
also in  several maladies occurring after partu-
rition, as well as in others implicating the cir-
culating vessels and fluids ;  and which, more-
over, fulfils the intentions of cure above speci-
fied (§ 54, 55, et seq.).
   54. Instead, moreover, of having recourse to
the more decided  antiphlogistic, or  rather de-
pressing, measures recommended by most of
the English and French writers on the disease,
I would advise the bowels to be  moderately
evacuated by means of a stomachic  aperient
(see Form., No. 266), or of castor oil and spirits
of  turpentine  (from three to five drachms of
each), taken on milk or some aromatic water;
and of an enema  containing  these latter sub-
stances.  The same remedies should be repeat-
ed, daily  or occasionally, or as circumstances
require ;  but  I have not found it necessary to
have recourse to them  oftener  than three or
four times, although I have prescribed the enema
 more frequently.  After evacuating the bowels
 by these  means, a pill, containing from two to
five grains of camphor, and one grain of opium,
 should be given, and repeated after three hours;
 and a third, or even a fourth,  dose may be giv-
 en after  six  or eight hours, according  to the
I state of the patient.  If there be irritability of 
PHLEGMASIA ALBA  DOLENS—Treatment.
289
stomach, a grain of caps cum, or a drop of
creasote, or bath, may be added to each dose ;
and these will also  diminish  or  prevent  the
headache  usually complained  of  after taking
opium.
  55.  Immediately upon first seeing the patient,
and the more  especially if  pain is detected in
the pelvic regions, either the warm terebinthi-
nate fomentation should be applied, in  the way
so frequently advised in this work, over the hy-
pogastric region and upper part of the affected
thigh, or flannels moistened with this  embroca-
tion should be kept  in the same situation as
long as possible, covered with a warm  napkin,
and renewed from time to time, as circumstan-
ces may require.
  No. 321.  R. Linimenti Camphors eo.: Linimenti Tere-
binthuia», 55, §iss.; Olei Oliva; Tmct. Opii, &a, fis.; Olei
Cajeputi, 3jss.  Misce bene, et fiat Embrocatio, mora dicto
utemla.
   56. This treatment will often arrest the dis-
ease in a very short time, if it be resorted to at
an early period ; and, even at  a more advanced
stage, it will  generally prevent the more dan-
gerous symptoms, and the passage of the affec-
tion to the sound limb.  If the disease be pre-
ceded or attended  by an offensive discharge
from  the uterus or vagina, a frequent injection
of a warm infusion  of chamomile  flowers and
camphor water, with or without a drop or two
of creasote, will be  of service; and enemata
containing spirits of turpentine, camphor, and
asafoetida, may be thrown up  occasionally.  If
the pulse be very frequent  and weak, or con-
tinue  in this state, after a recourse to the above
means, the decoction of bark should be given,
either with the hydrochloric, or nitro-hydrochlo-
ric acid, hydrochloric ether, and aromatic tinc-
tures  ; or with the  liquor ammoniae acetatis,
and full doses of the sesqui-carbonate of ammo-
nia ; or with the chlorate of potass and ether;
and  these remedies  may be  repeated  as fre-
quently as the case may require, and whether
the swelling be abated or not, the camphor and
opium being also taken as the severity of the
pain and other symptoms may indicate.
   57.  If low fever, delirium, and other indica-
tions of extension of the disease to the com-
mon  iliac veins, and of contamination of the
blood be  present, the decoction of bark, with
the chlorate of potass and hydrochloric ether,
or the alkaline carbonates and  serpentaria;
camphor, with aromatics and opium;  the in-
 jections into the rectum and vagina above rec-
ommended ;  the cautious exhibition of wine,
and even of brandy, with nutritious substances,
as with arrow-root, the yolk of egg, &c.;  and
suitable articles of diet, are indispensable.  It
sometimes happens, as I observed in  a severe
case, in which both extremities were affected,
that the very rapid subsidence of  the swelling,
and consequently the rapid conveyance of the
matters which had been effused into the circu-
 lation by absorption, so contaminates the blood
 as to occasion the most dangerous as well as
 alarming symptoms ; the patient labouring un-
 der low muttering delirium, with sopor or coma,
 and a very rapid, weak, or small pulse.  In this
 case  these symptoms did not appear  until the
 swelling of both extremities had subsided with
 remarkable rapidity; they were treated as just
 recommended, and terminated favourably, with-
 out  the least  change existing in either of the
     HI            19
! limbs, shortly or long after the attack, as fully
 ascertained on several occasions.
   58. The above treatment has been uniformly
 successful in the cases to which I have been
 called, although some of them have been very
 far advanced before I saw them.  As I have
 never met with an instance of the malady that
 has been attended by sthenic inflammatory ac-
 tion, or that  has  occurred in a plethoric habit,
 or even moderately robust constitutions, but in
 opposite states of the system, so I have not
 had recourse to vascular depletions.  If, how-
 ever, the disease should  occur  in the  former
 circumstances, vascular depletions  may pre-
 cede the means  now advised, although I  be-
 lieve that they are not even in such cases so
 indispensable as many writers have supposed,
 and who have most erroneously believed that
 inflammatory affections are to be removed only
 by depletions, without duly considering that in-
 flammations are various in character and diath-
 esis, as I have shown in  that article, and that
 they are often aggravated by a lowering treat-
 ment, and are then to be cured only by diamet-
 rically opposite means.    It will be seen that
 I have recommended measures altogether con-
 sentaneous with my views as to the treatment
 of lymphangeitis, neuritis, and phlebitis, and in
 accordance with the sound principle laid down
 by John Hunter, but now so generally over-
 looked, namely, that in all spreading inflamma-
 tions, and more especially in the inflammations
 of circulating vessels, the chief intention  of
 cure should be to enable the constitutional pow-
 ers to form coagulable lymph, whereby the dis-
 ease may be limited, and the extension of the
 mischief and contamination of the system pre-
 vented ; an intention to be fulfilled only by ton-
 ics and other restorative means.
   59. Upon  referring to  the writings  of the
 more recent writers, especially those upon mid-
 wifery,  much difference of opinion as to the
 treatment of this disease presents itself.  While
 Denman, Dewees, Blundell, Lee, Churchill,
 Raige-Delorme, Davis, and others advise vas-
 cular depletions, chiefly, however, by leeches,
 and only conditionally by  venesection, a small
 minority, among whom Dr. Burns is most con-
 spicuous, recommend tonic and restorative rem-
 edies.   Dr. Burns remarks, that "at first  we
 may use saline draughts;  but these are not to
 be often repeated, and must not be given so  as
 to produce much perspiration.  .In a short time
 they should be exchanged for  bark, sulphuric
 acid, and opiates, which tend to diminish the
 irritability.   In the last stage we may give a
 moderate quantity  of wine.  When  the pain
 shifts like rheumatism, bark and small doses of
 calomel are useful.   In every stage the bowels
 should be kept regular."   (Midwifery, p. 612.)
 It is evident from this that Dr. Burns and ray-
 self adopt the same principle or indication  of
 treatment,  and that his  remedies, as far  as
 they are stated, are the same as those I have
 advised.
   60. Much difference of opinion also exists as
 to the  local treatment of the affection.   I have
 already noticed (Y 55) what appears to me the
 most important part of that treatment.  Blisters
 were recommended to be applied  to the limb,
 immediately  upon discovering  the complaint,
 by Mr.  Sankev, and were considered by him
 as a specific.  He advises "the first to be ap- 
290
PHLEGMASIA ALBA DOLENS—Treatment.
plied to the calf of the leg, as the pain is gen-
erally most severe in that part, and there is less
fear "of its not healing than if applied lower.   If
required, he  repeats the  blister  every two or
three days, not  at the  same  place, but higher
or lower, according to the seat of the pain."
(Edm. Med.  and Surg. Journ., vol. X., p. 402.)
Some difference of opinion has been expressed
respecting this  practice.   Dr. Dewees disap-
proves of it, and Dr. Churchill expresses him-
self favourably as to it.  I have  seen blisters
employed only in one case, and I was led to be-
lieve them to have acted favourably, by pro-
curing copious discharges of serum and of a
sero-puriform matter,  and thereby preventing
or diminishing absorption and the extension of
the disease along the vessels.
  61. When  the more acute symptoms have
been subdued, and when the accompanying fe-
ver is either  abated, or does not assume a se-
vere or adynamic form, gentle support may be
afforded to the limb  by a slight flannel bandage
drawn gradually  tighter; and the embrocation
prescribed  above (§ 55) may be employed as a
liniment, with gentle friction of the surface, if
no abrasion  of the cuticle  have followed  the
application of it in the mode previously advised.
As the  disease subsides, a tonic, or at least a
restorative, treatment  is still generally requir-
ed, with due  attention  to the state of the bow-
els ;  and a light nutritious  diet—chiefly, how-
ever, of farinaceous articles.   The best aperi-
ent in this state of the disease is that consisting
of equal parts of the compound infusions of gen-
tian  and senna, with some neutral salt and an
aromatic tincture (sec Form., 266).  If the swell-
ing of the  limb  continue, the supertartrate of
potash may be given with the bi-borate of soda,
or the latter  may be taken in any aromatic or
tonic infusion in small doses, so as not to dis-
order the stomach.
  62. ;\s convalescence advances, change of
air, warm salt-water bathing, and subsequently
sea bathing, may be recommended.  But in this,
as well as in  the early periods of ailment,  due
attention  should be directed to the uterine
functions and discharges; and the  treatment
ought to be  varied accordingly, and after due
examination  of the state of the uterus.  At an
advanced period of convalescence the  prepara-
tions of iron, especially  the compound steel
mixture (mist, ferri comp.), or the muriated
tincture of iron, with the compound tincture of
camphor, are  generally most  serviceable;  but
much of the management of the patient should
depend  upon  the circumstance of each case,
upon  the contingencies which may arise, and
upon the complications  observed  in the course
of the complaint.
  63. The local states of disease, described above
(§ 35) as either closely resembling, or being iden-
tical  with, the affection now treated  of, should be
viewed  closely in connexion with those upon
which they occasionally supervene.  They can
hardly be treated apart from the original mala-
dies,  and in  some instances they will be  but
little benefited by any treatment whatever, es-
pecially when they occur in the course of ma-
lignant  and consumptive diseases.  In other
circumstances, the treatment must depend upon
the nature  of their exciting causes and  existing
pathological  conditions; the indications being
to remove them, and to enable the system to
 oppose their progress, or entirely to  overcome
 them ;  intentions which will be best fulfilled by
 the means already recommended.
   [Dr. James  Fountain, of Peekskill, N. Y.,
 divides this  disease into three  distinct stages,
 each requiring widely different  modes of treat-
 ment.  These are, 1st. The forming, or neural-
 gic stage; 2d. The  albuminous; and, 3d. The
 serous stage.
   The neuralgic stage commences at the inva-
 sion of the disease,  and continues till the vio-
 lence of the  pain has greatly subsided or near-
 ly ceased, when the limb  is at rest, and  the
 swelling has reached its acme, or  nearly so.
 This stage varies in duration, occupying from
 twelve to eighteen  hours.   The  indication in
 this stage of the disease, according to Dr. F.,
 is to  tranquillize or  allay nervous irritation at
 once, and  thus arrest the disease by breaking
 up the fiist link in the chain of morbid catena-
 tion.   This is to be  accomplished  by a full an-
 odyne,  as four to eight grains  of opium, with
 as much gum camphor, and repeat the dose, if
 necessary, every two hours, till  all pain ceases.
 Dr. F. states that he has prescribed this in six
 consecutive  cases, and always  with complete
 success.  The anodyne has generally been pre-
 scribed at bedtime,  in  full  dose, and  the next
 morning every symptom has  been  found re-
 moved  except a little stiffness.  He accompa-
 nies the opiate with  some warm vegetable  in-
 fusion, which  induces copious perspiration;
 and this is followed by a gentle laxative, with
 proper cautions against cold, to guard against
 a relapse.  The second, or albuminous stage, ia
 that in  which the limb is swollen, of a pearly
 whiteness, uniformly smooth, tense, and elas-
 tic, very sore and painful when  flexed, but not
 painful  when at rest, nor pitting on pressure.
 When the swelling commences at the onset
 of the  disease, Dr.  F.  states that it pits, be-
 cause the effusion is serous ;  that it ceases to
 do so in a short time, because  it  has become
 too albuminous or jelly-like, and, in  ordinary
 cases, continues so till the disease is changed.
 When,  however, the affection continues to in-
 crease in  intensity,  by maltreatment or other-
 wise, coagulable lymph is poured out, or pus is
 formed ;  hence sometimes the limb remains
 permanently  enlarged, or suppuration ensues.
 The indication in this stage is, to change the
 albuminous into a serous state, which is readily
 done  by emetics alone.  " No  class of medi-
 cines," says  Dr. F., "so soon and so effectu-
 ally reduce nervous erethism, break up morbid
 associations, and consequent disordered move-
 ment of the capillary system,  and set them
 right, as emetics.  These considerations first
 induced me to resort to them in this stage of
 phlegmasia dolens, and I have uniformly found
 their  operation to be decidedly and strikingly
 beneficial."   Dr. F. prefers  the  tart, antimony,
 as being  more  decisive in  its  action  on the
 nervous, and especially on  the capillary sys-
 tems.  " Often one emetic alone," he observes,
 " will change the character of the tumefaction
in twenty-four hours, freeing it from soreness,
and causing the swelling to pit freely and deep-
ly, being purely serous.  When one emetic fails,
a second may be given, or even a  third, at in-
tervals  of twenty-four hours.   I do  not hesi-
tate  to  say that three emetics  at most, and
very often one  alone, will  change any acutely 
PITYRIASIS—Description and Varieties.                      291
 sensitive and swelled phlegmasia dolens into a
 passive serous  state in  as many  days.  Ca-
 thartics are of no avail  in any stage of this dis-
 ease, any more  than to keep the bowels regu-
 lar.  In  conjunction with  emetics, the most
 advantageous local applications are,  soothing
 fomentations of hops or poppy-heads, especial-
 ly the latter, applied  warm ; over these a flan-
 nel  should be placed, to retain the warmth and
 moisture.  All kinds of  stimulating  liniments
 or embrocations are injurious, as is  every de-
 gree of opiation, during this period.   As soon
 as this course  has succeeded in procuring a
 freedom  from soreness,  and a doughy,  pitting
 feel, with coolness of the limb, the third, or
 serous stage,  is fully established."
   The third,  or serous stage of the  disease,
 which, according to Dr. F., consists almost en-
 tirely of a distention of the cellular tissue by a
 serous or watery fluid,  except in those truly in-
 flammatory cases  which pour out fibrin, and
 are nearly incurable, is  to  be treated as one
 of uncomplicated anasarca.  Our main depend-
 ance here is on the roller or bandage, extend-
 ing from the toe to the hip.  At first it is to be
 applied moderately firm, but drawn with more
 force daily.  The bandage should be removed
 every twenty-four  hours, and the  whole limb
 rubbed  with brandy, saturated  with  common
 salt, or with any stimulating  liniment.   Fric-
 tions with the hand or  flesh-brush may now be
 resorted to with advantage,  to give tone to the
 relaxed vessels.  In this stage  diuretics and
 tonics  are indicated, as  calomel and squills,
 some  bitter alkaline infusion,  and generous
 diet.   Among other  things,  Dr.  F. recom-
 mends  especially an infusion of the pyrola um-
 bellata and the apocynum cannabinum.   Several
 successful cases are detailed, illustrative  of
 the above pathology and treatment, which we
 would strongly recommend  to the attention of
 medical men.  See New York Journal  of Medi-
 cine and the Collat. Sciences,  vol. v., p.  15!.]
   Biblioo. and Refer.—Mauriceau, Malad. des Femmes
 Grosses, <fcc, t. i., p. 446.—Puzos, Traite des  Accouche-
 mens, &c, p. 350.—Levret, L'Art des Accouchemens, 4c,
 p. 932.—C.  White,  An Inquiry into the Nature of that
 Swelling in one or both the Lower Extremities which some-
 times happens to Lying-in Women, 8vo.  Warringtou, I'M.
 — C. B. Frye, An Essay on the Swelling of the Lower Ex-
 tremities, &c, Svo.  Lnnd ,  1792.—/. Feriiar, On an Af-
 fection of the Lymphatic Vessels hitherto misunderstood:
 in Medical Histories and Reflections, vol. ni., p. 112.  Lond.,
 1798.-7. Hull,An Essay on Phlegmasia Dolens, 8vo. Man-
 chester, 1800.—T. Chevalier, in Trans,  of Med. und Chi-
 rurg. Society of London, vol: ii , 1811. — Sankey, in Edin.
 Med  and Surg. Journ., vol. x., p. K'8— H'yer, in ilnd., vol.
 xv., p. 156.—J.J. Westberget Albers,\n Hufeland's J'.urn!
 der Praia.  Heilknnde,  Feb, IslT. p. 3.— J L.  Casper,
 Comuientaires de Phleg. Alba Dolente, Svo. Halle, Ibio'
 —D. D. Davis, An Essay on  the Proximate Cause of the
 discalled  Phlegmasia Dolens: in Trans, of Med. and Chi-
 rurg. Society, vol. xii.,  p. 419  Lond..  1843.-17. Law-
 rence, in ibid., vol. xvi., p. 58. — Duges, Revue Medicale, t.
 iii., 1824—7. W.  Francis, in New-York Med. and Phys!
 Journ., No. i., 1824.—D. Hosack, Observations on Cruritis
 or Phlegmasia Dolens : in ibid., and in Med. and Chirurg.
 Review, vol. in., p. 432.—.1/.  Ryan, in London  Med. and
 Surg. Jonrn., vol. iv., p. 325.-7. Davies, A Case of Phleg-
 masia Dolens, which terminated in Sphacelus of the Le"
 and Foot: in London Med. Repository, vol. xxin., p. 451.—
 A. Velpeau, Recherches et Observat. sur la Phlegmasia
 Alba Dolens: in Archives Generates de Medecine, t. vi., p.
 220. — Meissner, in Siebold's  Journ., <fec, t. iv., p. 73. _!
 Fraser, in ibid., t. vii., p. 647.—Hermann, in ibid., t. xi!—
 Loewenhard, in ibid., t. x., p.  352. — Kruger, in Horn's Ar-
 chiv., t. iv., 1831.—G. R.  Treviranus, in Annales  Chir. Hei-
delberg, t. v., p. 492.-7. L. Struve, Comment, de Phleg-
matia Alba Dolente, Observationes, xv. practicas continens
8vo.  Tubing., 1825.-R. Lee, A Contribution to the Pa-
thology of Phleg. Dolens, in Trans, of Med.  and Chirurg
Soc. ol Lond., vol. xv., p. 132, 369,  and Cyclop, of Pract.
 Medicine, vol. iii., p. 339, and Diseases of Women, <fec, p.
 117.—7. Bouillaud, Diet, de  Med. et Chir. Pratiques, art.
 Phleg.  Alba Dolens, t. xii.—L. Pfeiffer, Versuch  iiber die
 Phlegmasia Alba Dolens, 8vo.  Leips., 1837.— Raige-De-
 lorme, in Diet, de Medecine, 2U edit., art. Phleg. Alba Do-
 lens.— F. Churchill, Observations on the Diseases of Preg-
 nancy and Childbed, 8vo.  Dublin, 1840, p. 414.  See, also,
 the Works on Midwifery and the Diseases of Women by
 Denman, Burns, Capuron, Gardien, Davis, Dewees, Camp-
 bell, Blundell, and others.
   PHRENITIS.    See  Brain and its  Mem-
 branes—Inflammation op.
   PHTHISIS.  -See Tubercular Consumption.
   PICA.   See  Appetite—Morbid States of.
   PILES.   <See Haemorrhoids.
 PITYRIASIS.—Synon.  flirvpiaaic, from tutv-
   pov,  bran.—fltrvpudeic, furfurosi, quibus as-
   sidue furfures  in capite  gignuntur,  Galen.
   Alvarati, Avicenna.   Porrigo, Celsus, Lorry,
   J.Frank.  Twea/Mr/Mnzcea,Sennert.  Tinea
   porriginosa,  Astruc.   Furfurisca,  Gilbert.
   Pityriasis, Vogel,  Willan,  Bateman,  &c.
   Lepidosis pityriasis,  Young  and Good.   Te-
   igne, dartre, dartre furfuracie, Fr.  Hautkleic,
   Schuppen, kleiengrind, Ger.  Dandriff, Scurf.
     Classif.—II. Order, II. Genus (Willan).
        III.  Class, I. Order (Author).
   1. Defin.—A chronic,  non-contagious, super-
 ficial affection of the skin, attended by the produc-
 tion of minute  white scales in  great  abundance,
 frequently  on patches of irregular form, variable
 dimensions, and of a very light or dull red colour.
   2. I. Description.—Pityriasis  may occur in
 any part of the cutaneous  surface, sometimes
 on several parts  in succession, and most fre-
 quently in certain parts in preference to others,
 but very rarely over the general surface.   The
 patches are often attended  by slight heat,  pru-
 ritus, and tingling.   The scales are thrown off
 soon after they are  formed, and are reproduced
 with great  rapidity.  They are generally small
 and micaceous  ; in  some situations, and in the
 more  inflammatory states, they are large and
 lamellar;  and in  others, especially  in  the non-
 inflammatory, or at least when  inflammatory
 action  is least  manifest,  they are  minute, pul-
 verulent, or measly.
   3. The  Varieties of  Pityriasis, according
 to Willan, are the rubra, visicolor, and nigra.
 But Rayer and Wilson divide  the complaint
 into general and local, subdividing the latter ac-
 cording to  its situations, and consider  the vari-
 eties versicolor and nigra  of  Willan as not
 properly  belonging to this affection, but  to
 those affections which consist  chiefly of altera-
 tions of colour.  Pityriasis, however, may be
 simple or non-inflammatory, and associated or
 consequent upon an erythematous or superficial
 inflammation of the skin.   I shall, therefore,
 view it in  these  phases, the former  of which
 has been overlooked by the writers just named ;
 retaining, also, the varieties rejected by Raver!
 As the local forms of this eruption are the most
commonly observed, I  shall consider them be-
 fore 1  notice the more general affection, the
occurrence of which is  comparatively rare.
  4. i.  Local Pityriasis.—This complaint, ac-
cording to the situation  and grade of the inflam-
matory action attending it, has been variously
denominated and described by writers since the
days of Galen  and Celsus down  to those of
Willan and J. Frank.    Hence different mean-
ings have been attached to the term pityriasis
and have occasioned no small  amount of con-
fusion.  The more precise descriptions of Caze- 
292                               PITYRIASIS—Varieties.
nave, Wilson, Rayer, and others have, in great
measure, removed this evil; but there still re-
main a few omissions to supply and imperfec-
tions to  remove, even in the accounts  which
they have  furnished.   Local pityriasis may be
non-inflammatory or  simple, and inflammatory
or complicated; and in either form it  may  pre-
sent, in some cases, shades of colour different
from those usually observed, even independent-
ly of any decided evidence of inflammatory ac-
tion in the part—facts not sufficiently adverted
to by some writers on the complaint.   The va-
rieties which I shall notice are the following:
Pityriasis capitis, simplex et associata; P.  pal-
pebrarum ;  P. labiorum et oris;  P. palmaris  et
plantaris ;  P. praputialis et pudertdalis ; P.  ver-
sicolor ; P. nigra.
  5. A. Pityriasis capitis has been too gener-
ally viewed as an inflammatory affection,  and
described  as  such.   That it most frequently
possesses  this character, especially  in adults,
cannot be disputed;  but it is occasionally,
even in this class of  patients, devoid of every
inflammatory appearance.—-a. Pityriasis capitis
simplex is  frequent in infants and old people,
and rarely observed  in  the middle-aged  and
young.  Its presence is  indicated by innumer-
able minute white scales, which are rapidly  pro-
duced and  thrown off.   They are thin, white,
and dry, and at first adherent at one side  and
free at the others, but are very readily detach-
ed.  Upon removing them the surface presents
no inflammatory sign, but, on the contrary, has
a dull, indolent appearance, and is without  any
visible capillary vessels.   The exfoliation  and
reproduction of the cuticle proceed with vari-
ous degrees of rapidity, and furnish, according-
ly, quantities of these  scales, which collect near
the roots of the hair, and fall out upon scratch-
ing the part, or combing the hair.  This form
of the complaint is not attended by any, or but
a slight, itching, which is chiefly owing to  the
presence of the accumulated scurf.   It  is  ob-
served chiefly in  those of a dark complexion,
or with black or dark-brown hair, and of a  del-
icate constitution, or disposed to disorder of
the digestive organs.
  6. b. Pityriasis capitis  rubra or complicata  is
most common, especially in the young and mid-
dle-aged.   Its occurrence is indicated by a num-
ber of minute scales, appearing in some part
of the scalp; usually  of a white, whitish gray,
or yellowish gray colour; very thin, especially
at their edges, and perfectly dry.   They  are
often imbricated in children, but in old persons
they are scattered  irregularly.  Their forma-
tion is often  so rapid that, although they may
be all detached by the comb, they will collect
in  nearly  equal  quantity  in a day or two.
When they thus accumulate the patient cannot
scratch his head, or even arrange his hair, with-
out detaching  numbers,  which fall  upon  his
clothes in the form of a  white mealy powder.
When  the  scales are  small, they are generally
of a pure  silvery white; but when they  are
larger they assume a duller, or even  a darker
hue.  Upon separating the hairs and removing
the scales the scalp is found to be dry, rough,
reddened, and shining in spots or patches.   In
very chronic cases  the surface  is often  of an
opaque, grayish white; the cuticle appears to
be  thicker and coarser  than natural.  The
scales are  generally larger and thicker in  this
variety than in the former, and sometimes they
attain a diameter of five  or six lines.  They
occasionally form by their union a thin layer,
especially in children, extending over a consid-
erable portion of the scalp, being thickest at
points where they are most abundantly evolved.
   7. The most frequent seat of pityriasis is the
scalp; and  when partial,  or in  patches, it is
most commonly seen about the  coronal and
squamous sutures, whence  it may extend  to
the  temples,  forehead, and  to the eyebrows.
The itching attending the  eruption is often an-
noying, causing the patient to  scratch the part
and to loosen  showers of scurf.  When the af-
fection is of long standing, and is attended by
much  superficial inflammation, or  where it ia
much  irritated by scratching,  it is often fol-
lowed by the evolution of eczematous vesicles,
and  eczema auriantacea is developed from the
admixture of  the scales of pityriasis with the
eczematous discharge.
   8. This complaint may continue for many
months, or even for  many years, especially in
the aged, and  may appear,  also, in various parts
of the face and body.  When it is approachwg
a  favourable  termination,  the scales are not
formed so rapidly, and at last they cease to be
produced ; the skin, however, remains for some
time of a light  or dull red, or yellowish  red,
and slightly shining.  But  it often appears in a
different part, or extends  or is aggravated af-
ter errors in diet, especially after overloading
the stomach, or after taking spirituous liquors
or fish, more  especially shell-fish;  and  it may
thus ultimately abate and be exasperated for*
long and indefinite time.
   9. B. Pityriasis palpebrarum may exist alone;
but it most  frequently commences  in the eye-
brows, or is an extension of the eruption in the
scalp.   It is apt to occasion the loss of some
of the eyelashes, and to give  rise to chronic
irritation or inflammation  of the conjunctiva.
It is to be distinguished from  psoriasis in this
situation by the smallness and thinness of the
scales, and the erythematous appearance of the
patches when the scales are removed.
   10.  C. Pityriasis  labiorum et oris differs k
nothing from the red variety of the complaint,
excepting the situation.   When affecting the
lips, it is apt to be confounded  with psoriasis;
but it differs from  this  latter in  appearing as
red stains, and not as papular elevations, fol-
lowed by thick  squamae.   To  the red  stains
succeed  a general redness and continual des-
quamation  of the epithelium of the lips,  and
occasionally of the cuticle  of the adjoining
skin.   Desquamation of their transparent lami-
nae,  resembling the dried healthy epidermis,
proceeds along the lips, the  laminae becoming
detached first  at the edges, and adhering long-
est in the centres.  The lips are tender, heat-
ed, and tumid ; the epithelium is yellow and
thickened, and then cracks and is detached as
just stated, a new epithelium being formed un
der that which is about  to  fall off  This new
cuticle  in  its turn  becomes  yellowish  anJ
cracked, and ultimately is  detached, and thro
the  affection  is  perpetuated.   It  is  differeri
from the slighter and more transient affection
much resembling it for a short time, that fol
lows exposure to cold and  various  acute  dis
eases,  and  is  a most obstinate complaint, a
one time nearly disappearing and again return" 
PITYRIASIS—Varieties.
293
 ing even in a worse form than before, and with
 considerable swelling of the lips.  M. Rayer
 remarks, that he met with this variety in two
 great talkers who were frequently biting their
 lips.  The epidermis of the external surface in
 the immediate vicinity often undergoes a simi-
 lar redness and desquamation, although the af-
 fection is sometimes limited to the epithelium.
   11. An affection of the internal surface of the
 mouth, closely resembling that of the lips, has
 been described by M. Rayer, and a few instan-
 ces of it have been  seen by myself.  It con-
 sists chiefly of redness, tenderness,  heat,  and
 protracted desquamation of  the epithelium of
 portions of the surface of the tongue and gums,
 and the internal  surface of the cheeks, and in
 rare cases of the whole surface of these parts.
 In all the  cases I have  seen there  has been
 more or less  serious  chronic disorder of the
 digestive organs.
   12.  C.  Pityriasis praputialis and P. pudenda-
 rum.  The prepuce of the male  and the labia
 majora of the female are sometimes  the seats
 of a superficial  chronic  inflammation, giving
 rise to exfoliations of the epithelium,  and to an
 iucreased  secretion of the follicular  fluids of
 these parts, especially in  persons who are sub-
 jects of pityriasis capitis;  and  occasionally
 even the external surfaces of the parts  now
 named are also  similarly affected ; generally,
 however, to a limited extent.   These affec-
 tions are usually ameliorated or aggravated by
 the states of tha digestive organs ; and some-
 times  they entirely  disappear for a time, and
 again return.  They are always obstinate.
   13. D. Pityriasis palmaris  and P.  plantaris
 are varieties which were confounded with pso-
 riasis affecting the palms and soles, until dis-
 tinguished from it by M. Rayer.   This eruption
 commences in these situations  as small red
 spots or  stains  of  irregular outline, which
 spread and soon acquire a yellowish hue.  The
 epidermis thickens, dries, and  cracks, and is
 constantly peeling off in foliaceous  lamellae,
 the exfoliation sometimes extending to the fin-
 gers and nails.  Attention to this state of the
 eruption at the commencement will readily de-
 termine its nature;  for psoriasis  begins "with
 papular elevations, the summits of which are
 soon afterward  covered with dry, thick squa-
 mae of a dull whitish colour.  Pityriasis of the
 palms or soles is attended by painful tingling
 and tenderness,  and increased heat, which be-
 come so much increased  when the patient is
 warm in bed as often to break his repose.
   14. E. Pityriasis versicolor appears in  the
 form  of continuous patches of various  size,
 covered by a furfuraceous desquamation.  It is
 characterized  by  a varied yellowish or yellow-
 ish-brown discoloration of the cuticle, which
 even continues for some time after the cure of
 the complaint.  It occurs chiefly on the neck,
 ohest, shoulders,  and  abdomen, and rarely on
 the face.   It is distinguished from the ephelides
 by the furfuraceous  desquamation, and from
 other cutaneous affections by the peculiar pale
 yellow or yellowish-brown hue of the cuticle.
 It is as obstinate to remove as the  other varie-
 ties already mentioned.  In the instances  of
 brownish discoloration, the scurfiness of the
surface  is often  but  slight; the discoloration
being more deeply seated than the cuticle, and
evidently existing in the rete  mucosum, as re-
 marked by Willan.  In some cases, however,
 the discoloured  cuticle is exfoliated,  leaving
 the new cuticle  of a red  hue, as in  the  more
 common  states of the  affection.  Mr.  Plumbe
 mentions instances in which no sensible eleva-
 tion was perceptible to the finger when passed
 over  the  discoloration, although a  dry cloth
 forcibly rubbed over it detached films  of deli-
 cate cuticle, leaving  the  surface underneath
 tender and inflamed.
   15.  F.  Pityriasis nigra is of rare occurrence,
 Dr. Bateman describes it  as commencing in a
 partially papulated  state of the  skin, and ter-
 minating in a black discoloration, with  slight
 furfuraceous exfoliations.   It appeared chiefly
 in the extremities, and in  the fingers and toes.
 MM. Cazenave and Schedel state that numer-
 ous instances of this variety were observed in
 Paris in 1828 and 1829.   The furfuraceous des-
 quamation appeared on a  deep black surface.
 The affection occurred in  two distinct forms.
 In the  one the epidermis was the seat of dis-
 coloration, and, if detached, a red surface ap-
 peared beneath.  In the  other the epidermis
 was transparent, and the cutis vera was the
 part discoloured.   Dr.  A.  T. Thomson re-
 marks, that  the affection which prevails in
 Mexico, termed the pinta, or blue stain, appears
 to be  a variety of  pityriasis nigra.  " It  com-
 mences with slight febrile  symptoms, which
 last a few days only, and, on subsiding,  leave
 the face, breast, and limbs  covered with yel-
 lowish areolae, which change to a blue, and, in
 advanced stages, to a black colour.   The skin
 assumes a rough  and scaly  appearance, and
 exhales an offensive perspiration."  (Bateman's
 Synop. of Cut. Dis.  by A. T. Thomson, p.  77.)
   16. ii. General  Pityriasis.—a. This  is a
 rare state of the complaint, and is much more
 rarely  met with in a simple or non-inflammatory
form.  Yet I have seen a very few instances in
 persons of a dark complexion, with  the limbs
 much covered with hair, of a furfuraceous ex-
 foliation of the cuticle, proceeding  with re-
 markable  rapidity, and followed by as  quick a
 removal of it in several parts of the body, but
 especially on the  outsides of the thighs and
 near the joints, appearing in one part as it sub-
 sides in another, without any apparent redness
 of the surface either before or after the exfoli-
 ations.  The scurf  which is detached consists
 of very minute silvery white scales, which the
 slightest friction detaches in great numbers.
 These  evidently proceed from exfoliation and
 rapid production of the epidermoid scales, ei-
 ther independently of inflammatory action or
 in consequence of so  slight a grade of it  as
hardly to be observed ; and depend more  upon
 the production and  nutrition of the  epidermis
than upon  increased vascular action.   In the
very few instances I have seen, the scalp, low-
er parts of the face, arms,  and lower extremi-
ties were chiefly affected.
  17. b. The inflammatory state of general  pity-
riasis is oftener seen than the foregoing, al-
though very much less frequently than the local
varieties.   It is a most obstinate affection, and
is generally complicated with disorder of one or
more of the abdominal viscera.  The eruption
is preceded by itching, tingling, or pricking in
the surface about to be its seat.  When closely
examined,  superficial erythematous spots or
patches may  be  detected.  The heat  of the 
294                       PITYRIASIS—Diagnosis—Procnosis.
surface is increased, and the  part is slightly
tumid.  The inflammatory  blush diminishes,
and even shortly afterward entirely disappears
within a few days, so that this variety of the
affection, if not seen early, may be  mistaken
for the non-inflammatory form.   The epidermis
then cracks, becomes less adherent, and des-
quamation  commences.   The  scales thrown
off vary in their appearances with the seat of
the eruption, and the grade and duration of the
inflammation.   On  the  insides of  the  limbs
they are usually small, micaceous, and pulver-
ulent.   On the outer surfaces of the extremi-
ties they are much larger, and often  vary  from
three to six or seven lines in diameter.  They
consist of  foliaceous lamella?,  which continue
to adhere by their centres or extremities  for a
considerable time  after  they are partially de-
tached ; and thus they appear as loosely float-
ing on the surface.   When removed, especially
by friction, the parts affected are of a rose col-
our,  and slightly tumid.   When the  accompa-
nying pruritus impels the patient to scratch the
part, the surface exudes a yellowish  serous flu-
id, similar to that observed in  moist eczema ;
and when this takes place to a considerable ex-
tent, the diagnosis is thereby rendered obscure.
Behind the ears, about the axillae, bends of the
arms, groins, wrists, and insteps, the inflamed
surface assumes much  of the  appearance of
intertrigo—is rough, moist, and chapped in the
direction of the natural  folds of the skin.   On
the breast and abdomen the desquamation  oc-
curs in much larger lamellae than on the  back.
On the olecranon  and  patellae, and  especially
on the  palms  and  soles, where the  cuticle is
much thicker than  on other parts, exfoliation
takes place in larger and thicker laminae  than
elsewhere.  On the face and  scalp  the scales
are much more minute  and powdery.
   18.  Pityriasis, particularly the more general
states of it, is  attended by much pruritus ;  but
this sensation is most annoying when the  erup-
tion is  recent and the inflammation  considera-
ble ; and the enjoyment, if not the  relief,  ex-
perienced from scratching is the greatest;  but
it is  generally followed, when indulged in, by
painful smarting, so as to disturb the rest.   It
is very rare that the more general states of the
eruption are seen without the  scalp being af-
fected  also.  In all  cases where this part is
implicated, the hair is not affected or changed
for a considerable time, or until the disease has
continued  long.  It then gradually changes to
gray, and  becomes  finer, softer, and weaker ;
ultimately it gradually falls out; but baldness
is rarely the result, unless in aged persons, al-
though it is generally thinner in protracted ca-
ses.
   19.  c. The course of general  pityriasis varies
in individual  cases.  It often  appears in one
place as it subsides or disappears from anoth-
er, and is always a most protracted complaint.
The scales become small and pulverulent when
it is  subsiding or  is still lingering, and  large
and foliaceous when it is recent or has been
irritated, and  the  inflammation considerable.
The surface is red and moist in this  latter case,
and pale white, or slightly yellowish, in  the
former.  When the eruption is most acute, or
is exasperated, especially on the lower extrem-
ities, and in these  even when  the redness  un-
der the scales is  hardly perceptible, tumefac-
tion of the affected parts is very common, ow-
ing more, probably, to  the thickening conse-
quent upon  the irritation than to the state of
the subjacent cellular tissue.  The hair cover-
ing the limbs is much more readily lost during
the eruption than that of the scalp.
  20. d.  Associations.—I have rarely, or  per-
haps never, met with an instance of this erup-
tion, whether local or general, without being as-
sociated with disorder  of  the digestive func-
tions.  In most instances there is chronic dys-
pepsia, often with torpor of the liver, and some-
times with indications of chronic inflammation
of the mucous surface  of the stomach or bow-
els, or of both.   Flatulence is often, also, com-
plained  of; and in females, dysmenorrhcea, in
some amenorrhoea, is not infrequently, also, as-
sociated  with it.   Fever  seldom attends the
local  or  partial states  of the eruption, but it
sometimes  appears during the  more general
and severe forms, or when exasperated by ex-
ternal irritation or a stimulating diet.
   21. II. Diagnosis.—The scurf seen on the
foreheads of very young  infants, and that on
the scalp of aged persons, are not always ex-
foliations of the epidermis, but  rather the in-
crustations consequent upon the state of the
cutaneous secretion and neglect of cleanliness.
Very slight attention, however, will enable the
physician to distinguish these cases.   M. Ray-
er remarks, " that the  scalp and extremities of
some adults, and  especially aged persons, are
occasionally affected with an habitual exfolia-
tion of the epidermis, which differs essentially
from pityriasis  by being  attended by neither
redness, heat, nor any other morbid sensation."
Now this is the condition which I have denom-
inated  simple, or  non-inflammatory,  pityriasis,
and stated to consist of a morbid or  excessive
exfoliation  of  the epidermis.  It is  often at-
tended by slight itching, and slight friction will
readily induce an inflammatory blush of the
surface, indicating increased irritability of the
vessels  of the  rete  mucosum, and  generally,
also, by disorder of the digestive organs.
   22. The exfoliation of the cuticle  in pityria-
sis differs from that which takes place in all the
varieties of psoriasis.  For in this latter erup-
tion the cuticle is thickened,  rough, dry, and of
a dull white colour ; and the red patches al-
ways rise above the level  of the surface, while
those of pityriasis are not at all prominent.  In
psoriasis, also, the inflamed surface, even when
deprived of the squamae, remains  dry, while
that of pityriasis exudes a serous fluid.  In the
former  the integuments are not swollen and
painful,  excepting in psoriasis invelerata, and in
it only to a limited extent;  while in the more
acute or inflammatory  states of the latter they
are often painful and swollen over a large ex-
tent  of  surface.   The  heat and pruritus in pi-
tyriasis, also, are  much more troublesome than
 in psoriasis.   The same circumstances  also
distinguish pityriasis from the  leprous form of
 psoriasis, with this distinction in addition, that
the leprous variety generally assumes a circu-
lar form, and heals from the centre to the cir-
 cumference.  The detachment of the cuticle in
 ichthyosis is not preceded by redness  or morbid
 sensation of the  skin, and  the desquamation
 following chronic lichen and eczema is preceded
 by papulae and vesicles.
   23. III. Prognosis.—Pityriasis is one of the 
PITYRIASIS—Causes—Treatment.                        295
most obstinate affections of the skin, more es-
pecially the more general forms of it.  Even
the local varieties are difficult to remove, and
often return  again and  again, especially after
errors  in  diet, and during  disorder of the di-
gestive organs.   Of these latter varieties, that
affecting the lips and mouth is the most rebell-
ious.  The duration  and extent of the affec-
tion, and  the association  of it with internal
disorder, as well as the nature of that disorder,
should all be duly considered  before an opinion
as to the probable effect of treatment is given,
and  before the means of cure adopted.  In all
severe and complicated cases, more especially
where  the eruption is more or less general, and
the digestive and respiratory mucous surfaces
affected, the removal of the complaint is a work
of time, and is not to be  accomplished without
effecting a change in the  constitution by diet
and  regimen.
   24.  IV.  Causes and  Complications.—The
causes of this eruption are often obscure, and
are  more  rarely local than  constitutional, or
such as affect the digestive  organs, and through
them the state of the constitution.   Local irri-
tants,  the use of combs, or hard hair-brushes,
the  kind  of  soap used,  and  the operation  of
shaving, have been  usually considered as ex-
citing  causes ; but I believe that they are much
less concerned in producing this affection  than
the  following, namely, too full or  rich living;
improper  or  unwholesome diet; the  frequent
use  of pork,  bacon, and dried, smoked, or pre-
served meats, or of shell-fish ; prolonged and
repeated irritation of the gastro-intestinal sur-
face, by these or by other  articles of an indi-
gestible kind ; drinking cold  fluids when  per-
spiring ;  a morbid condition  of the gastro-in-
testinal secretions ;  torpor of the  liver, and a
disordered state of the biliary and pancreatic
secretions; exhausting discharges, and anxiety
and  exertion  of mind.  There can be no doubt
of either or several  of these causes being the
most efficient in causing a  return of this erup-
tion in those who have  been before attacked,
and  in aggravating all  the  symptoms in those
who are already affected.  The more  general
forms  of the eruption are often associated with
dyspepsia, flatulence, and chronic inflammato-
ry action  of  either the pulmonary or the  gas-
tro-intestinal mucous  surface, or even of
both.
  25.  V. Treatment.—A. The local varieties of
pityriasis  generally require the  utmost atten-
tion  to cleanliness, and soothing and emollient
applications.—a. When the  hairy scalp is affect-
ed with the more severe forms of this eruption,
the hair should be cut as short as possible, and
the dried exudations  and squamae  softened by
means  of poultices and the vapour douche, the
latler of which should  be continued for some
time, and alternated  with alkaline or emollient
lotions. If there be much redness  and heat of
the  surface with  serous  exudation, leeches
ought  to be applied  behind the ears, and the
calomel ointment (one drachm of calomel to
one  ounce of ointment)  rubbed over  the in-
flamed  surface once in  the  twenty-four hours,
after carefully washing the  surface with an
emollient soap,  such  as  camphor  or  palm-oil
soap.  At the same time the bowels should be
freely evacuated, the  abdominal secretions and
excretions duly promoted, and the cutaneous
exhalations increased by means of purgatives,
alteratives, and cooling diaphoretics.
  26. Due attention ought also to be paid to
diet.  The stomach ought never to be overload-
ed, and the quantity of animal food should be
very  much diminished, if it be partaken  of
largely, or  even  more  than very moderately.
Pork, bacon, veal, fish,  particularly shell-fish ;
dried and smoked meats, and all other articles
of food which are apt to occasion or to aggra-
vate indigestion and gastro-intestinal irritation,
ought  to  be avoided, and  farinaceous  articles
of food and fresh vegetables substituted for the
meat dishes which are  relinquished, avoiding,
however,  all pickled, acid,  acerb, and acrid ar-
ticles whatever.
  27. b. These means  will  generally  remove
the more  recent cases of the eruption ; but the
more chronic states  are often but partially re-
lieved  by them.  I have considered that this
and other cutaneous eruptions, which are at-
tended  by the exposure  of a considerable por-
tion of the inflamed surface to the action of the
atmosphere, especially  of  the oxygenous por-
tion of it, are aggravated by whatever tends to
increase that exposure,  either by removing the
exudation and scales formed upon this surface,
or by preventing  their formation, and the pro-
tection they afford until a healthy epidermis is
formed beneath them ;  and, therefore, instead
of advising various  deterging  lotions, usually
recommended,  I have directed the surface  to
be covered, when the accumulated scurf and
scales have been removed, with some  albu-
minous or gummy application which may com-
pletely exclude the air  from the affected part.
The albuminous portion of egg, the solution of
isinglass,  or of gum acacia, or of tragacanth,
will answer this purpose sufficiently.
  28. c. In those cases which are attended with
flatulence, acidity, and  a predominance of the
uric acid  or urates  in  the urine, and, indeed,
in most of the  forms of this complaint, a suffi-
cient quantity of magnesia  and precipitated sul-
phur may be taken every night to procure a free
evacuation of the bowels in the morning, and
be continued for a considerable time, observing
due precautions as to diet and regimen, and at-
tending to cleanliness.  The variety of pityria-
sis capitis which  attacks adults, and especially
the aged,  and is  attended with little or no in-
flammatory action, requires chiefly attention to
cleanliness, diet,  and regimen, and the remo-
val of those symptoms of indigestion  and gas-
tro-intestinal irritation which are so frequently
observed to attend this eruption.  In these ca-
ses, the alkaline  carbonates, taken in  gently
tonic  infusions ;  the nitrate of potash, or  the
hydrochlorate of ammonia, in small  doses, with
emollients and vegetable bitters ; or these with
the hydrocyanic acid, will  often be of service.
The bowels should also be regulated by means
of magnesia and  sulphur,  as just advised.   In
these cases, dyspepsia and gastro-intestinal ir-
ritation are generally associated with debility ;
and we shall in vain endeavour to remove the
former if  we neglect the  latter, or to remove
the eruption if we  overlook these complica-
tions.
  29. d. Mr. E. Wilson advises, after the  in-
flammatory action is removed, some weakly-
stimulating application to the surface, such as
alkaline lotion, consisting of a drachm of liquor 
296
PITYRIASIS—Treatmint.
potassae to half a pint of emulsion of bitter al-
monds, or  camphor spirit, or a weak  solution
of the bichlorate of mercury.   A  solution of
two or three grains of bichloride of mercury, in
half a pint of emulsion  of  bitter almonds, he
considers best suited for patches on the face ;
and the zinc ointment for pityriasis palpebra-
rum, praeputialis, and pudendalis.   The vapour
bath or douche, with the white precipitate oint-
ment, are recommended  by Rayer for pityria-
sis, palmaris, and plantaris.  In these varieties,
I believe  that  the recently-prepared  calomel
ointment, and due  protection of the surface af-
fected in  the way  just advised (Y 27), will be
found preferable to the means directed by these
writers.
  30. B.  The more general  states of pityriasis
ate very frequently complicated with an inflam-
matory or congested state of the digestive or
respiratory mucous surfaces, or with  disorder
of the  abdominal  organs;  and hence  the ne-
cessity of having a strict reference to these as-
sociations of disorder during the treatment —
a. If the patient be young, robust, or plethoric,
venesection to  a moderate  amount, and even
the repetition of it, will be necessary, especial-
ly in recent and acute cases.   Sometimes these
complications  appear not until the pityriasis
has been of some duration ;  but in these blood-
letting may not the less be required.   Still, the
circumstances of the case  ought to  be taken
into account; for this form  of the eruption oc-
casionally appears in persons  exhausted by
mental exertion and anxiety; and for these
relaxation and a complete change of habits and
modes of living are required.  Temperate mu-
cilaginous baths, due regulation of the bowels,
cooling diaphoretics, especially the liquor am-
moniae  acetatis, spiritus  aetheris nitrici,  potas-
sae  nitras, or the ammoniae hydrochloras, taken
in emollients or demulcents; the nitro-hydro-
chloric acids, taken internally, or applied exter-
nally, and a farinaceous,  demulcent, and vege-
table diet, are  the means which  deserve the
greatest confidence.
  31. b. If the bowels require assistance, the
repeated use of the magnesia  and sulphur, as
above advised  (§ 28), will be found most ser*
viceable in this and in other forms of the erup-
tion.    If  they become  relaxed,  ipecacuanha
with any of the preparations of opium, or with
the tinctura camphorae  composita, and a fre-
quent recourse  to mucilaginous  baths, and to
applications of albumen, or  of solutions of
gum, &c., over the more  inflamed and  denuded
surfaces,  will  prove most  beneficial.   In this
as well as in most  other  forms of the eruption,
the  preparations of arsenic, or even of iodine,
are not so serviceable as in some other scaly
affections,  particularly when dyspeptic  symp-
toms or gastro-intestinal disorders are present.
But cases occasionally occur in which they are
very advantageously taken immediately after  a
meal;  and when  thus administered they will
not induce or aggravate these symptoms.
  32.  Mr. Wilson  remarks that the  local af-
fection " is to be  treated by emollient baths,
fomentations,  alkaline baths, and opium to lull
the pruritus."   Dr. A. T. Thomson advises  a
lotion,  consisting of one drachm of  the solu-
tion of potash ; one drachm of  the dilute hy-
drocyanic acid, and seven ounces of  the  mix-
ture of bitter almonds to be applied to the af-
fected surface, in order to quell the pruritus.  I
cannot quite approve  of these means of cure,
for the reasons already assigned (y 27), espe-
cially of the  more detergent substances em-
ployed, and am not surprised at  their frequent
failure.  The treatment recommended by Bate-
man  will be  found more successful  than that
now noticed, namely, a combination of antimo-
nials with decoction of woods, and warm baths.
And when the irritability of the skin is not very
great the application to the parts of an astrin-
gent lotion containing alum, or the di-acetate of
lead, or a  lotion containing borax.   Emollient
lotions and baths, containing also the sulphu-
ret of potassium, are often  useful.  Mr. Erich-
sen  advises them to be aided by an  ointment
of white precipitate of calamine, or of the ox-
ide of zinc.
  33. c. The Harrowgate and other sulphureous
waters are often of use in  all the varieties of
pityriasis.   In a remarkably severe case of the
general form of the eruptions in a married lady,
about the period of the  cessation of the men-
ses,  which was  under my care, a  prolonged
course of these  waters, following  an active
course of medicine, effected a complete and
permanent cure.   The discoloured varieties of
the eruption,  described by  Willan and Bate-
man, and but rarely met with, require the same
treatment  as that advised above.
  34. In most instances,  especially the more
chronic and  general  states  of  this  eruption,
comparatively little  benefit  will accrue from
any method of cure, if  the state of the digest-
ive organs, and the diet and regimen of the pa-
tient, be neglected.   For in this, as  well as in
all other chronic  diseases  of the skin,  a com-
plete and  enduring cure can be obtained only
by a change in the constitution, brought about
by a suitable diet and regimen, and habits of life.
What the diet, regimen, and  habits ought to be
cannot be stated with precision, as they should
be partially accommodated to the circumstan-
ces of individual  cases ; but, in general, those
in which  the patient  has   indulged  before and
during the commencement of the affection re-
quire change.  Abstemious and regular habits
should be  adopted, avoiding  rich, indigestible,
and  heating  articles  of food, and stimulating
beverages, and  substituting  farinaceous and
vegetable substances, as far as may be prudent.
Mental  exertion  and  anxiety should also  be
avoided as much  as  possible; exercise in the
open air ought to be regularly  enjoyed; and sex-
ual indulgences restrained  within due bounds.*
  Bibliog. and REFER.—Galen, De Composit. Medica-
ment, secundum Locum, lib. i.—Celsus, lib. vi., i.— Onba-
sius. Synopsis, lib. vi., cap. 25.—Aetius, lib. vi., cap. 66-—
Alexander Tral., lib.  i., cap. 5.— Paulus AZgineta, lib. iii.,
cap. 3.—Avicenna, lib. iv., Fen.  vii., tr. 2, cap. 24.—For-
esters, lib. viii., Observ., 12, 13.—Mcrcuriali, De Morbil
  * I have at present under my care a case of general pity-
riasis in a man, of great extent and severity.  He has tried
courses of the solution of the iodide of mercury and arsenic,
of the sulphur and vapour baths, and  the Harrowgate and
Leamington waters, without benefit.  He  is  about  fifty
years of age, has lost an arm, is of a full habit of body, and
has lived freely.  A severe diet, chiefly of farinaceous and
vegetable food, sponging the surface with cooling lotions,
exercise in the open air, and a course of alterative medi-
cines were prescribed for  him, but as yet the benefit de-
rived is only partial, the restricted  diet and prescribed
regimen not having been observed.  The great difficulty in
the treatment of this and other diseases of  the skin, is to
convince patients of the necessity of observing a strict reg-
imen, or rather to secure their faithful and continued adop-
tion of the diet and  regimen prescribed. 
PLEURA, INFLAMMATION OF THE—Definition.                 297
Cutis, c*p. vii.—Svmertus, Pract. Med, Ac, lib. v., pars
iii., sect. 1., cap. ~.—Alibert, Pre.cis Theonqun et Pratique
sur les Malad. de la Peau, 2 tomes, Paris, 1822, plate II —
Willan, On Cutaneous Diseases, 4to, 1805.—Bidoux, Re>
fkxions pratiques sur les  Maladies de la Peau, Svo.  Paris,
1826.—T. Bateman, Pract. Synopsis of Cutaneous Diseases.
Edit, by A. T. Thomson, 8vo. Lond., 1829, p. 71.—M. Good,
The Study of Medicine,  4th edit., 8vo.  Lond., 1634, vol.
iv., p. 413.—Plumbe, Pract. Treatise on Dis. of the Skin, 2d
edit., p. 802.—P. Rayer, Theor. and Pract. Treatise on Dis-
eases of the Skin.  Transl. by R. Willis, 8vo.  Lond., 1835,
p. 654.— W. C. Dendy, Pract. Remarks on Diseases of the
Skin, 8vo.  Lond., 1837.—J. Green, Pract. Compendium of
the Dis. of the Skin, with Cases, Svo. Lond., 1635, p. 233.
—/. E. Erichsen, Pract. Treatise on  the  Dis. of the Scalp,
8vo.  Lond., 1842. p. 164.—E. Wilson, Pract. and Theor.
Treatise mi the Diagnosis, Pathology, and  Treatment of
Dis. of the Skin, Sec, 8vo.  Lond., 1842,  p. 231.—Cazenave
and Schedel, Manual of Dis. of the Skin.  Transl. by T. H.
Burgess, Svo.  Lond., 1842, p. 217.—See, also, the Illustra-
tions of Willan,  Raver, and Willis,  &c.  Medical lit-
erature furnishes  little either truly satisfactory or practi-
cally useful respecting the pathology, the constitutional re-
lations, the complications, and the treatment of this obsti-
nate and generally symptomatic eruption.

   PLAGUE. See Pestilence, Septic or Glan-
dular.
   PLETHORA.   See Blood, Exuberance of.
   PLEURA, Diseases of.—Synon. U7\.evpa vel
ir\evpov, pleura, the  membrane covering the in-
ternal surface of the ribs, according to the an-
cient meaning;  now the  membrane covering
the internal parietes of the thorax, and reflec-
ted  over  both lungs.—Pleure, Fr.   Brustfell,
rippenfell, Germ.
   1. I shall  consider at this place those  dis-
eases which  commence and are  seated chiefly
in this membrane; but the consecutive changes
to which the pleura is liable  will also  receive
due attention.  Inflammations of the pleura will
be first discussed, and next  the other organic
lesions, which either commence in, or consecu-
tively implicate this membrane, will be treated
of, occasional reference being made to associ-
ated affections and diseases of the lungs  (see
that article) and of other connected and adjoin-
ing organs.
Inflammation of the Pleura.—Synon.  Pleu-
   ritis, Trfevpiric, w'ktvpZric voooc, morbus later-
   als, the side disease. Morbus pleuriticus, Cel-
   sus.  Passio pleuritica, Morbus costalis, Pleu-
   resis,  Auct. Var.  Febris  Pleuritica,  Hoff-
   mann.   Plcuritis  Pulmonis,  Pleuroperipneu-
   monia, Auct.   Pleuritis, Vogel, Sagar, Boer-
   haave, <Stc. Pneumonia pleuritis, Cullen. Cau-
  ma pleuritis, Young.   Empresma  pleuritis,
  Good. Inflammatio pleura;  Pleurisie, French.
   BrustfellenlzHndung, Seitenstich, Germ.  Pleu-
  rite, plurisia, Ital.   Plurisy.
    Classif—I.  Class, 2d Order (Cullen).   II.
      Class, 3d  Order (Good).  III. Class, I.
      Order (Author in Preface).
  2. Dbfin.—i. Nosolog.—Acute pain  in the
chest, aggravated by inspiration, commencing with
chills or rigours, followed  by  increased heat, a
hard and accelerated pulse;  short, dry cough;  and
by  difficult, short, or disordered  respiration.
  ii. Patholog. Defin.—Inflammation, commen-
cing in  or  implicating one or  more  parts  of the
pleural expansions, attended either  by  more or less
of a consistent albuminous exudation, false  mem-
brane or adhesion,  and by a fluid effusion, varying
in  their characters with the varying states of dif-
ferent  cases; causing  pain, symptomatic fever,
disordered respiration, dulness on percussion, and
alteration of the  respiratory sounds.
  3. Pleurisy has been mentioned by Hippoc-
rates and Celsus in several places, and  more
 distinctly  by Galen ;  but AretaEUs was the
 first to describe it with precision, and with ref-
 erence to the treatment.   Ccelius Aurelianus,
 Alexander Trallianus, and Paulus aEgineta
 have also  treated of it at considerable  length.
 All these  writers  have viewed  the disease as
 seated in the pleura lining the ribs, or external
 parietes of the chest.   Modern physicians, who
 agreed with ancients in limiting the malady to
 the pleura, did not also agree with them in be-
 lieving that it was confined to this portion of
 the pleural surface, but that it was seated, with,
 probably, much greater frequency, in the pleu-
 ra  reflected over the  lungs and other parts.
 While Boerhaave, his  commentator Van Swie-
 ten, and others contended for the separate and
 distinct  affection  of  the pleura,  Sydenham,
 Hoffmann,  Triller,  and Morgagni believed
 that the pleura and the substance of the lungs
 were  generally both implicated, and that  the
 one could  rarely or never be inflamed without
 the other  being also attacked.  Hence pleuro-
 pneumonia,  or pleuro-pneumony, was used to
 designate  inflammation of these distinct struc-
 tures.  This latter view was followed by Cul-
 len,  Portal,  the Franks,  and many  others.
 Nevertheless, it is now fully demonstrated by
 post-mortem examinations, as well  as  by the
 physical and rational symptoms during life, that
 inflammation may commence in, and be limited
 to, the pleura in some cases, and may be equal-
 ly confined to the substance  of the lungs in oth-
 ers ;  although in perhaps a still more  numer-
 ous class of cases, it may originate  in the one
 and extend to the other,  implicating either of
 them more or less, as I have fully shown when
 treating of inflammations  of the lungs (see art.
 Lungs, § 73-75), and as the researches of La-
 ennec, Andr*l, Louis, Cruveilhier,Williams,
 Forbes, Chomel, and  Stokes  also have fully
 demonstrated.
   4.  It  has been  fully shown  by Dr.  Stokes
 that  the superficial description of many ana-
 tomical writers has given rise to  incorrect views
 as to the  connexion between  the pleura and
 the  parts  over which the  pleura is reflected.
 Instead of this  membrane being connected to
 these parts simply by means of a subjacent cel-
 lular tissue, it has interposed,  between it and
 these parts, a thin but dense fibrous membrane,
 which entirely envelopes  the longs, and forms
 a strong capsule for these organs.  Dr. Stokes
 remarks, that this capsule, in the healthy state,
 though possessing great  strength, is transpa-
 rentr a circumstance in which it differs from the
 fibrous capsule of the  pericardium, and which
 has probably caused its being heretofore  over-
 looked ; and that it is always more perceptible
 in disease  implicating the pleura and subjacent
 tissues when they are more or less  hypertro-
 phied and  rendered opaque.   " This fibrous tu-
 nic invests the whole  of both lungs, covers a
 portion of the great vessels, and the pericardi-
 um seems to be but its continuation, endowed
 in that particular situation with a still greater
 degree of strength, for  purposes sufficiently ob-
 vious.  It  covers  the  diaphragm, where it is
 more opaque, and, in connexion with the pleu-
 ra, lines the ribs, and, turning, forms the medi-
astina, which thus are shown to  consist of four
layers, two serous and  two fibrous."  (P. 460.)
This  conformation of  the investments of the
lungs  and  adjoining parts is  interesting in a 
298              PLEURA, INFLAMMATION
physiological and pathological as well as an ana-
tomical point of view.   It establishes an addi-
tional analogy between the lungs and the pa-
renchymatous and glandular organs of the ab-
domen, which have their fibrous capsules;  and
illustrates the general law of the constant as-
sociation of serous and fibrous membranes, as
we see in  the  arachnoid, pericardium, perito-
neum,  tunica vaginalis testis, and the synovial
capsules. Considered pathologically, Dr. Stokes
adds, it may explain the pain of pleuritis  and
pleurodynia, and the rarity of perforations of
the pleura, so remarkable when considered in
connexion with the frequency of ulcerations of
the lung, which constantly approach so close to
the surface as to be bounded  by the fibro-se-
rous membrane  alone.  " In pleuritis, with ef-
fusion, its existence may assist  in explaining
the binding down of  the lung, and its corruga-
ted appearance  after the removal of the effu-
sion."   It may  also be the seat of ossifications
of the pleura ; indeed, there can be little doubt
of this being the case.
  5. Notwithstanding this structure of the tho-
racic linings, we find that the cavities are ca-
pable of considerable dilatation,  and that the
mediastinum yields much more than is gener-
ally supposed, before the pressure of intra-tho-
racic accumulations.   Hence, in  empyema, or
in pneumo-thorax of the left side, displacement
of the  heart, as Dr. Stokes has shown, occurs
long before the intercostal spaces are oblitera-
ted,  or  even the diaphragm  depressed.   It is
not improbable, however, that the strength of
this  fibrous tissue  varies in different persons ;
indeed, with respect to the pericardium, the
greatest difference of strength exists, for in
some subjects it is dense and opaque, while in
others it is nearly transparent.
  6. The varieties  or states of pleuritis are nu-
merous ; and they have been variously denom-
inated  and  arranged, according to the views of
those who have described them, and to the va-
rious morbid relations  they furnish.—(a)  Con-
sidered with respect to the character  of its
progress and duration, pleurisy may be  either
acute or chronic; and (b), both the one and the
other may also  be either attended by pain or
without pain—may be open or latent.—(c) In re-
lation  to its extent, pleurisy may be partial, or
circumscribed to a portion only of the pleura of
one side, or much  more extended on one side,
but still single, or it may exist on  both sides, or
be double.—(d) As regards the characters of the
pathological changes  attending it, pleurisy may
be dry, adhesive, or pseudo-membranous, or it may
be effusive, serous, sero-puriform, or purulent.—
(e) In relation to the causes and circumstances of
its occurrence, pleurisy may be primary or con-
secutive, or it may be spontaneous or traumatic.
(f) In  respect of antecedent disease, it may be
consequent  either upon other diseases of the
chest,  or upon  constitutional maladies, more
especially the eruptive fevers.—(g) Pleuritis
may, moreover, be simple or complicated; and it
may be simple from  the  commencement  and
continue so, or it may become complicated in
its course, and  it may be complicated from the
beginning, or it may be consequent upon the
malady associated with it; thus  it may be as-
sociated with catarrh, pneumonia, bronchitis, tu-
bercles, pericarditis, diaphragmitis, hepatitis, rheu-
matism, &c.—(h) Pleurisy may be even charae-
OF THE—General Cacses.

terized according to the states of the system and
the diathesis, and the circumstances in which it
occurs: thus it may be sthenic, or asthenic, or
bilious, or typhoid, or malignant, or cachectic, or
puerperal.—(i) It  may, lastly, be true or false.
  7. Having  premised these remarks, I shall
first notice the causes of pleurisy, and afterward
describe the  principal forms and states which
this disease  assumes, with their terminations,
their diagnosis, and the appearances on dissection,
concluding with  the  treatment  which appears
most appropriate  to each of these states.
  8. I.  The  General Causes of Pleurisy.—
Pleurisy occurs in all ages and  in both sexes—
in infancy and childhood as well as  in  adult
age; and in  this  latter somewhat more fre-
quently than  in old age.   It is much more fre-
quent in males than  females, probably in the
proportion of five to three, and owing to the
greater exposure  of the former to the  exciting
causes.  It is most  prevalent among  persons
much exposed to the vicissitudes of season and
weather,  and those actively engaged in  out-
door occupations, more particularly such as re-
quire physical exertion.  It is met with some-
what  oftener in those of a sanguine  tempera-
ment, and robust or plethoric habit  of body,
than in others; but  this may.admit of some
doubt.   It occurs more frequently in winter and
spring than in the other seasons, and in this it
accords with pneumonia, both  these  maladies
occasionally  becoming so prevalent  in those
two seasons  as to be almost epidemic.  Never-
theless, pleurisy may be more than usually prev-
alent, also, during summer and autumn, as it
manifestly was during the spring and  summer
of 1846, during which seasons,  however, there
seemed to be a tendency  to inflammatory af-
fections of serous membranes, and these often
of an asthenic character.
  9. A. The  various circumstances which predis-
pose pleurisy  are not determined with precision.
There can be no doubt, however, that previous
disease of the respiratory passages or substance
of the lungs, or  the  actual presence of these
and eruptive  fevers,  are the most frequent and
influential.   To these may be added the arrest
of accustomed discharges, and the suppression
of cutaneous  eruptions and of painful affections,
before the constitutional derangement of which
they are the  external manifestations is remov-
ed, for there  are often predisposing causes, al-
though  they may not actually excite or deter-
mine  this malady, other causes commonly fol-
lowing  upon  these, and determining the  mor-
bid action to the pleura or other serous mem-
branes.
  10.  B. The most  influential exciting causes
are certainly  exposure to cold in the numerous
modes of its  application, &c, and external in-
jury.—a.  The vicissitudes of season, of tem-
perature,  and of other atmospheric conditions,
have a marked influence on the prevalence of
this disease.   It is generally supposed that cold
and dry states of the air occasion pleurisies
more frequently  than cold  and humid states.
This is probably the case, but. it is not demon-
strated, nor is it easily demonstrable, as  there
are generally numerous other circumstances
which should be taken into the account.  There
can be no doubt, however, that cold applied to
the surface of the chest, or the cold generated
by currents of air passing over this part of the 
PLEURA, INFLAMMATION OF THE—Description of  Pleurisy.        299
body, or even over other  parts, and damp or
wet clothes upon either the trunk or the ex-
tremities, more  especially when the surface
has been perspiring at the time, or shortly be-
fore, are frequent causes of pleurisy.
   11. A.  Injuries or other mechanical causes are
frequent and  sufficiently  manifest, especially
fractures of the ribs, penetrating wounds of the
thorax, and contusions.   I believe that the in-
fluence of the last of these has often been un-
derrated, and  that contusions  and superficial
injury even of a slight kind have occasioned
pleurisy  more frequently than has  generally
been supposed.  In some states of the consti-
tution, by  no  means recognizable previously,
superficial and painful injuries,  such as severe
burns, scalds, and lacerations of the surface, are
followed by inflammation of the pleura ;  and in
some instances  the  injury may have been so
severe as to have its effects propagated  to the
intercostal muscles, and thence to the  costal
pleura ; but, in other instances, this explana-
tion can hardly be entertained, although the
frequency of pleurisy subsequently to such in-
juries fully justifies a  belief in the  sequence
being that of cause and effect, while nervous
communications, connexions, and influence suf-
ficiently account for the phenomenon.
   12. c. The pathological causes, or antecedent
diseases, require some notice in relation to the
occurrence of pleurisy, more especially as the
most frequent appearances of this malady are
of this description.  The common supervention
of pleurisy  upon general and lobular pneumonia,
upon tubercles in the lungs, the rupture of a
tubercular  cavity,  or tubercular perforation of
the lung, and upon other organic lesions of this
organ, is well known.  But it is not always suf-
ficiently  recollected, at least it has not been
sufficiently noticed by authors,  that pleurisy is
often consequent  upon inflammations  of the
liver, of the diaphragm, and of the pericardium,
and  still more  frequently upon  rheumatism.
Pleurisy may either follow or coexist with
these, and  more  frequently with inflammation
of the liver  and diaphragm than  is generally
supposed.   It may also follow partial or general
peritonitis, and  become the most dangerous
part  of the  complicated  malady.  It is  well
known that diseases of the mamma, more es-
pecially the malignant  maladies of this  organ,
often extend  to the pleura, and occasion one
of the worst  forms of pleuritis; and pleurisy,
generally with effusion, is one of the most un-
favourable  consequences, and not the least un-
frequent, of inflammations of the  veins  and of
the lymphatics, of punctures or the inoculation
of morbid fluids  during  dissections, and of or-
ganic diseases of the kidneys.
   13. Eruptive fevers are among the most fre-
quent pathological causes of pleurisy, this dis-
ease commencing either  during the acme of
the eruptive fever, or during the subsidence of
the eruption, or even during the period of con-
valescence.  When the pleurisy appears during
the acme of eruptive fevers, it may be manifest,
or be marked  by the other phenomena, or be
latent, and  be detected only after  death ;  and
it  may be similarly circumstanced when occur-
ring  at any  period after the decline of the erup-
tion.  In the first  instance, the  concomitant
pleurisy is to be imputed to the morbid poison
in  the circulating  fluids that has affected the
pleura in addition to the external surface, and,
indeed, other surfaces of the body.  In  the
later appearances of pleurisy in connexion with,
or subsequent to, an eruptive fever, it may be
inferred that the morbid condition of the circu-
lating fluids had  not  been  removed by  the
changes which had taken  place on the cutane-
ous surface, and by the other emunctories, but
that it was still sufficient to implicate the pleura,
especially if exposure of the surface, in its ex-
isting state of susceptibility,  favoured deter-
mination  of the circulation to internal parts.
Moreover, the cutaneous function is often not
restored for some time after eruptive fevers;
hence the blood  retains much uneliminated ma-
terials, which act  injuriously upon  serous ex-
haling surfaces, and often inflame  them ;  and
this  evil and its consequences  are  always de-
veloped or aggravated  by exposures to  cold,
even of the most evanescent and slightest kind,
during the early periods of convalescence  from
these fevers.  Besides, the sympathies exist-
ing between the skin and serous membranes,
already insisted upon  (t)  11),  are  also to be
taken into the account when speculating on the
connexions of inflammations of these surfaces.
  14. The puerperal state, more especially the
first month after delivery, is not an  unfrequent
cause of pleurisy ;  inflammation  of the pleura
occurring then either in a simple form, or asso-
ciated with  peritonitis,  or with pneumonia, or
with  phlebitis,  &c.  In this  particular state
there can be  no doubt of  the  disease  being
caused, in great measure, by the condition of
the blood  consequent upon  the absorption of
morbid matters  from the uterus, and even in
part from the digestive canal, aided probably,
in some cases, by suppression  or interruption
of the eliminating or depurating functions of
the skin,  kidneys, and intestinal  canal.  In
many instances, also, of puerperal fever, more
especially of the  adynamic and malignant states
of that disease, pleuritis appears both as a com-
plication or prominent local lesion, and  as a
consecutive malady ; and thus pleurisy, appear-
ing after parturition, may be viewed as result-
ing from analogous changes to those which oc-
casion it  in  connexion with  eruptive fevers,
erysipelas, and some other diseases of the  skin,
namely, from the states of the circulating fluids,
aided by interruption or suppression of the ac-
tions of the skin and other emunctories.
  15. II.  Description  of Pleurisy.—i.  The
Structural Changes constituting Pleurisy.
—It will be advantageous briefly to notice those
changes in the pleura constituting this disease,
in the earlier stages,  and which exist in all
cases in a greater  or  less degree,  however
early treatment  may   arrest  their progress.
These changes are identical with those charac-
terizing inflammations  of the peritoneum,  and
hence it will be  unnecessary to do more  than
to notice them briefly.  It is probable that, at
the very commencement of the inflammation,
there is a diminution of the serous  exhalation
that usually moistens or lubricates the pleura
in the healthy state.  This being the case, the
friction  between the opposing  surfaces would
be increased ; but this condition would soon be
followed by an exudation of lymph, or of an al-
buminous  serum, which would assume various
forms with the  intensity  and continuance of
that inflammation, and  the habit of body and 
300
PLEURA,  INFLAMMATION OF THE—Symptoms and Signs.
vital powers of the patient.  The pleura, more
especially in its subjacent or more fibrous lay-
er,  and  the  connecting cellular tissues, be-
comes more vascular, more opaque, and some-
what thickened,  at least subsequently, and the
lymph  effused more  copious.  The liquid or
lymph poured out consists of serum—an aug-
mentation of the serous  exhalation—and  of a
material  of nutrition, the albuminous, the co-
agulable, or albumino-fibrinous portion.   If the
inflammation continue, even for a short time,
the exudation of these  materials, in variable
proportions in different cases, proceeds rapidly,
and gives rise to  changes depending much upon
the proportion of the latter material contained
hi the serous fluid.  In its smallest proportion,
the coagulable material  is held in solution by
the effused fluid; and, when withdrawn from
the body, it gelatinizes upon cooling, the liquid
mass assuming a jelly-like appearance.   When
the  coagulable portion  is more  abundant,  it
forms films or coats of lymph upon the surface
of the membrane; and this  deposition is gen-
erally the more considerable, and the more dis-
posed to speedy organization, the more acute
the inflammation, the more plethoric and robust
the patient.  This coagulated lymph thus forms
the false membranes,  and the substance of the
adhesions  so frequently formed  between the
surfaces of the inflamed pleura.   But the false
membranes may exist with or without adhe-
sions,  the  existence  of  adhesions  depending
much upon the  quantity  of the fluid effusion
between the pleural surfaces.  This effusion,
especially  when considerable,  will  generally
gravitate to the most depending portions of the
pleural  cavity;  and  there,  especially,  it  will
tend to keep the pleura?  separate.  But if the
upper portions of the pleura be inflamed, they
will more  readily adhere, unless the fluid be
very abundant.  If the pleura; be inflamed  only
in their lower expansions, a small quantity of
fluid  will  be  sufficient  to  keep them  apart.
When the lymph effused on the  inflamed sur-
faces becomes organized it forms  a false mem-
brane ; and if the lymph cover opposite  sur-
faces, adhesions, through the medium of these
membranes, often become firm or permanent.
When the liquid effusion is small, or even con-
siderable, various adhesions may be formed,
and vary in number, appearances, and extent,
in connexion with the effusion; or partial ad-
hesions,  coexisting with  false membrane, may
exist without any, or with very slight, effusion.
In more  prolonged cases, and in various other
circumstances, which will appear in  the sequel,
various consecutive  changes are observed in
the pleura, and  in the matters effused  in its
cavity; but these will be more fully noticed
hereafter.
  16. ii.  The Symptoms  and Signs of  Pleu-
risy.— A. Of  Simple a\cute  Pleurisy — or
Sthenic  Acute  Pleurisy.—This, as well as
other inflammations, generally commences with
chills or  rigours, the  continuance and severity
of which are generally in proportion to the se-
verity  of the attack.  The rigours  are  either
preceded, or accompanied, or followed—for no
precise order of procession of their symptoms
is observed—by pain or stitch in the side, aggra-
vated by inspiration  and cough.  To the rig-
ours succeed  heat,  of surface  and the usual
phenomena of sympathetic inflammatory fever,
which vary with the constitution, idiosyncrasy,
and vital power of the patient.  The respiration
is short, frequent, sometimes nearly  forty in a
minute, superficial, and anxious.  Inspiration
is interrupted, or, as it were, cut short by the
lancinating pain.  Cough is dry and suppressed.
The chest, on percussion, furnishes a dull sound
on the  affected  side; and, at the same  time,
there are diminished motion and sound of res-
piration, with other morbid signs, on that side.
The accompanying fever is attended by noctur-
nal exacerbations,  with more or less manifest
remissions.   From the fifth to the  ninth day
the fever subsides, either with or without crit-
ical changes.  The pain of the side abates, and
with it  the feeling of oppression or  tightness,
and expectoration and respiration become more
easy.  Still the  local changes, evinced by per-
cussion and auscultation,  remain, and  often
continue for a considerable period ; and even,
to a certain extent, during life.  But more com-
monly they gradually disappear, and the patient
recovers health and strength.  Dulness on per-
cussion is the sign which is the last observed,
the breath-sound returning  often  long before
the dulness entirely disappears.   Thesi> phe-
nomena result from the several products of in-
flammation collected in the cavitj of the pleura,
that are generally removed during the period
of convalescence.  This view of the symptoms
of pleurisy requires,  however, a more particu-
lar examination, in respect both of the diagno-
sis and of the treatment.
  17. a. The pain  or stitch in  the side, charac-
teristic of this state of the disease, indicates a
more or less developed period of it.   This pain
is sharp or lancinating, often severe, recurs at
each inspiration, and prevents the dilatation of
the thorax, thus confining  inspiration within
certain limits.   Its seat is most frequently un-
der the nipple, at the margins of the  lateral at-
tachment of the diaphragm.  It has been asked,
to what is this pain  owing?  M. Cruveilhiek
answers this  question  by referring it to the
friction of the costal pleura over the pulmonary
pleura, which he believes to  be greatest at this
situation.   But  I doubt the existence of much
friction between these surfaces,  and believe
that the pain  is to be  imputed chiefly to tho
stretching of the inflamed fibrous layer of the
membrane during inspiration, and to the devel-
opment of its morbid  sensibility by this act.
The pain maybe felt in other situations besides
that now mentioned.  It may exist at any part
of the affected side of the chest.  It may even
extend  to the lumbar  region, or to the  lower
margins of the  ribs  and down to the crest of
the ilium ; and  it may exist in the mammary
and sub-sternal regions, and rise as high as the
margins of the third  or second rib, extending
even to the  shoulder.   The pain varies  as to
intensity and  duration : it may be permanent
or temporary, remittent or  intermittent.  It
may be so intense as to threaten suffocation or
asphyxia,  either from attempting to move, or
owing to the inability to dilate the chest.  This,
however, is most remarkable in extreme cases,
and in those of double pleurisy (A 61).   In other
instances the pain  is comparatively slight, and
is felt chiefly during a full  inspiration, or upon
coughing or sneezing, &c.   In some  cases the
pain extends over nearly the whole  of the side,
and is increased upon pressure, especially on the 
3F THE—Symptoms  and Signs.          301
              PLEURA, INFLAMMATION (

 intercostal spaces, upon  percussion,  &c.  I
 have seen, also, the pressure of the stethescope
 endured with difficulty, and a certain degree of
 puffiness or oedema of the  side  or of  the ex-
 ternal parietes.   In a  case of pleurisy conse-
 quent  upon hepatitis, very recently under my
 care, this external cedema and tenderness were
 very remarkable.   I have imputed these phe-
 nomena to inflammation of the  costal  pleura,
 and to the external propagation  of several of
 the  local changes, especially excited vasculaT
 action, increased  sensibility, and serous infil-
 tration  to the sub-cutaneous  cellular  tissue.
 Moreover, the pain may be entirely absent, or
 may exist in a situation which may not suggest
 the existence of pleurisy ;  and hence the dis-
 ease has been called latent pleurisy, which will
 be considered hereafter (y 49.)
   18. b. Respiration is short,  interrupted, su-
 perficial, and very frequent.  It may even reach
 fifty in a  minute.  The frequency of respira-
 tion is generally in proportion  to the severity
 of the pain, which checks the dilatations of the
 chest, and creates a necessity for an increased
 frequency of the act.   In these cases a  sudden
 attack of  cough or sneezing almost threatens
 asphyxia;  but I  cannot  agree with M.  Cru-
 veilhier, that asphyxia ever occurs under these
 circumstances, unless in double pleurisy, when
 much  effusion has taken  place.  Great  fre-
 quency of respiration may, however, exist in-
 dependently of pain; but in this case there is
 generally  considerable effusion.   Hence this
 state of respiration, although no pain is com-
 plained of, should always induce a suspicion of
 the existence of pleurisy.   When the remark-
 able acceleration of breathing is  caused by the
 effusion, then attacks of cough, sneezing, &c,
 may be followed by fatal asphyxia, but  this is-
 sue more frequently supervenes without either
 of these contingent causes having occasioned
 it.
   19. c. Cough most frequently attends pleuri-
 sy ; but it is short, dry, and suppressed, owing
 to the pain it causes.   It sometimes, however,
 brings up some  bronchial or tracheal  mucus,
 and when pleurisy is complicated with catarrh,
 then the cough is much more  severe and dis-
 tressing, and often attended by  a copious ex-
 pectoration of the sero-mucous fluid of catarrh.
 Occasionally the  catarrhal symptoms  are not
 developed until the acute stage  of pleurisy is
 subsiding, and when a free, abundant, and co-
 pious expectoration then takes place, it may be
 viewed as being critical;  but when the  sputum
is viscous, adheres closely to the vessel, is rus-
ty or streaked with blood, it may then  be con-
sidered an indication of the extension of the
inflammation to the substance of  the lungs, and
to the minute bronchi.
  20. d. Immobility of the thorax on the affected
side  has been considered characteristic of pleu-
risy ; but this is the case only to a certain ex-
tent, and is not  to be depended upon, for in
many severe cases it is difficult  to see much
difference  in  the  degree of motion  of both
sides, or of different parts of  the same side.
 Besides, immobility is often  caused by pain,
which may exist in the side independently of
inflammation, as will appear hereafter.
  21. e. Decubitus is most  frequently on  the
back during the acute stage of pleurisy; some-
times it is upon the sound side,  and rarely on
 the affected side as long as pain is considera-
 ble ;  but when  effusion has taken place, and
 the acute stage has passed away, the patient
 can lie only on the back or on the side in which
 the effusion exists.  Indeed, in all chronic ca-
 ses of pleurisy, or whenever effusion into the
 pleural cavity is great, the lung on the sound
 side  only remains capable of performing the
 respiratory  functions,  and it  necessarily re-
 quires  to be  unembarrassed during the  dis-
 charge of these functions, either by position or
 any other circumstance.
   22. /. The fever attending pleurisy may pre-
 cede, for two or  three days, the local symp-
 toms, or accompany them.  It generally sub-
 sides, before these symptoms  disappear, for a
 longer or shorter period.  The heat of surface
 varies considerably, but generally  it is co-ordi-
 nate  with  the strength and hardness  of the
 pulse, and is increased  towards evening or
 night.  The fever is  seldom perfectly contin-
 ued ;  it is generally slightly remittent;  some-
 times more manifestly so.  It is much less fre-
 quently intermittent, although the latent form
 of the disease  often presents complete morn-
 ing or daily intermissions.  The pulse is hard,
 concentrated, or constricted, and more or less
 accelerated, while in pneumonia it is full and
 developed.  Hardness of the pulse was consid-
 ered by Baglivi as the most distinctive symp-
 tom of pleurisy.  The concentration and hard-
 ness  of the pulse are generally remarkable in
 proportion to the acutenessof the pain   When
 effusion takes place, or is considerable, espe-
 cially about the third or fourth day, or later, the
 febrile symptoms subside, or remit more deci-
 dedly, and  sometimes  the  pulse intermits.
 These phenomena may be referred to the influ-
 ence  produced by the effusion upon the  func-
 tions  of the lungs and heart, and consequently
 upon  the  blood itself.   The least mental  or
 physical agitation, however, occasions  great
 acceleration of the pulse in these cases, and a
 febrile exacerbation returns at night.
   23. Although the sharp pain in  the side,
 catching and restraining every  inspiration, and
 rendering deep  breathing or coughing almost
 intolerable;  the short  breath,  and short  dry
 cough thereby  caused; the hard and  quick
 pulse, heat of skin, &c, are often characteris-
 tic of pleurisy; yet acute  inflammation, and
 its most important consequence, copious effu-
 sion,  may have existed for many days in the
 pleura, without this array of symptoms.  Even
 effusion may have taken place  to a very great
 amount without either disturbing  the respira-
 tion very sensibly, or even rousing the sensi-
 bility  of the parts, if it  have proceeded gradu-
 ally or slowly.   On the other hand, the physical
 signs  are more to be depended upon than those
 symptoms which have  been now considered.
 And, although they do not indicate the inten-
 sity of the inflammation, they  seldom fail  in
 announcing  the presence, and most serious
 consequences of it.  I shall therefore analyze
 these  signs in  the order in which they com-
 monly appear.
  24.  B. Physical  Signs of Pleurisy.—a.  Di-
 minished motion is usually observed as already
stated, and is at first to be imputed to the pain;
but, as pain may exist independently of inflam-
 mation, this sign cannot be depended on.  The
sound of respiration is also diminished in pro- 
302
PLEURA,  INFL.\MMATION OF THE—Symptoms and Signs.
portion as the movements are restrained in the |
parts affected with pain.
  25. b. A sound of friction,  or a  creaking
sound, is sometimes heard  during the move-
ments  of  the chest.  This  is ascribed by Dr.
Stokes, M. Reynaud, and others to a defec-
tive  lucubration of the opposite pleural surfa-
ces during the early or incipient stage of in-
flammation—to a dry pleurisy.   Dr.  Williams
ascribes this  sound to the presence  of lymph,
and  believes  that its production is favoured by
the  lung being partially distended or pushed
against the walls of the chest  during respira-
tion.  It is most  apt to occur where the  lung
is confined by adhesions or false membrane, or
partially distended by tuberculous or  other de-
posits.  This sound is commonly heard about
the  middle parts of the  chest.  It generally
ceases as  soon as effusion into the pleural  cav-
ity is announced by percussion ; but in the dry
pleurisy it may continue  for a long time.  Dr.
Williams remarks that, in three cases in which
the sound was heard a few days before death,
the pleura were thinly coated with a few small
patches of soft granular lymph ; and that, on
gently rubbing the lung upon the costal pleura,
a friction-sound was produced  by the patches,
but by no other part of the  pleura.   The pleu-
ral inflammation  and effusion were very slight
in these cases.
  26. c. Dulness  on percussion,  at the most de-
pendent parts of the affected  side, is present
when effusion has taken  place ; but there may
also be some dulness on percussion of other
parts,  or  where  a  considerable  effusion of
lymph, or  false membrane, is interposed be-
tween the opposite surfaces.  The effused fluid
collects in the lowest part of the cavity, float-
ing,  to some extent, the lung upon it; and
hence the dulness in that part.  As, however,
the vesicular and peripheral parts of the  lung
yield more readily to pressure than the tubular
or more internal parts, the fluid mounts up, as
it accumulates between the lung and ribs, and
occasions more or less dulness, which is  then
distinctly heard if the percussion be gentle and
abrupt.  But in all cases  the sound should be
compared with that  emitted by corresponding
parts on the  sound side.
  27. d.  Diminished sound of respiration,  with
diminution of the extent of the motions of res-
piration, necessarily result  from the accumu-
lation  of  fluid in  the  pleural cavity.   The
breath-sound is more and more weakened and
shortened  as effusion proceeds,  and is  ulti-
mately abolished in most parts, excepting those
about to be noticed.   This sign, as well as that
preceding and those following it, may be modi-
fied, or rendered less distinct, by  adhesions
previously existing between the pulmonary and
costal pleura.
  28. e. Mgophony, or the modification of the
vocal resonance so denominated, occurs when
the  dulness  on percussion  and diminution of
the  respiratory sound reach the middle regions
of the chest.  The vocal resonance is heard
more distinctly than usual in those  regions,
" and  it  is superficial, as if produced in  the
spot, separately from the  oral voice ; and it is
changed  to  a small bleating, trembling note,
which so much resembles the voice of a goat,
that Laknnf.c termed it aegophony.   This mod-
ification of the voice is heard  most  distinctly
between the third and sixth ribs, which corre-
sponds with the situation of the middle-sized
bronchial tubes ; about the spine it is generally
mixed with more of a common  bronchophony
from the larger tubes at the root of the lung."
The liquid interposed between the lung and the
parietes  of the chest renders the voice more
audible  in the above situation, by condensing
the tissue of the lung, and thereby making it a
better conductor of sound.  The layer of fluid
thus interposed, being thrown into vibration by
the sound propagated from the bronchial tubes,
transmits the voice to the ear of a tremulous
and wiry character, or imparts to the voice,
heard upon auscultation in  this situation, this
particular character.  The high or sharp tones
of the voice are best transmitted in this way.
Hence aegophony is most evident in boys, wom-
en, and  children with  high voices.   In per-
sons with a  bass voice  it is more commonly
limited to the inferior angle of the scapula, or
near the spine ; and it  then  approaches nearer
to bronchophony from its being seated in larger
tubes.
  29. As the liquid increases, the tegophony be-
comes weaker, more distant, and loses much
of its tremour, the  sound much  resembling a
small, deep-seated voice, or a silvery echo  of
the original.  This is owing to the amount  of
effused  fluid, and  to the compression of the
lungs and tubes ;  and when  these are much in-
creased, the  sound ceases altogether.  It has
not been ascertained what quantity of effusion
is sufficient  to produce this last effect. Dr.
Williams thinks that much sound of the voice
is not transmitted when the layer of serum ex-
ceeds an inch in thickness.  If the aegophony
continue stationary for several days, it may  be
inferred  that the effusion is moderate, and in-
creases very slowly, which is a favourable sign.
But it is often very transient; and cases often
do not come under treatment until the pleuritic
effusion  has  become too great to give rise to
aegophony.   Former and existing adhesions,
however, modify this as well as the other phys-
ical signs.  When  aegophony is most distinct
it is often accompanied with bronchial respira-
tion, especially between the scapulae, where,
also, there is a good  deal of common bron-
chophony with it.  Indeed, aegophony is merely
the bronchial voice modified by transmission
through a layer of fluid ; and hence  it may  be
changed into bronchophony by causing the pa-
tient to  change his position so  as to allow the
fluid to gravitate to a different part of the cav-
ity.  Hence, also, aegophony and bronchophony
often present mixed and doubtful states, which
do not admit of easy distinction, although they
differ sufficiently when their respective charac-
ters are well marked.   The former may  be
stated to be a tremulousness  of the voice when
it is superficial,  and an echo-like smallness
when it is deep-seated ; while the latter may
present  several other varieties.
  30. /.  The diffused vibration of the voice, which
is usually felt by the hand applied to the chest,
is generally intercepted and  prevented by effu-
sion into the pleural cavity.   M. Reynaud first
pointed  out this sign, and showed that the  vi-
bration caused by the voice pervading the com-
mon tissue of the lung, and transmitted to the
parietes  of the chest, is muffled and destroyed
by a layer of fluid interposed between the lung 
PLEURA, INFLAMMATION  OF  THE—Physical Signs.              303
and the parietes, although  aegophony may be
heard at the same spot, the vibrations of the
latter being too fine to be  felt  by the hand.
When dulness on percussion is caused by so-
lidification of a portion of the lung, the vocal vi-
brations are transmitted with  unusual force
from the tubes to the walls of the chest,  and
hence the opposite effect occasioned by the fluid
interposed  becomes  an important  diagnostic
sign, in regard of these lesions.   Partial adhe-
sions, however, of the lungs to the costal pleura
may very materially  interfere with these phe-
nomena ; for  there may be even more vibra-
tions than  usual felt at the adhering parts, or
where the lung is pressed close to the walls of
the chest;  and, on the other hand, there may
be solidification of the lung, and fluid or other
obstruction in the bronchi may  prevent  the
fremitus of the voice from  being transmitted
through them ; or more or less fluid may be
interposed  between the solidified lung and the
walls of the chest.
   31. g. Mgophony and all sounds of the voice
cease throughout the  affected side as the liquid
effusion  increases, excepting  within two or
three inches  of  the  spine;  or where the lung
may adhere to the walls, which frequently hap-
pens at  the  upper  parts  of the  chest.  The
sound of respiration is not heard in all the parts
of the affected side, except the interscapular
region  and under the clavicle;  but it is much
weaker in these  parts.
   32. h.  Enlargement and  immobility of the af-
fected side may  always be detected  when the
effusion is considerable. This side is first seen
to be larger than the other at the  end of expi-
ration, it not diminishing equally with the sound
side, especially at its lower region.  The dif-
ference between the sides may  be rendered
more evident by encircling the chest by a piece
of tape, and by fixing it at the spine and ster-
num ; when the tape will slacken and tighten
with expiration and inspiration, more evidently
on the sound than on the  diseased side, which
latter remains more fixed  in proportion to the
amount of effusion  and  degree of distention.
As the effusion augments, the enlargement of
the side becomes the more obvious to the eye
during the respiratory act, the want of symme-
try being apparent in  whatever position the side
is viewed from ;  but the  amount  of difference
should be  ascertained by  measuring the chest
horizontally with a piece of tape.  Having made
the tape, or riband,  to meet at the middle of
the lower end of the sternum, it should be ta-
ken at  the  precise point of it3 crossing the spi-
nous processes of the vertebrae, and  the differ-
ence of length between the two sides will  give
the amount of enlargement; recollecting, how-
ever, that the right  side of an adult is about
one third of an inch larger than the left.
   33. i. Displacement of the parts and organs
bounding the effusion becomes more  and more
manifest as the amount of fluid increases.  La-
ennec,  and many after him,  have  remarked
that the intercostal spaces on the side  of the
effusion do not present their usual depressions,
and that they are sometimes, especially in chron-
ic cases, equal with the surface of the ribs, or
even more prominent than they are; but  this
sign is hardly perceptible in acute cases, unless
in the more asthenic  states, and  when  the pa-
tient is thin or emaciated.   In such cases, Dr.
Williams has noticed an evident fluctuation,
which, however, is  a rare  occurrence.   The
smoothness of the side, from the yielding of
the intercostal muscles and consequent  oblit-
eration of the spaces, as well as the yielding
of the diaphragm, and the pushing before it of
the viscera  of the upper regions of the  abdo-
men, are remarkable  when the effusion is great,
and are ascribed by Dr. Stokes to paralysis of
these muscular parts, consequent upon the in-
flammation of their serous linings.  " The true
explanation," he remarks, " of the protrusion
of the intercostals  and diaphragm will be  found
to be that they are affected by paralysis follow-
ing inflammation of a contiguous structure—
that their contractile powers are lost, arfd that
hence they yield easily to a pressure, which in
their healthy state (as in vesicular emphysema,
in hydrothorax, and the first stage of pleurisy)
they effectually resist."  (P. 464.)
   34. Displacement of the organs more imme-
diately adjoining the effusion, especially that of
the heart and of the liver, is one of the  chief
indications of the existence and of the amount
of liquid  effusion into the pleural cavity, and
was first noticed by Dr. Stokes and ToWnsend.
When effusion is considerable in  the left side,
the consequent displacement  of the heart ren-
ders its recognition easy.  In this case the pul-
sations of the heart are felt and heard most dis-
tinctly under or to the right of the sternum, or
as low as the epigastrium, instead of between
the cartilages of the fourth and sixth left ribs.
If the effusion be on the right side, the liver is
pushed down much  below the margins of the
ribs, and its position  is easily traced by percus-
sion and by the touch.  It may even be pushed
so far as to form a tumour in  the  abdomen,
and hence  lead to a serious mistake in the di-
agnosis, if the  symptoms and signs referrible
to the thorax be not  duly investigated.   When
effusion in  the right cavity is very  great, the
heart may also be  pushed farther than usual to
the left, and it may  be felt beating to  the  left
of the nipple, or even below the axilla.   The
mediastinum may  also be displaced  by a copi-
ous  effusion, so that a dull percussion  sound
will be given out over nearly the whole of the
sternum, and  even for half an inch beyond it
upon  the sound side, owing to the mediastinum
being pushed to this side by the effusion, which
thus occupies the space behind  the sternum.
The dulness on percussion in these cases is
most evident below the juncture of the second
rib with  the sternum.   The  above displace-
ments may  also be caused by air in the pleural
cavity, but  in this case the tympanitic sound
would be present instead of dulness.
   35. k.  The motions and somids of the healthy
side, especially when compared with those of
the affected side, indicate either no sign of dis-
ease,  or an increase  of the signs of healthy ac-
tion, owing to  the increased work performed
hy the sound side.   This side moves more ful-
ly and rapidly than usual, and the respiratory
sound is so  loud in it as to resemble  the respi-
ration of children.
  36.  /.  Old, or  even  recent,  adhesions very re-
markably modify the  physical signs of pleurisy.
When the adhesions  are loose, or are stretched
by the effused fluid, so as to form bands  trav-
ersing the effusion, or cells filled with fluid, the
lung may be thereby kept at a moderate dis- 
304               PLEURA, INFLAMMATION OF THE—Dry Pleurisy.
tance from the parietes of the chest, and aegoph-
ony would thus be continued  as  long as  this
state continued.   Where  the  adhesion  is ex-
tensive and close, fluid poured out in the vicin-
ity will  compress one  part of the lung,  and
stretch and ultimately  compress  the part ad-
joining, in or near the place of adhesion.   Thus,
as not infrequently observed, adhesions may be
found  in the  upper regions of the  chest, and
the fluid effusion in the lower parts may be so
great as to press the lungs against the upper
portion, and there occasion a loud bronchophony
and bronchial respiration transmitted from the
large tubes by the adhering dense column of
lung;  and thus the case may be mistaken for
one in which cavities  exist underneath this sit-
uation ; but the prominence of the intercostal
spaces, the dulness on percussion, the enlarge-
ment of the side, and the displacement of parts,
as above described (§ 32, et seq.), will readily
distinguish its real nature.
  37. In rarer instances, the pleura of the up-
per and posterior parts  of  the lung may be af-
fected, and that of the inferior portions may be
adherent to either the diaphragm or lower walls
of the chest.  In these the lung will be press-
ed, by effusion  into  the  upper and posterior
parts, against the anterior or other portion of
the walls of the thorax, according to the seat
of effusion, and to the manner in which the
fluid is bounded by the adhesions or false mem-
branes ; and the sounds will be  tubular, loud, or
clear, or otherwise vary, wi:h  the part of the
lung thus pressed to the sides of the chest, and
with the proximity of the larger bronchial tubes;
and a more or less loud bronchophony will also
be heard.
  38. C. Consecutive Changes in Acute Sthenic
Pleurisy.—If inflammatory action  subsides in
consequence either of the  treatment or of the
effusion which takes place, absorption  of the
fluid and of the lymph usually  results, and the
compressed lung expands  under the efforts of
respiration in proportion as absorption proceeds.
The signs evincing the increased effusion grad-
ually disappear; and aegophony and the sound
of respiration  return in the situations, general-
ly the upper  parts of the chest,  where  they
were last heard.  With the return  of these, the
side  assumes its  natural  appearance,  and  a
gradual improvement  takes place of the sound
on percussion.  In modern cases, as Dr. Will-
iams remarks, the fluid is absorbed before—in-
deed, long before—the  lymph  or albuminous
matter is removed ; and when the pleural sur-
faces covered  with this  matter  come together,
a rubbing or rustling sound is sometimes heard,
which soon ends in the adhesion of these surfa-
ces by bands, or by more continuous false mem-
branes.  If these false membranes are formed
after the fluid has been  Temoved, and the lung
has recovered its full expansion, they are adapt-
ed to its free motions, which are not material-
ly interfered with by them.  Hence adhesions
are often formed, which are lengthened in the
lower parts of the  chest, where the lungs de-
scend  somewhat as the ribs rise, and which
are short in the upper  parts, where the  lungs
more closely follow the movements of the pa-
rietes.
  39. In severe cases,  the inflammation con-
tinues after the effusion has become abundant;
and not only increases or perpetuates the fluid
effusion, but also throws out " albuminous mat-
ter in various conditions, which  by its present
qualities or subsequent changes may produce a
variety of  prejudicial effects, all  tending more
or less to interfere with the restoration of the
organs to a healthy state."  These consequen-
ces  arise from the continued  or  unsubdued in-
flammation, whether  it  has been  imperfectly
treated, or entirely neglected ; and they furnish
strong proofs of the value of the physical signs,
which are never absent, and which rarely  faii
to point out the existence of these consequen-
ces.  They will  come more appropriately  un-
der  consideration under the heads of Chronic
Pleurisy ((j 63, et seq.).
  40. D. Termination of Acute Sthenic Pleurisy.
—The most frequent terminations of this form
of pleurisy are, 1st, by resolution ; 2d, by pass-
ing  into the ehronic state ; and,  third, by fatal
asphyxia.—a. Resolution may  be  complete, the
effused fluid and the false membranes being ab-
sorbed, cellular adhesions being the only traces
left  of the disease, or it may be incomplete,
In this latter case, the fluid effused is absorb-
ed, but  the false membranes  remain, undergo
changes, and  occasion phenomena which will
be noticed when the second of these  termina-
tions are considered.—b. Death by asphyxia may
occur in the most severe cases, either in double
pleurisy, or in the single state of the disease
when the effusion is rapid and  very great; but
this termination is much more frequent in pleu-
risy than in pneumonia.   It is, moreover, very
rare in the acute stage and simple form of the
disease,: it occurs chiefly in the chronic stage,
and  in the more complicated states.
  Before  I proceed to describe the  changes
observed  in the pleura  and   in the  matters
thrown out on the surface of this membrane
after inflammation of it, I shall first notice the
several states  or forms of pleurisy which dif-
fer from that which  has  now  been described,
as being the more common type of the disease.
Certain of these, indeed, differ from that just
considered in  very little  farther than in the
seat or limitation of the disease, or in the stage,
period, or continuance of it; and hence the ne-
cessity  of considering them all  in close con-
nexion.
  41. ii. Dry Pleurisy—the Pleurisie skke  of
Anoral.—a. This state of the disease deserves
notice chiefly because it  has  been particular-
ized by Dr. Stokes and M. Andral ; for it can
hardly be considered a distinct form, but rathei
as being  particular periods, of pleurisy modi-
fied, more  or less, by peculiarity of constitution
and  by the grade of inflammatory action.  Dr.
Stokes remarks that this  term may be applied
to that  form in which nothing is effused but
lymph.  The characters of this state, in gen-
eral, are, that the constitutional and local dis-
tress is comparatively slight, that organization
rapidly advances, that the sound is  clear, ornear-
ly so, on percussion, the phenomena of accumu-
lated effusion  being wanting, and  that the fric-
tion  signs are evident.  Dry pleurisy occurs, ac-
cording to  these writers, as an  original and un-
complicated disease, or as consecutive of  fe-
ver,  erysipelas, or diffuse inflammation.  It
may be  associated with or succeed to any of
the diseases of the lungs, or occur as a compli-
cation of cardiac or hepatic disease.  The cir-
cumstances in which I have met with it, in the 
PLEURA,  INFLAMMATION OF THE—Dry Pleurisy.
305
 least equivocal form, are either associated with,
 or consequent upon, acute rheumatism, acute
 hepatitis, and pneumonia.
   42.  b. The physical conditions of dry pleurisy
 Dr. Stokes believes to occur in two stages of
 the ordinary disease, namely, in  the  earliest
 periods, before effusion takes place ; and in the
 latter  stages, when the  liquid effusion is ab-
 sorbed.  In the  first case, the duration of the
 friction phenomena depends on the rapidity of
 effusion ;  in the second, on the vigour of the
 constitution  which influences the  process of
 organization.  At  the commencement,  pain is
 often felt  in or near the situation of the  inflam-
 mation, but it soon subsides.  The characters
 of the friction-sound, generally soon afterward
 heard  in the situation of thcpain, are  various;
 but this sound always conveys the idea  of two
 rough or  dry surfaces moving uninterruptedly
 upon each  other.   It accompanies inspiration
 and expiration, but it may be absent during or-
 dinary breathing, and yet become manifest on
 forced respiration.  In some instances the rub-
 bing sensation is felt by the patient for a  long
 time, but the sound may often be  heard  long
 after he ceases  himself to feel the obstruction.
 Dr. Stokes states, that the friction-sound in the
 early stages of the simple disease, or immedi-
 ately after  the  absorption of an  empyema, is
 often accompanied by a rubbing sensation, per-
 ceptible to  the  hand.  Like the  former sign,
 this may  be absent during ordinary breathing,
 but become manifest when the patient inspires
 deeply.  In the progress towards cure,  this is
 the first of  the physical signs to subside ;  it is
 apparently connected with the least organized
 state of the  effused lymph.
   43. The duration of the friction-sound, de-
 pending upon the absorption of the fluid  and
 the rapidity of organization, varies remarkably
 in different  persons ; it is comparatively short
 in the  young  and  robust; while in the feeble
 and cachectic it may continue without  chang-
 ing, especially when the disease is consecutive
 or complicated, longer  than  a month.    It is
 rarely heard, or continues but a short time, at
 the commencement of pleurisy, attacking the
 cachectic, or complicating febrile maladies.
 When, however, it follows  the  absorption of
 an effusion, it may continue from several da,ys
 to  some weeks.  It is heard  most distinctly
 over the middle parts of the chest.  The  fric-
 tion is rarely heard when the dry state of pleu-
 risy is consequent upon pneumonia with hepa-
 tization of a considerable portion of the lung. \
 It is more distinct when the pleurisy is  conse-
 quent upon, or complicated with, acute hepa-
 titis.  When pleurisy is  associated with peri-
 carditis, the rubbing sounds seem double, but
 the combination of that  caused by the  action
 of the  heart, with that following  respiration,
 often causes a confusion,  which requires atten-
 tion and practice to distinguish and duly  recog-
 nise.
  44.  c. The causes of the friction-sounds have
 been differently stated by  pathologists.    These
 sounds, variously modified with the nature of
 the case, have been heard in certain states of
 inflammation of the pleura, pericardium,  and
 peritoneum ;  and as they have not been heard
 in those states which are attended by a copi-
ous liquid  effusion, but in  that in which an un-
organized  lymph is presumed to exist on  the
    IK.             20
  surface  of the inflamed membrane, so  they
  have been viewed  by M. Renaud,  Dr. Corki-
  gan,  and Dr. Stokes as being caused by the
  presence of this lymph in the situations where
  these  sounds are heard.  Still this cause ad-
i  mits  of  doubt; for the  creak, or leather-creak,
I  admitted to be one of these  friction-sounds, is
  rather to be viewed as given out by the mem-
  brane itself in certain morbid states of it,  than
  by the friction of the opposite surfaces when
  covered by unorganized lymph.  The fact, how-
'  ever, of Dr. Corrigan  having  produced  the
  sounds in question  by rubbing two  portions of
  the inflamed membrane one upon the other,
  may appear conclusive  of this  point; still, I
  believe the matter  still to require  farther ex-
  amination.
|   45. d.  The existence of dry pleurisy, it should
  be mentioned, even as a stage of pleurisy, has
  been doubted very recently by a no  less distin-
 guished pathologist than Professor Hasse.   He
 remarks, that the attempt has been  made  to
  reckon the progress of pleurisy by defined sta-
  ges ;  first, the period  of dry  inflammation,
  which is of shorter  or  longer duration,  and
! comprehends all the changes observed in the
  pleura and  sub-serous cellular tissue (see y 112),
 but without, as is supposed,  any serous effu-
 sion.  Now, he  adds, that he has  never en-
 countered this dry stage as  described, having
 always, even at the very outset, found the se-
 rous fluid somewhat, however  slightly, augment-
 ed in  quantity, and  marked by its deep yellow
 tinge  and  its  increased  consistency.  There
 were, likewise, present those grayish or  yel-
 lowish points, the initial and quickly-expand-
 ing rudiments of membranaceous formations.
 "The so-called dry pleurisies  of Andral (Clin.
 Med., 4mo  edit, t. iv., p. 405)," he  continues,
 " are, therefore, probably to be understood  in a
 comparative sense only—effusion too scanty to
I be detected by physical signs  during life. Such
  a ground of distinction is, however, obviously
  opposed to the strict  principle of pathological
  anatomy."  The second stage has been viewed
[  as eminently that of effusion, which, although
  not confined to  any  one period, is  not suffi-
 ciently copious and  characteristic  to constitute
 a secondary and distinctive stage until the ori-
 ginal inflammation has become thoroughly de-
 veloped.  But to  divide the period of effusion
 into two  stages, and thus to attempt to  dis-
 criminate between  the development of liquid
 effusion on the one hand, and of coagulable
 lymph and adventitious membrane on the  oth-
 er, are discordant with the process which gives
 rise to these  productions.  The  third period
 has been  considered to be the organization of
 the  plastic  exudation.   This, however, does
 not  take  place at any particular stage, nor is
 it a process to which every form of plastic ef-
fusion is necessarily subject.  It would be dif-
ficult to reconcile, in this arrangement, those
pleuritic exudations which exhibit  traces of
organization after the  first twenty-four hours,
with those in which  the organizing powers  has
been ineffectually exerted for weeks or months.
While,  therefore, this division  might seem
justified in  some  instances by the procession
of morbid phenomena,  it would  in  others be
quite inapplicable.   It  would probably be pref-
erable to  consider the secondary changes m
pleurisy according to the  degrees  of intensity 
306             PLEURA,  INFLAMMATION
OF THE—Latent Pleurisy.
of the primary  inflammatory act, and  to the
rapidity with which they ensue upon this act.
  46. E. Pleurisy as above considered—whether
it be attended by little or no liquid effusion at
an  early  stage,  by a rapidly increasing and
abundant  effusion, or  by more or less organi-
zation of the exuded lymph—generally presents
a sthenic character, more especially when it oc-
curs primarily,  and in  a previously  healthy
constitution.  It then,  particularly in the young,
robust, plethoric, or sanguine temperament, is
accompanied with highly inflammatory symp-
toms, local and constitutional; runs its course
frequently with great  rapidity, and  evinces  a
greater  tendency to the  organizing or  forma-
tive process, even although effusion, to a great
extent,  may  rapidly supervene.  The sthenic
character may also exist, although in a much
less marked  degree, in more delicate or even
in  lymphatic subjects, especially when the dis-
ease  is primary, but  it is  then  attended by
much less fever and less severity of local suf-
fering, the symptoms  more nearly approaching
the  state of the disease next to be noticed.
The sthenic  character may  likewise be  evin-
ced in pleurisy consecutive of, or complicated
with, pneumonia,  hepatitis, pericarditis,  or
acute rheumatism, in all which, although  it
sometimes assumes more or less completely,
or approaches  to, the asthenic character, the
sthenic  is more frequently observed, unless in
the aged, the debilitated, and cachectic.
  47. iii.  Asthenic Pleurisy.—Pleuritis Ner-
vosa, Richter ;  Cachectic Pleurisy.—This form
of pleurisy is generally  met  with in persons
who have been debilitated by previous acute or
chronic diseases ; in   the cachectic, or those
subject to some constitutional vice ; in per-
sons whose constitutions are broken down by
intemperance and dissipation, and more espe-
cially in the course of other maladies in which
the circulating fluids  are contaminated  either
by the absorption of morbid matters, or by in-
terruption of any of the eliminating or depura-
ting processes.  It thus  not infrequently su-
pervenes  in the course of, or during convales-
cence from, typhoid or adynamic fevers, exan-
thematous fevers, puerperal fevers, erysipelas,
organic changes in the kidneys, phlebitis, dif-
fuse  inflammation, or spreading and  diffuse
suppuration,  and consecutive abscesses.   In
all  these, effusion  is  more  or less rapid, the
dry  stage hardly or not at all exists, and albu-
minous exudations either are not formed into
membranes and adhesions, or do not become
organized unless a  change is produced during
the course of the disease in the stales of vital
power and of vascular action.  Indeed,  in the
majority of cases of asthenic pleurisy,  the al-
buminous portion of the exudation is more or
less mixed with the serous  fluid, the fibrinous
or fibro-albuminous character not being present.
  48 This form of the  disease  is seldom at-
tended  by acute or painful local symptoms.  It
is  generally latent, and often  effusion is far ad-
vanced, or has long existed before the disease
is  detected.   It  is rarely a  primary affection,
is  most frequently associated with some other
disorder or structural change.  It is sometimes
very sudden in its occurrence, and indicated
at first  by the shortness and frequency of res
piration, by the position of the patient, and the
sinking of the powers of life, rather than by
local distress or pain, or by febrile symptoms,
which, if they  be  present, are  usually of an
adynamic character.  This  state  of pleurisy,
as may be expected from its nature and the
circumstances  in which  it appears, is always
removed with great  difficulty, or not removed
at all, especially if copious effusion has taken
place before it was detected.   It may supervene
in the course of the maladies just  mentioned
(v 47), and escape detection  until  dissection
after death discloses its existence, although at-
tention has been directed to its  contingent ap-
pearance, especially  when  the  effusion  has
been small, or when it has taken place shortly
before death.   I have thus met with it in the
last stage of malignant or infectious puerperal
fevers, in open cancer of the  mamma, conflu-
ent smallpox, &c.   I have seen albuminous ex-
udations covering the pleura in  some of these
cases, but the  serous  effusion was abundant,
and the membranes formed by these exudations
evinced no indication of incipient organization.
  49. iv. Latent Pleurisy.—Pleuritis Occulta,
Richter.—The term latent has been applied to
pleurisy when it takes place without pain in  a
situation where it can be referred to the pleu-
ra.   And this state of the disease is more fre-
quently associated with the asthenic than with
the sthenic character; or, in other words, as-
thenic pleurisy is much more frequently latent
than sthenic pleurisy.   M. Cruveilhier sup-
poses that this state of the disease is more fre-
quent than any other.   The numerous instan-
ces of adhesions between the opposite surfaces
of the pleura found on dissection of cases, in
which  no symptom of pleurisy  had  been com-
plained of, appears to justify this opinion.  Still
we often hear of instances of pain in the side
ascribed to  pleurodynia, or to rheumatism of
the intercostal muscles, where a more accurate
examination  may have detected  pleurisy. Be-
sides, pain is often present for a time, and ei-
ther overlooked  or forgotten, or ascribed to
some other than the real cause.
  50. Latent pleurisy may be either acuts or
chronic.  In  its latter  state, it will be  noticed
hereafter.  It may be either primary or consecu-
tive, or  associated with  some  other disease.
Pleurisy may be latent in either of two ways,
owing, 1st. To the absence of all pain whatev-
er.   2d. To pain being felt in some part remote
from the thorax, and suggesting the existence
of disease in some other quarter.  This second
form  of latent pleurisy has hitherto not been
noticed by writers;  but I have  met with sev-
eral instances of it, and recently with three ca-
ses which were  primary and  uncomplicated.
In all these the pain was referred to the iliac
region of the same side, no pain  being felt in
the chest, at any part, upon a full inspiration,
or when coughing, although it was  excited in
that remote situation.  In most cases of latent
pleurisy  there  are  chilliness, thirst, heat  of
skin, especially  in  the  trunk, dryness  of the
general surface ; and, as effusion becomes co-
pious, shortness of breathing, with  more or less
difficulty or oppression, upon  the least exer-
tion.  This form of pleurisy often  affects chil-
dren and old persons ; and in both classes of
persons it is frequently associated with catarrh
or influenza.   Indeed, so often is this compli-
cation met with in these subjects, that a care
ful examination of the chest should be made in 
               PLEURA,  INFLAMMATION

all cases of severe catarrh or influenza affect-
ing them.
  51. v. Partial Pleurisy.—Circumscribed or
partial pleurisy may occur primarily or consec-
utively  of other diseases, but much more fre-
quently in the latter than in the former state.
Circumscribed or limited pleurisy may also be
attended either with adhesions only, or with ef-
fusion, adhesions, however, of various extent
also existing in the latter class of cases.—A.
The adhesive form of partial  pleurisy is very fre-
quent, and is commonly consecutive  of tuber-
cular formations in the lung, of either of the
forms of pneumonia, and of inflammatory irri-
tation of any kind in the vicinity of the part of
the pleura becoming thus affected.   It is a very
usual  consequence  of tubercular depositions,
softened tubercles or cavities, when either ap-
proach to the surface of the lung, the pulmona-
ry pleura then becoming inflamed,  and throw-
ing out lymph which agglutinates it to the op-
posite  costal or diaphragmatic  pleura,  most
frequently to the  former at its  upper regions.
The pleuritic affection is in these  cases often
slight, but it is  seldom latent to the close ob-
server.  It  is generally indicated by more or
less pain, uneasiness or tenderness in or over
the part affected; by  a feeling of constriction
or tightness, by frequent superficial breathing,
and by diminished  motion  of the ribs  in that
situation ; somewhat  increased dulness on per-
cussion,  increased  pain  or uneasiness  upon
stretching or exerting the  adjoining muscles,
and a greater intolerance of a strong  percus-
sion over the part than in any other place, are
often, also, present.   The  pain is sometimes
sharp,  evanescent, and even so slight or brief
in duration as hardly to be noticed or recollect-
ed.  This form of partial pleurisy is often sal-
utary in its effects, in respect of the tubercular
malady, of which  it is so  generally a conse-
quence, inasmuch  as the  adhesions  between
the opposite pleural  surfaces prevent ulcera-
tion  and perforation of the pulmonary pleura,
and the  escape of  the tubercular  matter into
the pleural cavity.  Although this  state of the
disease is sometimes  latent, it is less frequent-
ly so  than has  been stated by some writers, it
being  rather overlooked, owing to the slight-
ness or evanescence of the  symptoms just men-
tioned.
  52. B  Partial pleurisy with effusion is  much
less frequent than the foregoing.—(a) It is com-
monly a  consequence of a more general state
of the disease, in  the course of which  adhe-
sions  have taken place between  the  opposite
surfaces  in one part, and effusion or even sup-
puration  in  another.   In some instances,  the
pleurisy attacks a  person who has previously
been the subject of this disease, and in whom
adhesions of greater or less extent already ex-
ist ; and this subsequent attack affects merely
that portion of  the  pleura  which  is non-adhe-
rent ;  the adhesions limiting the extension of
the inflammation, and bounding the liquid effu-
sion, or purulent formation.  Partial pleurisy,
accompanied with liquid  or puriform effusion,
may occur in any situation ; but its nature can
seldom be ascertained with any degree of cer-
tainty during life.
  53. (b)  The above observation applies to  in-
terlobular pleurisy, or inflammation, and  its con-
sequences affecting the  opposite surfaces  of
OF THE—Partial Pleurisy.            307

two corresponding lobes of the  lungs.  This
particular form of partial pleurisy is rarely pri-
mary,  but is  generally consequent  upon the
more general  state of the disease, or upon tu-
bercles in the lungs or pneumonia.  The vom-
ica, so  often  said to have  been  found in the
lungs,  have very probably been puriform col-
lections between the  opposite pleural surfaces,
circumscribed by adhesions,  in  this and the
preceding states of partial pleurisy.
   54. (c) The question has been put by M. Cru-
veilhier,  whether or not a costal pleurisy can
exist independently of a pulmonary pleurisy, or
the latter exist  without the former.  Bichat
believed that it could not, and contended that
the inflammation  always extended  from  the
one surface to the other continuously, or with-
out any interruption at the non-adherent parts.
I am convinced, however, that this  is not the
case, unless in the asthenic or spreading form
of the disease ; but that the inflammation origi-
nating in either surface is followed by an exu-
dation of lymph which acts as an irritant, when
brought in contact with  the  opposite surface,
and inflames  this latter; and  thus  inflamma-
tion, or adhesion, or even effusion, is often de-
veloped in  the opposite surfaces without  the
continuous extension  of the morbid action over
the intervening, non-adherent, or unaltered part
of the  membrane.
   55. It has  been supposed by some writers
that inflammation of the pulmonary pleura is
not attended by pain, and that pain is felt only
or chiefly  when the costal pleura  is implicated.
This  opinion  has been  considered  to derive
much  support from  the  different anatomical
connexions of the two portions  of  this mem-
brane.  This distinction, however, is by  no
means  determined; farther  and  more precise
observation is required before an opinion can
be given respecting it.
   56. (d)  Costo-pulmonary pleurisy may be  at-
tended by liquid, or sero-albuminous, or puri-
form effusion or  collection, limited by adhe-
sions  to  a  smaller or larger space, as shown
above  (Y 52).  The circumscribed purulent col-
lections—the  empyema necessitatis of various
writers—sometimes  met with, and  that point
externally,  are of this kind.
   57.  C.  Mediastinal Pleurisy.—This  form of
circumscribed pleurisy has been considered, as
far as  the subject admits of consideration, in
the  article  Mediastinum.  It is  unnecessary,
therefore, to add more at this place than to  re-
mark, that inflammation may originate in that
portion of the pulmonary pleura in contact with
the mediastinum, and extend to this latter,
forming adhesions  between  them, and giving
rise to liquid  or puriform effusion, which may
be  bounded by these adhesions.   In cases of
considerable duration, the liquid collection may
assume puriform and encysted  appearances.
The exact nature of these cases  is seldom ac-
curately ascertained  during life; for they are
most frequently  secondary  and  complicated
with pneumonia, or with tubercles in the lungs,
or even with  pericarditis.  The  symptoms of
this state of  the  disease, as far as they are
known, are  the same  as those stated in the ar-
ticle Mediastinum (v 3, et seq.).
  58. D. Diaphragmatic pleuritis is of frequent
occurrence, especially in the course of inflam-
mations of the liver and peritoneum,  and even, 
308            PLEURA,  INFLAMMATION OF THE—Chronic Pleurisy.
although much more  seldom, of the liver and
of the spleen.—(a) This  form of pleurisy may
be consequent upon  either acute or  chronic
disease  of these parts, especially upon  the for-
mer.  I have at another place (see Liver, y 41,
et seq.) remarked upon the  »ot unfrequent  ex-
tension  of inflammation from  the liver to  the
diaphragm and diaphragmatic pleura, and even
also to the costal and pulmonary pleura ;  and,
although this occurrence  is  sometimes met
with in  connexion with abscess of the  liver, it
also not unfrequently  takes place in the course
of sero-hepatitis, or in cases  of inflammation
of the superior serous surface of the liver, and
of partial peritonitis in the superior abdominal
regions.   I have met with  several cases of
acute sero-hepatitis in which the inflammation
rapidly extended to the pleura, the disease con-
sisting,  during the greater part of its  course,
of hepatitis complicated with pleuritis.
  59. It is very rare,  however, unless in cases
of this kind, that is, in those consequent upon
inflammation of some  one of the abdominal vis-
cera,  that pleurisy is  limited to  the diaphrag-
matic pleura;  and even  in those it soon  ex-
tends, more or less, to the pulmonary or costal
pleura of the same side  as that on which the
viscus first  attacked  is situated.  This  mode
of extension is not, however, always observed; !
for, in a case at this  moment attended by me,
but which I  did not see at its commencement,
there are chronic hepatitis, with tenderness in
the region of the liver, effusion into the perito- I
neal  cavity, and pleuritic effusion  into the left
pleural cavity, the heart being pushed towards
the right side  of the chest.
  60. (b) The symptoms of diaphragmatic pleu-
ritis  differ but little  from  those  of the more
usual states of pleurisy.   Generally, however,
when this portion of  the pleura  is more espe- J
cially affected, there are  acute pain, augment-
ed by inspiration, by  physical efforts, by vom-
iting, or even by the  eructations of flatus, and
seated at the base of the  thorax on either side,
or about the attachments of the diaphragm to
the  thoracic  parietes ;  anxiety,  difficulty of
breathing, or orthopncea,  the patient being obli-
ged to sit up,  with the trunk of the body bent
forward ; an anxious  and distressed expression
of the  features; sometimes nausea or vomit-
ing,  and singultus ; and  considerable sympto-
matic fever, occasionally with delirium.  When '
effusion is considerable, or collections of sero-
puriform or  purulent matter  are  present be-
tween the base of the  lungs and the diaphragm,
this latter is pressed downward, and considera-
ble fulness,  with dulness on percussion,  is ob-
served  in the  hypochondrium of the affected
side,  and thus the  semblance of an enlarged
liver or spleen may be occasioned.  When the
liquid collection  is completely circumscribed
between the  base of the lungs and the dia-
phragm, the diagnosis is usually difficult.   The
antecedent symptoms, especially pain or stitch
in the side, with symptomatic fever, ushered in
by rigours, will indicate the nature of the dis-
ease.  Complicated cases, however, may  oc-
cur in which  the diaphragmatic  pleura is af-
fected on the  one side, and the peritoneum, or
some infra-diaphragmatic viscus, on the other,
and be attended by great  difficulty of ascertain-
ing the  exact seat and extent of mischief;  but
a careful examination of the physical signs and
the symptoms during the progress of the dis-
ease, and  a due recollection of the fact that
inflammations not unfrequently extend  from
one side of the diaphragm to the  other,  espe-
cially from the peritoneal  to  the  pleural sur-
face, will  often aid the physician  in his  diag-
nosis.   In some cases of diaphragmatic  pleu-
risy of the  right  side, excessively acute pain
along the  margins of the right  side ; short,
anxious respiration, jaundice, protrusion of tho
liver downward by the fluid effused  between
the diaphragm and lungs, and much symptomat-
ic fever, were the most prominent symptoms.
  61. vi. Double Pleurisy.—a. Pleurisy  rare-
ly attacks both sides of the chest  at the same
time and  in a primary form ; but instances of
this double disease occasionally present them-
selves, especially in a secondary form, and con-
secutively of adynamic, or malignant, or of ex-
anthematous fevers, of erysipelas, or of those
states of constitution which have already  been
noticed as imparting an asthenic character to
pleurisy, more particularly morbid states of the
circulating  fluids.   In double pleurisy,  both
sides of the  thorax are not always affected to
an equal extent, nor are the inflammatory prod-
ucts always the same, in respect either of the
effusion or of the more consistent exudation.
One or other may be much more  abundant in
one side than in the other, and even be other-
wise modified or different; and very generally
the patient  is carried off, either  by asphyxia,
or by the  effect upon the  powers of life occa-
sioned by the extent of lesion, before effusion
has taken place in both pleural  cavities to a
great amount, or before the false membranes
which may have been exuded have presented
any advancement towards organization.
  62. b. The symptoms and signs of double
pleurisy, in most instances, readily evince the
extent of the disease.   In  some cases, howev-
er,  there  is difficulty in determining, 1st, the
existence of pleurisy; and, 2d, its presence in
both sides of the thorax.   When effusion takes
place, then the bronchial  respiration, aegopho-
ny, and the obscurity of the sound, can leave
no doubt as to the nature of the disease.  The
sound emitted on percussion  is  attended by
greater difficulty, because  the means of  com-
parison are wanting.  Pain  is not always a
certain symptom, as it may be wanting in ei-
ther side, although the amount of disease may
be even greatest in the side where it is not felt.
Generally, however, the  history  of the case,
the state of respiration, the positions of the pa-
tient, and the constitutional symptoms, viewed
in connexion wiih the physical signs, will  indi-
cate the extent of the  malady. This state of
pleurisy is much  more dangerous  than the or-
dinary forms ; indeed, the  patient may be car-
ried off by it, aided by some other associated
complaint, before  the  more  advanced  lesions
have supervened, and even before the amount
of effusion or the character  of the symptoms
had admitted of the recognition of the full ex-
tent of the malady.
  63. vii.  Chronic  Pleurisy. — Empyema.—
Pleurisy assumes  every grade  of severity, of
activity,  and even of duration.   It  may  be
most acute, as respects the degree of suffer-
ing, and the rapidity of its progress ; and it
may be most latent in its character, and  slow
in its course, and in the progress  of the  sue- 
PLEURA, INFLAMMATION OF THE—Chronic Pleurisy.            309
cessive changes attending and consequent upon
it.  Between the extremes  of these,  the in-
termediate grades of morbid action  and dura-
tion, and shades of character, are innumerable.
Ckronicity, therefore, in respect of pleurisy, is,
perhaps, more of a conventional  term  than as
regards almost any other malady.  The chronic
state of this  disease  is commonly consequent
upon the acute, when this latter has been either
neglected or improperly treated ; but it is also
sometimes primary, or rather the advanced or
prolonged state of a  pleurisy which  has com-
menced in a latent and silent, perhaps also in
a slight or sub-acute form, and  has  continued
thus to advance until the  amount  of  effusion
has given rise to phenomena such as have  been
described above ($ 30, el seq.), and as could not
be neglected any longer by the patient  or over-
looked by the physician.  Chronic pleurisy may
even be an  intercurrent malady, or  supervene
secondarily  in the course  of some  other  dis-
ease, although not so frequent as acute pleuri-
sy.  Thus it may occur in the course of chron-"
ic disease of some contiguous viscus, as of the
lungs, liver, spleen, peritoneum, stomach, &c,
or of malignant affections  of the mamma, or
diseases of the skin, &c.; while  the acute
states of pleurisy most commonly occur in the
course of malignant or adynamic, exanthema-
tous, and other fevers, or of inflammation of
adjoining organs.  Chronic  pleurisy may  thus,
as  well as  in  other forms  of succession, be
complicated with some other disease ; indeed, it
frequently  becomes  thus associated from the
very circumstances of its duration.
   64. Chronic pleurisy, in the state of full de-
velopment,  is attended by  great effusion of
fluid;  and to this condition, whether  it be the
consequence of a violent  attack, or of a sub-
acute, or of a latent  state  of the disease, the
term empyema has  been  given, although the
composition of the  fluid effused is often very
different from pus;  it  being more frequently
serous, sero-albuminous,  or sero-puriform,  or
 sero-sanguineous, as will  be more fully shown
 in the sequel.
   65.  Although  I  agree  with  Dr. Williams
 that the transition of the  acute  to the chronic
state is so indefinite, and  the symptoms of the
 recent disease  sometimes  have so little of  an
acute character, while  that of  a long duration
 occasionally manifests  so much greater an in-
tensity of irritation, that  the terms acute and
chronic would seem to be less applicable  to
pleurisy than to  other inflammations, still I
cannot consent that the distinction  in question
should be altogether set aside.   I readily, how-
ever, subscribe to the circumstance that  much
of the difficulty connected with this distinction
is to be ascribed to the anatomical relations of
the pleura :  this being a shut sac, it is liable  to
have its acute inflammations rendered chronic
by the retention of the inflammatory products;
and the chronic state is equally liable  to be ex-
cited into an acute state by the irritating and
distending  influence  of these products,  more
especially the fluid products. Still, differences
in character or form, in connexion with  dura-
tion, are very apparent  in many cases; in the
prevalence of  high inflammatory fever, severe
local suffering, and rapid progress in some ; or
in the absence of fever, or in the existence of
hectic or remittent  fever,  with but  little or
slight local suffering or  discomfort, and slow
progress or long  duration  in others ;  in  the
sthenic character of vascular action and vital
power in many; in the asthenic condition of
both action and power in some ; and in the va-
rying grades of pain, of irritation, and of sym-
pathetic disturbance in all.  These differences
can hardly be  described in all their phases of
existence as they are presented to our view in
practice ; but  they require to be pointed out in
such a way as will most remarkably fix our at-
tention, and render them safe  guides in devi-
sing our indications and means of cure.
  66. Effusion being the  characteristic condi-
tion of chronic pleurisy, as well  as of the  ad-
vanced state  of the  most frequent form of
acute pleurisy,  it follows that all that has been
stated above with reference to the latter (§ 24,
et seq.) is equally applicable to the former.  The
disease,  whether  denominated  acute pleurisy
with effusion,  or chronic pleurisy with effusion,
or empyema—or whether or not the liquid be
purulent,  or sero-albuminous, or of any other
description hereafter to be noticed—is attended
by the same local and physical phenomena and
signs, however much the  states of vascular
action, of vital power,  and of constitutional
disturbance may differ, in each case, with its
duration and  progress.  Chronic effusion, even
to the extent  of compressing the lung and dis-
placing the mediastinum, and  even the dia-
phragm, may  exist without distressing consti-
tutional symptoms, which may either have sub-
sided, or, in fewer cases, never existed.   Dr.
Stokes truly  remarks  that, if we separate the
physical signs, we find  nothing characteristic in
the  general symptoms alone.   Hectic may or
may not be present;  and no characters of the
cough, expectoration, respiration, decubitus, or,
with a single  exception, the appearance of the
patient, are sufficient  to distinguish  this from
 other diseases of the lung.   This exception is
 the dilatation of the side and  intercostal spa-
 ces.  But if,  in addition  to the  symptoms of
 pulmonary irritation and obstruction, as shown
 by cough, shortness of breathing, dyspnoea, in-
 creased by exertion, or by lying on  the affected
 side, and by a sense of fulness and oppression
 referred to one side, which is often  cedematous,
 the physical signs of  fluid accumulation, com-
 pression, displacement, &c, be also present, we
 may safely diagnosticate the disease.
   67. In certain cases the general symptoms
 are nearly wanting.   Instances are not rare of
 persons with copious effusion  of considerable
 duration to be without fever, pain, or local dis-
 tress ; to look tolerably well, and to have good
 appetites ; to lie  nearly equally well on either
 side, and even to pursue  their  usual occupa-
 tions, when these are not laborious.  The phys-
 ical signs are hence of the utmost importance
 in chronic pleurisy ; indeed, of greater value in
this than in any other thoracic disease.  Most
cases of bronchitis,  of pneumonia, and  of
phthisis can  be,  at least, recognised,  as Dr.
Stokes remarks, without these aids ; but such
is not the case with  pleurisy ;  and it is fortu-
nate that its  physical signs are more  simple,
numerous, and striking than those of any other
of the complicated diseases of  the  lung.
  68  When  chronic pleurisy is not  accompa-
nied by much fever or pain, the patient may not
be obliged to  keep his  bed.  He complains only 
310
PLEURA,  INFLAMMATION OF THE—Chronic Pleurisy.
of shortness of breathing on exertion ; and he
often pursues his usual occupations.  He mere-
ly believes himself indisposed, and  considers
that he is not the subject  of  serious disease,
until  the pallor  and emaciation  of his  fea-
tures, the general loss  of strength  and flesh,
the coldness of the extremities, the short, sup-
pressed cough, the frequent and short respira-
tion, increased on the least exertion or mental
emotion; the loss of -appetite, the rapidity of
his pulse, especially during evening exacerba-
tions, of hectic ;  and the inability of lying on
any other than the same side, attract his no-
tice, and direct the attention of the physician
he consults  to the  nature of his complaint.
These symptoms having suggested the seat of
the mischief, an examination of the chest read-
ily discloses  its nature and extent.
   69.  B.  The physical signs of chronic pleurisy
are those already described (§ 26,  et seq.) as
evincing extensive fluid accumulation  in the
pleural cavity ; but they become,  with several
of the general symptoms, much modified by the
duration of the effusion, and by the  changes in
the pleura and lung.  The state  of the liquid
effusion also modifies the course  and phenom-
ena of the disease; and hence  it is necessary
to notice briefly those changes which thus influ-
ence the character of the malady.  When pleu-
risy has continued for some  days,  alterations
take  place not only in the more consistent exu-
dation, but also in the fluid effused.   These al-
terations depend much upon the diathesis of the
patient, and the states  of vital power and vas-
cular action ; and although some  of them may
be inferred to be present by the symptoms and
 signs during life, yet others are, owing to their
 nature, incapable of being indicated until dis-
 closed after death.
   70. (a) In healthy, young, and robust per-
 sons, lymph of a highly organizable quality is
 thrown out upon the inflamed surface, of great-
 er or less thickness, with a  serous effusion ;
 and this lymph, forming a layer, or  false  mem-
 brane, over the surface,  although  diminished
 by absorption, becomes more dense as it is or-
 ganized, and thus restrains the expansion of
 the lung, and impedes the absorption of the ac-
 cumulated serum.   In cases where the  mem-
 brane is less dense or  thick, the  expansion of
 the lung and the absorption of the fluid may
 proceed, especially when vital power is not de-
 fective, until ultimately the fluid is removed,
 and the lung acquires very nearly or altogether
 its natural expansion.  In this case adhesions,
 cellular, partial, or otherwise, may  form, and the
 functions of the lung not be materially impeded
 (see fj 115).
    71. (b) In  other cases, by  no means differ-
 ent  from the above, or varying only in  the
 states of vital power and vascular action, and
 generally  of a less active  inflammation and
 more prolonged duration, organization proceeds
 slowly, and  the false membrane  is of a more
 dense  and  rigid nature.  Consequently,  the
 lung is prevented  from expanding, even al-
 though the  fluid effused  be  partly  or nearly
 altogether absorbed.  In many cases, especial-
 ly in those of considerable duration, the false
 membrane  covering the lung shrinks  or con-
 tracts  in its superficial extent, in the manner
 stated when describing the changes consequent
 upon peritonitis, or like cicatrices after  burns
of the skin, and thus not  merely prevents the
expansion of the lung, but actually compresses
this organ still more closely.  In more chronic
cases the membranes formed on the pleura as-
sume a  state of cartilaginous induration, ot
become more or less  extensively ossified, or
they may be  cartilaginous in parts and ossified
in others.  These changes  often coexist with
the  shrinking  just  noticed,  and  are to be
ascribed in part, in some cases at least, to the
irritation produced by the effused fluid on the
surfaces enclosing it.
   72. (c) In  some  cases, when the vital ener-
gy is insufficient to enable the inflamed surface
to throw  out a readily organizable  lymph, the
exuded matter assumes a curdy appearance, of
greater or less thickness, almost solely albu-
minous, and  presents much less  of a fibrinous
character than in the foregoing cases ; and the
fluid part of the exudation is turbid, or contains
loose shreds or pieces  of albumen (see I) 116,
 117).   In some instances a false  membrane of
'some density is  found  covering  the  inflamed
surface, but  it is imperfectly organized, or pre-
sents no traces of organization.   In  other ca-
 ses, a coating of albumen, without adhesion or
 organization, covers the  pleura,  the fluid  effu-
 sion being turbid, serous, or sero-albuminous,
 or otherwise changed or coloured, according as
 colouring particles of the blood may be exuded.
 This class of cases is more frequently of much
 shorter duration  than the  foregoing classes,
 are always  asthenic, and are more closely al-
 lied to the acute asthenic form of the disease
 (§ 47),  being more prolonged instances of that
 form.
   73. (d) The albuminous  or nutritive matter
 may be  thrown out in a more  diffused form
 with the serum;  or the  formative  process,
 characterizing so frequently inflammations of
 serous surfaces, may be still less exerted, and
 a puriform,  or sero-puriform fluid only be pro-
 duced.   It is probable that, in some instances,
 when the immediately preceding  state (I) 72) of
 the disease is much prolonged,  the sero-albu-
 minous exudation may pass into a puriform oi
 sero-puriform state. This purulent state of the
 effused  fluid appears  most frequently in the
 most chronic cases, but it also  is sometimes
 observed in the most  acute, and is that to
 which  the term empyema is strictly applicable.
 It depends rather upon the state of vital power,
 or the diathesis of the patient, in  connection,
 probably, with the condition of the blood, than
 upon  the duration  of the  disease.   Dr.  Wil-
 liams very justly remarks, respecting this state
 of the disease, that •' the solid matter is thrown
 out in  a  disintegrated state, utterly insuscepti-
 ble  of organization, and  diffused through the
 fluid in flakes or particles, forming a mixture
 more or  less resembling pus, which is the fluid
 or empyema.  Although in many instances this
 is the result of a more chronic form of pleurisy
 than that which forms lymph, and owes its per-
 sistence  and tendency to increase to the want
 of vitality in its solid matter, yet we do meet
 with cases of empyema which arise from very
 acute forms of inflammation.  In these instan-
 ces the fluid is more strictly purulent, the solid
 matter being in the  form of globules, like those
 of pus, and seems to be the result of what may
 be  called a suppurating diathesis, in conse-
 quence of which all the albuminous products of 
PLEURA, INFLAMMATION OF THE—Chronic Pleurisy.
311
inflammation  tend to assume a purulent char-
acter."  It should be remarked, also, that the
continued  access of air will cause the inflamed
pleura  to  secrete pus instead of coagulable
lymph, this membrane being  similarly influ-
enced by this cause to other tissues.  When-
ever pleurisy  is consequent  upon perforation
of the  lung, the  effused  fluid is always puru-
lent.
  74.  (e) The other  lesions which are contin-
gently  associated with chronic pleurisy, espe-
cially  the  tuberculous, schirrous,  encephaloid
or fungoid, and melanotic,  generally proceed
from  their respective constitutional  taints :
they will receive due consideration hereafter.
  75.  It is obvious that the above states, into
which  the lesions of chronic  pleurisy may be
divided, are not precisely defined in  all  cases;
but that instances occur, owing to changes of
vital power and vascular action in their course,
in which intermediate conditions, or transitions
from one state to another, may be found on close
examination.   The truth  is, that  in many in-
stances, even after the acute action  has subsi-
ded to the chronic state, the retained effusion,
owing to the nature and combination of the sev-
eral elements, may rekindle  an acute or sub-
acute  state of action, or keep up  a  continued
irritation,  which cannot fail of producing a va-
ried series of changes not only in the  false
membranes, but also in the pleura itself and the
subjacent  tissues;  and that  the effused fluid,
as well as the surrounding structures, both nat-
ural and adventitious, will consequently under-
go changes varied in numerous ways, although
most frequently presenting the general features
now pointed out, and those about to be more
minutely described (§ 118, et seq.).
  76.  In some cases the condition of lesion, in
respect both of the move consistent exudation
and of the fluid accumulation, may be predica-
ted during life from the  indications of vital
power and vascular action furnished by the pa-
tient.  "Thefir.it and second of these conditions
($  70, 71) are generally attended by  a more
Bthenic state  or diathesis,  by less  failure of
constitutional power, and a stronger grade of
vital resistance.  The third (() 72) is accompa-
nied with more marked asthenia ;  with greater
depression of vital energy and resistance than
the first and  second; with more or less of a
cachectic appearance, or of a morbid condition
of the circulation.  The fourth (§ 73) of these
conditions, or that to which the term empyema
is more strictly applicable, is generally attend-
ed  by  hectic of a marked  character, by night
perspirations, and  often by various pulmonary
symptoms in  connexion with physical signs of
accumulation of fluid in the plural cavity.
  77.   When we reflect upon the effects conse-
quent upon the retention of the products of in-
flammation in the pleural sac; upon the con-
stricting action  of the  organized  false mem-
branes on  the lung ; upon the irritation caused
by the nature of the fluid effusion, and the con-
sequent resuscitation of inflammatory action in
acute or subacute states, extending more or
less to the parenchyma of the lungs ; upon the
influence  of constitutional  diathesis and taint
upon the states of vascular  action and adven-
titious productions ;  and upon the numerous
contingencies, intrinsic  and  extrinsic, moral
and physical,  to which the patient is exposed,
we may readilv infer that chronic pleuritis, if
not soon remedied, must necessarily be follow-
ed by farther alterations, not only of the adven-
titious formations, and of the consistent and
fluid deposits in the pleural cavity, but also of
the lungs,  bronchi,  pericardium, and parietes
of the chest.  These successive alterations  all
tend to  impede absorption, and thereby to per-
petuate the disease ; and are the most impor-
tant  lesions which complicate  the  advanced
course of the more unfavourable cases of chron-
ic pleurisy.   Nevertheless,  absorption  does
take place in many instances—sometimes even
in prolonged cases, especially when vital pow-
er and resistance are tolerably maintained, and
when the consecutive lesions, or complications,
about to be noticed are not developed.
  78. C. Signs of Absorption of the Effusion.—
(a)  Many of the cases of acute and subacute
pleurisy recover without contraction of the side
or depression of the shoulder, such as will  be
noticed  hereafter; but  in these cases the  ef-
fusion is more or less readily absorbed.  It  is,
however, comparatively rare  for the fluid to  be
removed, in the more chronic cases,  without
these changes in the appearance of the affected
side being  observed.  When  the lung is bound
down or constricted by the false membranes,
as stated above (() 71), or when it is  so con-
densed  by  long-continued pressure, or by the
extension of inflammation to its parenchyma,
as no longer to be  capable  of expansion, the
removal of the fluid accumulation by absorption
necessarily occasions, owing to the atmospheric
-pressure, more or  less contraction of the affect-
ed side, which, instead of being enlarged be-
yond the size of the healthy side, now gradu-
ally becomes smaller—sometimes very remark-
ably smaller, than that side.   The contraction
appears at first in  the upper part of the chest;
the  shoulder being  depressed,  and,  with the
whole side, much more fixed  than the  sound
side, which presents the  full development and
active motions of  respiration.  As the diseased
side contracts, the ribs approach closer togeth-
er, and sink lower; the scapula is more prom-
inent, and nearer the  spine;  and  the  sternum
and spinal column are somewhat curved, so as
to be concave  on  this side.   While the upper
parietes of the diseased side are thus pressed
inward,  the lower walls are similarly affected  ;
the  diaphragm is  carried upward, and with it
the liver, or the stomach and spleen, according
as either side is affected.  In cases where  the
absorption  has proceeded  far, or has  taken
place long  previously, more  especially in chil-
dren and young persons, the healthy  lung  be-
comes so expanded or developed from its aug-
mented  function as to  press  the mediastinum
over into  the affected  side,  and thus even to
prevent a still  greater  contraction of the side
from occurring.  Cases  are not very  rarely
seen in which the heart has been thus pushed
either to the right  side,  or  drawn upward to
the left, owing to  the two causes of absorption
of the effusion in the  side  toward which  the
heart and  mediastinum are drawn, and  of  ex-
pansion of the lung in the sound side.   In cases
of this kind, the displacement, instead of bein"
the result  of liquid  effusion, or of a collection
of air or gas pushing these parts to the  sound
side, is caused by the  removal of fluid from  the
affected side, in the manner now pointed out. 
312            PLEURA,  INFLAMMATION OF THE—Chronic Pleurisy.
In a few instances, as remarked by Dr. Stokes,
the contraction is confined chiefly to the lower
portion of the side, the shoulder not being ma-
terially depressed.   In  those  instances, occur-
ring in young persons, in which the sound lung
becomes much expanded, the deformity  often
is much diminished in process of time.
  79.  M. Laennec has insisted strongly on this
termination being most frequent after what he
terms the hamorrhagic pleurisy, or that state of
acute  pleurisy in which the fluid effusion is very
great,  and more or less tinged  with blood-
globules,  and  which  often  becomes  chronic
owing to  the slow removal of the  fluid.  Al-
though contraction of the chest is most apt to
accompany the cure of the most severe cases,
or those in  which the effusion has been the
greatest  or  most  prolonged, yet  it is by no
means confined, as Laennec supposed, to  those
cases  which he  denominated haemorrhagic, or
even most frequently consequent  upon these;
for, as Dr. Forbes has remarked, it is a  com-
mon consequence of the removal of all fluid ef-
fusions of considerable duration, and  of  puru-
lent collections in the pleural cavity;  " and, if
other  evidence were wanting, we have it in the
analogous contraction  in chronic pneumonia
and phthisis."
  80.  In some instances the contraction con-
sists chiefly of a flattening of the  anterior por-
tion of the side, causing more  deformity than
diminution of size.  In others, the affected side
approaches  somewhat to a  triangular  form,
" the base of the triangle corresponding to the
mesial line, and the apex to the centres of the
ribs."  One of the first signs of absorption with
contraction is the increased prominence of the
inferior angle  of  the  scapula.  Dr.  Stokes
thinks it likely  that the paralysis  of the  inter-
costals and diaphragm, which he believes to ac-
company pleurisy, has  an immediate  effect in
producing the  subsequent contraction, by pre-
venting the expansion of the  side.
  81.  The condition of the side  of the  chest
changing  thus  from that of dilatation, conse-
quent upon the effusion, to that of contraction
caused by the removal of the fluid, it may be
supposed  that the transition from the one to
the other  will  not be indicated  by the form of
the chest; and this is really the case in  some
instances, although in the majority the transi-
tion is not uniform, but partial.  More frequent-
ly the contraction commences at the upper part
of the thorax before the dilatation and displace-
ment  have entirely disappeared at  the lower.
An  irregularity of the shape of the affected side
is hence often  observed during the removal of
the effusion  by absorption, the upper parts be-
ing unusually  contracted or  depressed,  while
the lower are  more or less bulged  or  dilated.
This appearance assists  in the diagnosis be-
tween consolidation of the lung and progressive
absorption.of a pleuritic effusion, for which this
latter  may be mistaken.
  82.  But the  effusion into the pleural cavity
may not be to the extent of filling this cavity  ;
it may be  partial only, or limited by adhesions
and false membranes, as above described (v 52).
In these cases of partial adhesions, the  walls
of the chest cannot so contract as to accommo-
date themselves to the vacuities caused by the
removal of the fluid.  Sometimes slight or ir-
regular contractions may take  place;  but the
spaces are chiefly occupied by a partial rising
of the diaphragm, and expansion of the healthy
lung on both sides ; and most frequently a por-
tion of the more consistent or albuminous con-
tents of the effused fluid still remain, present-
ing a curdy or semi-solid state, which is  prob-
ably ultimately removed when the patient per-
manently recovers.
  83. b.  The auscultatory signs furnished by a
side contracting after chronic pleurisy are of
importance, inasmuch as during the progress of
the contraction the  disease may be mistaken
for  chronic pneumonia, or consolidation of the
lung, or for tubercular diseases of this organ,
or even for enlargement of the liver.  In many
cases,  especially when  the effusion  has  been
copious and of long duration, the sounds of res-
piration and percussion continue permanently
imperfect, even although the fluid may he com-
pletely removed, and they are universally more
or less impaired for months after the  attack.
They thus correspond with the diminished mo-
tion of the affected side, and are owing to the
same lesions.   Dr. Williams  correctly states
that an improvement is generally indicated first
in the upper part of the chest, and near the
spine.   With the return of a weak respiratory
murmur, and slight  resonance on percussion,
some degree  of vocal resonance may also ac-
company the removal of the fluid in  the upper
parts of the chest, " amounting to loud bron-
chophony, often accompanied with a remark-
able buzz; in other parts being merely the dif-
fused vocal fremitus, according to the size of
the bronchial tubes, and the degree and perma-
nence  of their compression."  In some cases
of this kind  some of the  physical signs may
mislead, if attention be not paid  to all these
signs, and to the  history  of the case; for, as
remarked by Dr. Stokes and Dr. Williams, if
at the  first time we see a patient with the above
signs,  and he  happen  to  have bronchitis, we
may be induced to believe that the resonance
of the  voice and the  dulness are caused by con-
solidation from recent inflammation of the lung,
or from  tubercles; but  this error will be pre-
vented by attending  to the history of the case
and the appearances of contraction.  The dul-
ness on  percussion  of the contracting side is
owing both to the falling inward of the thoracic
parietes and to the absence of air in the com-
pressed lung.   The  physical conditions of the
lung and of the wall of the chest are much
changed in this state of the disease; for both,
especially the former, owing to the loss of their
resiliency—the lung  being constricted by  false
membranes, and compressed by the effusion,
and thereby in great  measure deprived of air;
and the parietes of the thorax being insufficient-
ly antagonized  against the pressure from with-
out by the much-diminished supply of air to the
lung—are incapable of furnishing not only the
usual sounds on percussion, but also the true
indications of their existing states, unless by a
strong pressure of the  fingers, which are the
media  of percussion against the walls of the
chest, and by varying the force, direction, &c,
of the stroke.
  84. Recovery from chronic  pleurisy,  with
contraction of the  chest, is  more or less com-
plete according to  the reduction that has been
made in the size and functions  of the lung by
the  previous lesions.  The recovery is rarely 
PLEURA, INFLAMMATION OF THE—Chronic Pleurisy.
313
so complete in persons advanced in life  as in
the young.   In children, placed otherwise in
favourable circumstances, and in  young  per-
sons, recovery is often not only complete, but
little or no inconvenience is caused by the con-
traction, which sometimes  diminishes,  espe-
cially in growing persons, owing to the increas-
ed development of the healthy lung.  Some in-
dividuals, who have their sides contracted from
the state of the disease, have continued to en-
joy good health, and  to pursue active occupa-
tions.  Laennec has alluded to a distinguished
surgeon in Paris who had his side remarkably
contracted by pleurisy in his youth, and yet en-
joyed excellent health, and was in the habit of
lecturing twice a day without inconvenience.
In most instances thus occurring in young sub-
jects the contraction  is not excessive, and the
respiratory murmur is not altogether abolished.
But in  a greater number of cases, particularly
those occurring in advanced  life, contraction
of the chest occasions such an habitual short-
ness of breath and tendency to palpitation as
to incapacitate the subject of it from active ex-
ertion.  Persons thus circumstanced also ex-
perience distressing  dyspnoea, and otherwise
suffer most severely from slight bronchial at-
tacks, from catarrh, and febrile affections. Dr.
Williams very justly remarks, that before the
system becomes accommodated to the abridg-
ment of respiration which this lesion produces,
and  even afterward, under unfavourable cir-
cumstances, there is  an enfeebled or cachectic
state of the whole  frame, in which  various
trains of disorder may arise ; and unless care
be taken to counteract them by the means most
favourable to the general health, scrofulous or
dropsical disorders may be engendered, and de-
velop new mischief in the respiratory  organs
or elsewhere.  Although, therefore, contrac-
tion of the side of the chest may be viewed as
a mode in which pleurisy may be cured, " it  is
one of the least favourable kind, and liable to
many detracting circumstances."
   85. D.  Empyema.—In those cases in which
the effusion is not removed by absorption, or in
which the morbid secretion or effusion  equals
or preponderates over absorption, the accumu-
lated fluid  is productive of changes ultimately
of a fatal tendency, if it be not evacuated either
by a spontaneous perforation  of the pleura, or
by an operation.  The persistence and charac-
ter of the accumulated fluid  are to be ascribed
rather to the continued inflammation and change
of structure of the  pleura than to any other
cause.   The nature of the matter effused, its
purulent  character  more especially,  also fa-
vours the accumulation or impedes absorption.
Something, also, may be imputed to a congested
Btate of the lung, to tubercular infiltration, or
to consolidation of its structure.  When the
circulation through the heart  or blood-vessels
is obstructed, the cause of increasing fluid ac-
cumulation is more manifest.
   86. a. The signs and symptoms  of empyema
are nearly the same as those already described
in connexion with very copious liquid effusion
into the pleural cavity ($ 26,  et seq.).  In this,
however, the more chronic state of disease, the
accumulation of fluid, proceeding more slowly,
generally is greater, and is attended by a more
marked displacement of the walls of the chest,
and of the viscera more immediately adjoining
them.  Although the more urgent symptoms
have  in great measure subsided,  particularly
fever, dyspnoea,  and pain, yet the enlargement
of the side, and the displacement of the pari-
etes,  are  often  the more  remarkable.   The
slow increase of the accumulation, the prolong-
ed pressure, and, probably, as Dr.  Stokes con-
tends, the paralyzed state of the muscles bound-
ing the effusion, favours the greater amount of
fluid collection in this class of  cases  than in
most others.   The duration of the disease, the
side which is affected (more frequently the left),
the nature of the associations or  complications,
and the temperament and diathesis of the pa-
tient, modify both the extent and the phenomena
of the accumulation, more especially the extent
of enlargement of the side and visceral dis-
placement.  There is no certain indication usu-
ally  furnished of the  purulent  nature of the
fluid.   When rigours or chills recur, with hec-
tic, a soft, open pulse, perspirations,  or even
when these last  are very  prominent, there is
great probability of the  fluid being purulent;
but these symptoms may be either but  slight
or nearly wanting.  Protrusion of the  inter-
costal muscles is considered by Dr. Stokes and
Dr. H. Roe as more especially diagnostic of a
purulent state of the secretion.
  87. b. When the fluid  is purulent, ulceration
and perforation may ultimately attack the pleura
at some point, and permit the fluid to be evac-
uated in a direction, according to the seat of
the ulceration—either through the lungs, the
walls of the chest, or the diaphragm ;  causing
parts through which the evacuation takes place
to be involved and more or less affected.  Gen-
erally, the perforation  of the pleura is conse-
quent upon excavations in the layer of organ-
ized or semi-organized lymph coating this mem-
brane ;  and sometimes death occurs before the
perforation has become complete,  or even pro-
ceeded farther  than  this  false membrane.
When, however, the pleura is  perforated, the
 structures external to the ulcerated point in the
 pleura  also become inflamed  and ulcerated,
 and the accumulated matter makes its way in
 the direction of the ulceration, often burrowing
 between muscles or tendons, and even causing
 caries of the adjoining bones, as the vertebrae,
 ribs, or sternum.
   88. Laennec  and Hasse considered the per-
 foration of the pulmonary pleura and discharge
of the  matter of empyema by  the lungs and
 bronchi of more frequent occurrence  than per-
 foration of the walls of the chest.  Dr.  Will-
iams doubts this, according to his own experi-
ence ; and I think with good reason, as regards
the  whole parietes of the chest—costal and
diaphragmatic.   When the matter is  discharg-
ed by ulceration through the lungs and bronchi,
there is generally a violent fit of coughing, re-
sembling  or accompanied  with  vomiting, and
attended by a copious expectoration or evacu-
ation of it;  the efforts, together With the quan-
tity discharged, threatening suffocation ; but
remarkable alleviation of all the  symptoms, and
diminution of the  evidence of dilatation and
displacement, are the  results.   Dr. Townsend
describes the  ulceration through the lungs and
bronchi, in these cases,  as being preceded by
the formation of a gangrenous eschar, which is
detached, the  fistulous passage being lined with
a false  membrane, which prevents the matter 
314       PLEURA, INFLAMMATION OF THE—Complications of Pleurisy.
from infiltrating the substance of the lung, and
conducts it to the air-tubes (see i) 125).
  89. When  the ulceration of the pleura com-
mences, and  proceeds in a situation favouring
the pointing  of the  matter externally, a soft
fluctuating swelling is felt at some part of the
chest;  and it may generally be presumed to com-
municate  with the pleural cavity by its becom-
ing tenser during expiration,  and softer during
inspiration, or by a sort of fluctuation caused
by coughing.   Dr. Williams remarks, what I
have also  seen in several instances, especially
in children, that the matter  not  uncommonly
burrows under and between  the muscles and
integuments of the chest, and points at several
places, and at a distance from  the perforation
of the pleura.   He has seen abscesses connect-
ed with empyema point in three  cases under
the pectoral muscle, once in the right hypochon-
driac region, and once close to the spine.  That
in the hypochondriac region had been mistaken
for an abscess of the liver : in this case it was
found,  after death, that there  were three perfo-
rations of both  intercostal  muscles  and dia-
phragm ;  and between the layers  of the latter
the matter passed to the margins of the ribs,
and there  spread under the integuments, com-
municating with the other perforation between
the ribs.   In  a case of empyema in the son of
a medical  friend, aged about six years, the mat-
ter was discharged near the margins of the right
false ribs, and the  boy recovered, and is now
well, at the age of fifteen.
   90.  The  superficial  abscesses consequent
upon perforation of the  pleura are sometimes
tender and painful;  but they are  occasionally
also neither the one nor the  other.  They are
generally  slow in their progress to the forma-
tion of an external opening;  usually spreading
between   the  muscles  and  integuments, and
causing a  diffused or puffy tumour.  When  an
opening is at  last formed, there is a more or less
copious discharge  of matter, that recurs from
time to time, especially during a forced expi-
ration, or  during coughing.   " Sometimes air is
drawn in  through the  orifice during full inspi-
rations, and the next jets of matter issue with
greater force, occasionally mixed with bubbles
of air."  After air is admitted into the diseased
cavity, the pus, which was at first inodorous,
generally  becomes in  a few days more and
more fetid, and exhales the odour of sulphu-
reted hydrogen.  With this change in the dis-
charge, or, rather, as a cause of this change, the
constitutional symptoms  assume  an  asthenic
and  irritative character.  The pulse  is  much
more accelerated ; is quick and irritable ; soft,
open, and sharp;  and the skin is alternately
hot or burning, and bathed  in  a colliquative
perspiration.   The  bowels  become  irritable;
and general depression and asthenia, with irri-
tative  fever  and rapid emaciation, soon carry
off the patient.
  91. The matter of empyema may be discharg-
ed by a fistulous opening, either uninterrupted-
ly or at intervals, with more  or less temporary
relief.  The  recurring  discharge may exist for
weeks, often for months, and, in rarer instan-
ces, even for years; the patient  occasionally
recovering, but much more frequently sinking
from the extent and nature of the disease.  Re-
covery is  oftener seen in the young than in per-
sons even moderately far advanced in life ■ and
when it is likely to take place, the discharge
soon becomes less, and either does not present,
or loses,  its  fetid  character.   The external
opening closes, and  the side becomes  con-
tracted, as already described (v 78, et seq.), res-
piration partially returning in some portions of
the chest.
  92. D.  The terminations  of  chronic  pleurisy
may be readily conceived from what has been
already stated.  The duration of this state of
the disease varies from  six weeks to a year,
or even much more, when it terminates either
in recovery or in death.—(a) Recovery often takes
place after a gradual absorption of  the effused
fluid and of the albuminous exudations, or after
the organization of the latter into  false mem-
branes.  This mode of termination is evinced
by the signs  mentioned above, and by the de-
pression and contraction of the affected side ($
78).—(b) Recovery much more rarely occurs by
the evacuation of the accumulated fluid through
a perforation of the pleura, and a fistulous open-
ing, either in the lungs and bronchi, or in the
thoracic parietes (§ 88).—(c) Death is frequent-
ly caused,  1st. By the general  exhaustion and
hectic attending the  disease, especially when
the accumulated fluid is puriform, or when the
substance of the lungs is consolidated or tuber-
culous : in these cases the patient sinks in the
same  manner  as in  tubercular consumption;
2d. By the sudden asphyxia of the  patient: in
these, sudden attacks  of  dyspnoea,  almost
amounting to suffocation, sometimes are com-
plained of, at intervals, before the fatal seizure;
these attacks often occur during the night, and
may return almost nightly.  Death may take
place very nearly as  suddenly  as from disease
of the heart, and may be thus mistaken for death
from this cause, if the history of the disease be
not known or ascertained.
  93. III. Complications of Pleurisy.—Pleu-
risy, in either of the states  described above, is
very  frequently a primary and simple disease.
But it is also often associated with inflammation
of an adjoining tissue or organ, or with some
other  lesion  or  malady.   In  this  complicated
state, it may be either the primary  or the sec-
ondary disease; the exact  condition and suc-
cession being of importance in respect both of
the prognosis  and  of the  treatment.  I will,
therefore, notice some of the more frequent com-
plications of it observed in practice;  and, in
some  instances, a  mere  notice is  all that is
necessary, as the suggestion of the associations
which the disease so often presents will put the
physician  on his guard, when he will not fail of
detecting  it.—a. Pleurisy in any form, but more
especially in the acute, is often associated with
inflammation of the substance  of the lung, forming
pleuro-pncumonia, described in the article Lungs
(§ 73-75), or pleuro-pneurnonilis, peripneumonia,
or peripneumony, of various writers.  It is un-
necessary  for me  to notice this  complication
farther at this place, than to add that the in-
flammation,  in these cases, most commonly
assumes a sthenic character, although the as-
thenic state is occasionally also met with ; and
that,  although both  diseases, or, rather, the in-
flammation of the two different structures, may
be coetaneous as well as coexistent,  yet the
pleuritic is more frequently  consecutive of the
pulmonic  affection than the pulmonic is of the
pleuritic.   This may be owing, in great part, to 
PLEURA, INFLAMMATION OF THE—Complications of Pleurisy.        315
 the nature of the tissues, and of the connexion I
 existing between them ;  but it is more probably I
 owing to the general tendency of inflammations
 of parenchymatous organs  to  extend to the
 periphery.
  94. b.  Pleurisy,  either in  a simple form, or
 associated with pneumonia or with  bronchitis,
 is one of the most important complications of
 exanthematous and  continued fevers.   When  it
 is the complication or associated local affection
 in these  constitutional  maladies, it  is always
 acute, unless when  it  appears in the course
 of convalescence from  either of them ; and  it
 presents  the same characters or  diathesis, in
 respect of vascular action and vital power, as
 these possess;  but the  asthenic, in its various
 grades, is the most common, especially if it su-
 pervene  at an advanced period of  the fever,
 when the vital energy is depressed or exhaust-
 ed, and when the circulating  fluids are morbid
 or contaminated.  Whenever the breathing is
 very short and frequent, with or without cough
 or pain in the side or chest,  in these diseases,
 then this complication should be suspected, and
 a careful examination be  immediately institu-
 ted, as  the  progress of the  local mischief is
 generally rapid when it occurs in the course
 either of these or other constitutional maladies.
  95. c.  Pleurisy, generally  of an  adhesive
 form, and of chronic duration, very frequently
 accompanies tubercular consumption and chronic
 tubercular pneumonia.   This  pleurisy is  gen-
 erally the consequence of  the  irritation or
 chronic inflammatory action occasioned by the
 tubercular deposites in the  lungs,  especially
 when these  exist  near  the  surface, or when
 the tubercles soften in  that  situation, and are
 followed  by cavities.  In these cases the pul-
 monary pleura becomes implicated in  the in-
 flammatory  action in the immediate vicinity,
 throws out lymph on its free surface, which ex-
 cites  a corresponding morbid action  in the op-
 posite part of the costal pleura, and forms close
 and firm adhesions between  the lung and walls
 of the chest.   This state of chronic  or  sub-
 acute pleurisy is most frequently observed near
 the summits of the lungs or upper regions  of
 the thorax ; is most commonly attended by ad-
 hesions,  without fluid effusion ;  or, if such effu-
 sion occur, it is soon absorbed (see  <$ 120).  In
 some cases, however, tubercles soften and cav-
 ities form near the surface of the lung, and per-
 forate the pulmonary pleura at the nearest point
 to them,  without giving rise to  adhesion to the
 opposite  surface.  In these,  fluid effusion often
 takes place before  the perforation  is completed,
 and air passes into the pleural cavity, giving
 rise to the  lesion denominated pneumothorax,
 which is  fully considered in another place.  The
 association  of  pleurisy with tubercular con-
sumption is more fully considered in the article
on this latter malady.
  96. d Pleurisy  is  sometimes complicated with
 pericarditis.   Generally the pericarditis  is of
 the dry form, in  which it has been remarked in
 several instances by Dr. Stokes.  In two ca-
 ses, to which I was called shortly before death,
 the previous history of which was not precise,
 but which were considered and  treated as very
acute cases of pleuro-pneumonia, the post-mor-
tem examination disclosed the  association of
pleurisy with pneumonia and pericarditis. In
both these cases  there were considerable  effu-
I sion, with shreds and pieces of lymph, into the
I left  pleural cavity and  pericardium, the dia-
 phragmatic pleura being much affected.   Dr.
 Stokes remarks, that where the pericarditis is
 of the dry form, the symptoms are not so vio-
 lent as in that with effusion.   He has observed
 this complication in  cases  of acute pleuritis,
 and in two instances of very chronic empyema.
 In the latter cases, the usual symptoms of peri-
 carditis were altogether wanting, and no new
 suffering marked the  invasion of the disease,
 which  was  discovered only  by auscultation.
 The observations of M. Broussais apply chiefly
 to cases of this complication,  with copious ef-
 fusion into the pericardium, in which there are
 generally pains  in  the praecordia, with great
 anxiety and want of  sleep.  The patient sits
 bending forward, with his head resting on his
 knees ;  and yet, notwithstanding  great con-
 centration of the pulse, there  is a tendency to
 fainting, and almost complete absence of fever.
 (Traite des  Phlegmasia Chroniqucs, t. i.)
   97. e. Although pleurisy is  more  frequently
 caused  by, than  associated with, acute rheuma-
 tism, still this  complication is occasionally ob-
 served,  the still  farther complication with en-
 docarditis or pericarditis being also met with in
 rare instances.   This very complicated state
 of disease has been seen by me in children be-
 tween eight and thirteen years of age, in three
 cases, in all of which  it was recognised during
 life, and ascertained by inspection after death.
   98. /. The complication of hepatitis, especial-
 ly of inflammation of the convex surface of the
 liver, with pleurisy, is by no means infrequent,
 and supervenes  chiefly in the  course of the
 acute form of hepatitis.   It occurs also in the
 chronic form, especially when an abscess of the
 liver is  passing through the diaphragm, either
 into the pleural  cavity, or into  the  lungs and
 bronchi, adhesions having been formed between
 the opposite surfaces of the pleura.  This form
 of the  complication is noticed in the article on
 the diseases of  the Liver (§ 141-145); but I
 have seen  cases of chronic hepatitis, not con-
 nected  with abscess, that have been associa-
 ted with empyema of the left side,  the heart
 being pushed over towards the right side.   I
 am at  this time  attending a female  in Brook-
 street, aged between  thirty and forty, who, ac-
 cording to the history of the case furnished me,
 appears  to  have  been attacked  by subacute
 hepatitis, attended  by suppression of the ijien-
 ses, and followed by ascites, and by chronic
 pleurisy of the left side, with effusion, displace-
 ment of the heart, and dilatation of the thora-
 cic parietes.  I was recently requested, by Mr.
 Sims, a surgeon who had  practiced in India du-
 ring many years, to  see a lady, aged  about
 fifty, who was the subject of a most acute at-
 tack of hepatitis, to which  rapidly  succeeded
 dry pleuritis and  pneumonia of the right side.
 In this  very remarkable  case, the  symptoms
 and signs of hepatitis, of diaphragmitis, of dia-
 phragmatic pleurisy, and of  pneumonia with
 rusty  expectorations,  were  distinctly  recog-
 nised by Mr. Sims and myself.  The patient re-
 covered, and is now quite well.
   99. g. Pleurisy may also be consecutive or,
 and  complicated  with,  peritonitis,  especially
 partial  peritonitis of either of the superior ab-
 dominal regions.   I have  seen several instan-
 ces of acute asthenic pleurisy, with abundant 
I
     316    PLEURA, INFLAMMATION OF THE—Pleurisy in Infants and Children.
sero-albuminous or sero-sanguineous effusion,
complicating the several varieties of puerperal
fever, and  puerperal peritonitis  and phlebitis;
but in these  complications the  pleurisy was
generally latent, death having taken place be-
fore obvious dilatation of the side or displace-
ment  of organs occurred.  Indeed, in most of
these  cases, the pleuritic complication  was
double, although the fluid effusion and other le-
sions  were much greater in  one side than in
the other, the amount of effusion in either side
not being so great as to compress the lung in a
remarkable manner.
  100. I was lately called to a gentleman who
had just arrived from the A^zores with ascites,
consequent upon repeated attacks of peritonitis;
pleurisy, with effusion, having also supervened,
and proved the more immediate cause of death.
Upon  examination, the appearances described
in the article  Peritoneum (§ 88, et seq.) were
found, the   adhesions  being numerous,  very
long and thick, and  the serous effusion  very
abundant.   Some of  these adhesions  were
round, as large as the first or second finger,
with serous or polished surfaces, and formed
cylinders, the  external  layers of which were
organized and  dense, and two or three lines in
thickness, the  interiors being loose  and cellu-
lar, yet containing very much fatty matter, or,
rather, consisting almost entirely  of adipose
tissue.  A  turbid serum was found in consid-
erable quantity in the left thoracic cavity, in
smaller  quantity in the right, and adhesions,
cylindrical  or  nearly so, stretched through the
effused  fluid, from the  pulmonary to the dia-
phragmatic and costal pleura, in several places,
and presented similar appearances to those in
the peritoneal  cavity ; the thicker and the more
cylindrical  adhesions having organized serous
surfaces, and cellulo-adipose  centres ;  but the
adipose matter was not so abundant in them as
in the peritoneal adhesions.
   101. h. In most of the  complications above
mentioned, the pleuritic inflammation is sec-
ondary, or consecutive of that with which it is
complicated, unless in some cases of pericardi-
tis.  But in the course of many cases of chron-
ic pleurisy, or empyema, complications  may
occur, and render still more dangerous, or  even
fatal,  this already dangerous  disease.  This is
more  particularly the case when  the fluid accu-
mulation in the pleural cavity is of a purulent
kinjj.   In these, especially, various alterations
take place in the surrounding structures, caused
both  by  the nature of  the  accumulated  fluid
and by the mechanical influence of it.   The
substance of the lungs, the bronchi, the  peri-
cardium, and the  mediastinum are either more
or less  implicated by the early stages of the
pleuritic inflammation, or are consecutively ir-
ritated,  inflamed, or otherwise changed by the
nature and quantity of the effusion.  Consoli-
dation or atrophy of the lung often results ;
chronic pericarditis, with adhesions to the heart,
sometimes takes place; the bronchi  undergo
various changes, and are often  inflamed ; the
vessels  of the lungs  are  altered,  pulmonary
phlebitis even  occasionally supervening; and
the vertebrae, or even the ribs, sometimes be-
coming  carious.  In addition to these effects,
the actions of the heart and large vessels are
impeded or disordered ;  while  the blood be-
comes morbid, owing to  the greatly impaired
function of the lungs, and all the vital actions
consequently languish.
   102.  IV.  Pleurisy in the  dark  Races.—
Pleurisy is very often met with  in  the  negro
and  other dark  races, particularly  when they
pass into high latitudes and cold  regions; and
in these circumstances it is very  frequently as-
sociated with pneumonia, tubercular consump-
tion, bronchitis, &c.   Acute  pleurisy in  these
races is frequently latent, most commonly pre-
sents asthenic characters, and is generally at-
tended by copious serous, sero-sanguineous, or
puriform effusion.   Hence, unless the short-
ness of breathing, acceleration of pulse, short
cough, and debility, with rapid exhaustion after
slight exertion, usually attending  the early sta-
ges of the disease in these varieties of the spe-
cies, attract due attention, acute pleurisy will
rapidly pass to its ultimate period, or may ter-
minate  fatally before its  existence is ascer-
tained.   Chronic pleurisy  is also frequent in
these races, especially when  they  migrate to
colder than their native climates.   It  often
then assumes the  purulent form, and is gen-
erally  complicated  with pulmonary  tubercles.
Pleurisy, both in acute and chronic states, fre-
quently with effusion in the  former stale, and
often with adhesions in the latter, is not an un-
usual complication of pulmonary tubercles in the
dark races, especially after change of climate
and  exposure to cold, and is very commonly
either latent or masked by the symptoms caused
by the bronchitic complication, which is also
frequently present.
   103. V. Pleurisy in Infants and Children.
—Pleurisy is met with in children of all ages;
but it is most frequently seen, especially in an
uncomplicated form, in children upward of five
years of age.   Before that epoch, it is rarely
unassociated with pneumonia, and even, also,
with  bronchitis, pleuro-pneumonia  being the
most common state  of disease.  In children,
as well as in adults, pleurisy is much more fre-
quent in male than  in female children.  In this
class of subjects it is frequently consecutive of
pneumonia, and of eruptive fevers, either as a
complication of those fevers, or  as  a sequela
of them during some period of convalescence.
Indeed,  there is a remarkable disposition to
the supervention of pleurisy, or of pleuro-pneu>
monia,  during the whole period  of convales-
cence from these fevers, more especially until
the healthy functions of the  skin are  entirely
restored.  In other respects  the  causes of the
disease in  children are the same as those of
adults ;  but, as shown when  remarking on the
prevalence of pneumonia in children (see Linms,
Inflammations of, v 122,  et seq.),  these causes
act more injuriously,  and their effects, whether
in the  form  of pneumonia, of pleurisy, or of
pleuro-pneumonia, are the  more to be  dreaded
the younger the child which becomes the sub-
ject of them.
   34. Pleurisy in children is  most frequently
single,  as in adults.   MM. Rilliet and Bar-
thez  state that, in  the uncomplicated state,
pleurisy is somewhat more frequent in the right
than  in  the  left side, while the complicated
states occur more frequently in the left.  This,
however, does not agree with my experience;
as I have found, in children as well as in adults,
pleurisy in  every form more frequent in the
left than in the right side of the chest.  As to 
PLEURA, INFLAMMATION OF THE—State of the Blood in Pleurisy.
317
the products of inflammation of the pleura, false
membranes, and serum more or less turbid, are
most commonly observed in  this class of pa-
tients, and  the false membranes are most ex-
tensive and most generally found in the pul-
monary pleura, and least abundant and frequent
on the diaphragmatic pleura.
  105. The  accession of pleurisy is not always
attended by rigours or chills, especially in young
children—never in infants; and the  decubitus
in them especially is not much different from
the usual.   Sometimes decubitus on the back,
with the  shoulders  raised, is  preferred.  In
young children and infants especially, when as-
sociated with pneumonia, as  pleurisy usually
is, little or  no fluid accumulates in  the pleural
cavity, although lymph is thrown out.   The
infant is  restless, cries  constantly, especially
when moved or held erect; the skin is hot and
dry ; and the rubbing or creaking sound is heard
on auscultation, the respiratory movements of
the affected side being diminished.   During the
acute or early  stage of  the disease,  in older
children  effusion, although abundant, seldom
causes dilatation of the  side : this symptom is
rarely observed until the disease has become
chronic, and then it is  often  remarkable and
attended by pallor, enervation, debility, night
perspirations, and loss of appetite.   If the fluid
be not absorbed or evacuated by an operation,
death ensues, after one, two, or more months,
the patient being in a state of complete maras-
mus.   In the case of  a  young relative of my
own, pleurisy, followed by empyema of the right
side, occurred at the age of eight years, and the
matter was evacuated externally by a fistulous
opening, as described above (§ 99).   He perfect-
ly recovered ; and the functions of the lung and
the size of the side are now natural.
   106. The complications of pleurisy are most
to be dreaded in children ; more especially when
pleurisy occurs in the course of eruptive fevers,
or of  pneumonia or hooping-cough.   In very
young children, and  in  infants, this disease,
whether simple or complicated, and more par-
ticularly when associated with pneumonia  or
bronchitis, or when developed in the  course of
hooping-cough,  is very  frequently fatal; and
in infants it may terminate fatally, by causing
suffocation in twenty-four hours.  In older chil-
dren, especially when uncomplicated, pleurisy,
even in  the more acute forms, is much more
disposed to assume a chronicjbrm than  in the
very young, in whom the more prolonged states
of the disease are rarely seen.
   107. VI. The State of the Blood in Pleu-
risy has recently received attention, but more
as regards its chemical constitution than as re-
spects its sensible appearances.  Formerly, and
with much belter reason, these appearances at-
tracted the chief, and  indeed no  small atten-
tion ; for they furnish very important informa-
tion as to the states of vital power and of vas-
cular action characterizing the disease at  the
time when the  blood is abstracted;  and they
 moreover  aid the physician in forming his di-
 agnosis—still  more in giving his  prognosis—
 but most of all in determining his indications
 of cure, and in selecting the means of fulfilling
 them.  Yet this important source of informa-
 tion is neglected, and the particular  mode of
 studying the conditions  of the blood in disease
 that actually furnishes the smallest amount of
useful information to the practical physician is
that which now attracts attention, although this
very small amount cannot  possibly be ascer-
tained by the practitioner at the only time when
it can prove in any way advantageous, while it
causes the neglect of that knowledge which in-
stantly furnishes the most important patholo-
gical and therapeutical indications.
  108.  A. The appearances of the blood, espe-
cially of the coagulum, vary remarkably in pleu-  *
risy, according to the states of vital power and
vascular action.—a.  In the sthenic acute form
of the disease, the blood taken from a vein gen-
erally presents the buffy coat and a firm coagu-
lum, the quantity of fibrin being generally about
double the proportion observed  in health.   If
the first bleeding has been early in the disease,
the blood will generally present a firm and rath-
er large coagulum, but  frequently be neither
cupped  nor buffed, or but slightly so, although
a second venesection, performed only a few
hours afterward, will present these  appearan-
ces in a high degree, a third depletion also pre-
senting them, but in slighter grades.  Howev-
er,  nothing can with certainty be affirmed  as
to the effects of a second or third depletion, as
much will depend upon the quantity of blood
taken away relatively  to vascular fulness and
action, and to the powers of the constitution ;
but commonly the proportion of the coagulum
to the serum, or of blood-corpuscles becomes
diminished, while the fibrin may be increased
in the second blood-letting, but diminished in
a third and fourth.   In these cases, as well as
in pneumonia and acute  rheumatism, the quan-
tity of  fibrin  is generally great in  proportion
to the degree of fever, pain, and sthenic action,
while the blood-corpuscles, or hasmato-globulin,
is diminished with the quantity of blood taken
 away.  In fat persons,  especially, the serum
 often assumes a whitish or milkly hue after re-
 peated venesection, owing to the fat absorbed
 and conveyed into the blood,  (See art. Blood,
 $ 84, 96-108.)
   109.  b.  In  the asthenic, cachectic, and latent
 states, as well as in most instances of chronic
 pleurisy, the appearances of the blood are still
 more various than in  the sthenic form; but in
 many instances they furnish important indica-
 tions of cure.  When vital depression is very
 remarkable, and vascular tone impaired or ex-
 hausted, the coagulum is either soft or the blood
 coagulates imperfectly, although the quantity of
 fibrin  may be  greater than in health; and a
 large soft coagulum is often imperfectly separ-
 ated from the serum.   In many of these cases
 the blood presents much of the appearance de-
 scribed in the article Blood (y 94); but I have
 so rarely seen blood taken from a vein in these
 states  of the disease, that  I am unable to add
 more from my own observation, as to the ap-
 pearances of the blood in these circumstances.
   110.  B. Analyses of the blood in pleurisy have
 been made  by  Andral and  Gavarret,  who
 found that the quantity of fibrin was increased
 to very much  more  than  double the natural
 quantity; and that  the increase was greatest
 in the most acute and most febrile and painful
 cases, and was the least in the chronic and non-
 febrile.   Becquerel and Rodier analyzed the
 Mood of five men attacked  with acute pleurisy,
 and found the fibrin much more  than double
 the healthy proportion, while the albumen and 
318    PLEURA, INFLAMMATION OF THE—Pathological Anatomy of Pleurisy.
  blood-corpuscles  were somewhat  diminished ;
  but the results of the observations of the phy-
  sicians above mentioned are in no  way precise,
  nor are the changes very remarkable, excepting
  only as respects the quantity of fibrin ;  the pro-
  portions of the several constituents of the blood
  depending much  upon  habit of body, sex, and
  constitution of  the patient;  upon the state,
  grade, and form of the disease  ; upon the states
  of febrile action and vital power ; upon the stage
  of the malady, and the quantity of blood previ-
  ously abstracted.   Let the candid and practical
  reader peruse the accounts of numerous anal-
  ysis  of the blood  made by German and French
  chemists  and pathologists,  especially those
  made with a view of showing  the  composition
  of it in pneumonia, pleurisy, rheumatism, ery-
  sipelas, &c, and  he will find, according to the
  summaries of these analyses given in  Simon's
  Animal Chemistry applied to  Physiology and
  Pathology, with  the additions  by Dr. Day, the
  very slight differences, or even the sameness,
  of the results, as regards these and some oth-
  er diseases.   Having obtained the full  amount
  of knowledge he possibly can derive from these
  sources, let  him next endeavour to apply it to
  practical purposes; and  if he can do so, with
  only one tenth of the advantage which may  be
  derived from attention paid to,  and an acquaint-
  ance with, the sensible appearances and prop-
  erties  of the blood, he will be much more for-
  tunate than  I can credit.
    111. It  is very justly remarked by Vogel,
  that  it is very difficult—indeed impossible—to
  draw any  certain conclusions  from the state-
  ments of the  above-mentioned and  other ob-
  servers, respecting the changes of the several
  constituents of  the blood, or  the causes of
  these changes.   In fact, our whole knowledge
  of the chemical  constitution  of the blood  in
  both health and disease is most unsatisfactory,
  and the statements of different writers vary  so
  widely, that it is impossible to  deduce any gen-
  eral  laws  from them.  .\nd I  may add to this
  opinion of this able pathologist, that writers on
  the chemical constitution of the  blood in dis-
  ease have shown  only how very little informa-
  tion  they were able to  give upon the subject;
  and that little evinces its insufficiency even for
  the purposes of either a theory or a hypothesis,
  and its almost total inapplicability  to any prac-
  tical purpose.  It is, therefore, to the old fash-
• ion of observing the sensible changes and states
  of the blood, and of connecting these changes
  with the states of vital power  and  of vascular
  action  upon which they manifestly depend, that
  we must recur with any hopes, in  the  present
  state of our knowledge, of practical advantage.
    112. VII.  The Pathological Anatomy of
  Pleurisy.—A. The earliest appearances of in-
  flammation of the pleura are  similar to those
  which  I have  described as  being  observed  in
  inflammation of the Peritoneum ($ 81,  et seq),
  and consist of a congested state of the capilla-
  ries, which  are  congregated,  here and there,
  beneath the still transparent membrane.  The
  red colour produced by these vessels at certain
  points, deepens  and becomes  more diffused.
  These points are  somewhat  prominent, and, al-
  though scattered  and distinct at first, they soon
  enlarge and coalesce.   Patches and streaks are
  also  observed, either darker than  the rest, re-
  sembling small ecchymoses, or of a pale red
hue, as if from imbibition.  The pleura now be-
comes  dull, and loses its  polish and  smooth-
ness.   The redness spreads and becomes more
and more  uniform.   Soon afterward the rudi-
ments  of adventitious membrane may be per-
ceived.  The spots originally reddened  by re-
pletion of the capillaries  present  little, dull,
whitish or  yellowish points, which rise  above
the surface in the form of flat granules, and
ultimately  coalesce.   The pleura,  as Hexle
has shown, consists of several layers of super-
imposed cellular tissue, more and more closely
attached to each other, the free surface  being
a thin layer of epithelium cells.  Blood vessels
penetrate all  these layers, excepting the ex-
ceedingly delicate epithelium membrane  form-
ed by these cells.  The inflammation, therefore,
is not  seated, or does  not commence, in the
epithelium membrane, but in the subjacent cel-
lular  layers, this  epithelium being thrown off
at an early period of the disease  While  these
changes are proceeding in the pleura, the lay-
ers of cellular tissue connecting the pleura to
the subjacent parts are more than usually vas-
cular, and  are more  or less infiltrated with a
yellowish,  semi-gelatinous fluid; but this im-
plication of the external cellular tissue is only
occasional, or exists  chiefly at the commence-
ment, and  is removed as  effusion or other ad-
vanced changes take place.  In  rare instances
only are alterations of the pleura and of the
subjacent cellular structure observed to pro-
ceed, pari passu, with each other, more partic-
ularly as regards  the costal pleura.
  113. Consequent  upon the changes now de-
scribed, especially upon the grayish or yellow-
ish  points mentioned  above, which are the ini-
tial and expanding rudiments of the consistent
or membranous effusion, a slight, sometimes a
much more abundant exudation of serum is also
observed.   When  the progress  of the inflam-
mation  is soon arrested these products are in-
considerable ; but more  frequently, and when
the disease proceeds but little farther, the  pleu-
ra is found as far  as the inflammatory injection
extends, to  be lined  by  a very thin layer of
plastic exudation, forming a delicate membrane,
mostly  opaque, which veils the inflammatory
redness underneath it.  The liquid effusion con-
tained in the pleural cavity consists of a small
quantity of a yellowish limpid fluid, or of a  more
abundant collection of a turbid, or of a reddish
or mahogany-coloured serum, containing deli-
cate flocculi.  Hasse  supposes that upon the
condition  of the  thin  adventitious  membrane
covering the pleura depends the length of time
requisite for the absorption of the  fluid; and
that the more heterogeneous the quality of the
former, the greater will be the impediment to
the absorbents acting upon the  latter   How-
ever, there are other circumstances besides the
state  of this membrane, which will either im-
pede or accelerate absorption of the  contained
fluid,  and it can  hardly oppose  any great ob-
stacle, as  it either enters  into organic union
with the serous tissue, or else it is gradually
dissolved in the fluid.
  114.  When the inflammation  either contin-
ues  unabated, or  steadily, and  gradually, or
more or less rapidly increases, the morbid  prod-
ucts accumulate  in proportion,  exhibiting at
the same time the  most manifold differences.
These differences  depend  more or  less  upon 
PLEURA, INFLAMMATION OF THE-Pathological Anatomy of Pleurisy.   319
 iathesis  or peculiarity of constitution  and
 empcrament, upon the grade of inflammation,
upon its character and the degree of tone or of
vital power attending it, and upon the state of
the  blood itself.   The German  and French pa-
thologists, more especially Hasse and Andral,
while they describe these  differences with
much precision, take insufficient  note of the
several pathogenic conditions upon which they
certainly depend more  or less; although it is
very difficult  to  assign these  differences  or
states of the inflammatory products in this dis-
ease to any one or more states of the system
or of the circulating fluids, inasmuch as these
products evidently undergo various changes af-
ter their accumulation  and  during their reten-
tion, and, moreover, the states of vital power,
of inflammatory action, and of the blood at-
tending their exudation  and collection,  soon
change and become very different when they
are retained for some time, these states being
rather the  consequences of the accumulation
and retention   of these products, and of the
changes these products have undergone, than
the  causes of  the  differences or peculiarities
they present when they become the  objects
of examination.  To say, therefore, that vari-
ety of character in  the products of inflamma-
tion of the pleura "is entirely founded on  in-
dividuality," as some  pathologists  have con-
tended, is to confess ignorance under the mask
of a term.   That the  varieties observed are
chiefly to be referred to the states just enumer-
ated will be confirmed  by more close and pre-
cise observation, although the difficulties of as-
certaining  the  dependapce of  certain altera-
tions upon determinate states of vital action,
while the products  of these states cannot be
immediately examined, I am still disposed to
believe.  The exact appropriation of the sev-
eral varieties of these products to the patho-
genic states which produce them can hardly be
expected, seeing that both the causes and the
 effects are the subjects of continual change ;
 but an approach to it may be made  sufficiently
 close for all practical and useful purposes.
   115. a. The product of pleurisy, most sim-
 ple^ and most  frequently observed, is  a trans-
 parent yellowish jelly or lymph,  arjd which is
 effused with great rapidity and in considerable
 quantity when  the inflammation is intense.   It
 is partly diffused in layers between the pulmo-
 nary and costal  pleura, and partly subsides to
 the lowest part of  the pleural sac in pellets or
 flakes surrounded by a small  portion of fluid.
 This gelatinous  exudation or lymph consists
 almost exclusively, and often in nearly equal
 proportion, of the  fibrin  and serum  of  the
 blood, the latter most frequently predominating,
 with a very little colouring matter, attracted
 here and there to the  inflamed surface.  It is
 susceptible of organization throughout, and blood-
 vessels form   in it with surprising rapidity.
 Hassf. met with a case in which plueritic pains
 occurred twenty hours before death, and found,
 at   the  corresponding part,  this  gelatinous
 lymph, in which delicate vessels were observed
 shooting from the borders.   This product soon
 adheres  to the surfaces of the pleura where
 they approach each other, and a very few days
 suffice  to  produce  an extensive cohesion  be-
 tween the  two.  The rapid growth of vessels
 gradually confirms the union, and the aqueous
portions of the effusion soon being  absorbed,
the formerly separate surfaces  now adhere by
means of a soft vascular and cellular layer or
false membrane.  The disease often terminates
thus favourably, without the function of the af-
fected part being materially or permanently
disturbed.   But the inflammation, having given
rise to these changes, either partially or fully,
and being nearly extinguished, may be rekin-
dled,  and the  incipient  adhesions  may be
stretched, or torn  away, or even dissolved by
the fluid poured out during the  consecutive at-
tack, and various other changes  produced in the
products  previously formed, as well as other
more novel deposites may take place.
   116. b.  The  pleuritic exudation or lymph is
not always of this organizable  kind, or  so ger-
man  to  the organism, owing   to a depraved
habit of body, to the state of vital power, and
most probably, also, to  the condition  of the
blood.  Without, however, ascribing the differ-
ence to these states, Professor  Hasse believes
that ingredients very often enter into the com-
position of the  pleuritic effusion which, either
from too early consolidation, or, from some pe-
culiarity of character, render it  less susceptible
of consolidation.  These substances he consid-
ers as being far less easy of assimilation, and,
acting as  foreign bodies, serve to embarrass the
surrounding parts.  Adventitious membranes
of this kind, and which are only conditionally
susceptible of organization, appear not to form
so rapidly as those just described.   They gen-
erally consist of several either homogeneous,
or else distinctly different  layers, largely in-
vesting and firmly adhering  to  the  pleura.
Their consistence  resembles that of a hard-
boiled white of egg.  They tear easily, and pre-
sent, when torn, a fibrous-like texture.  The
colour of  these plastic or albuminous masses is
mostly of a yellowish or dull white; but they
 occasionally vary greatly,  passing  to  a faint
 red,  or into a violet or mahogany  tint.  The
 tinge is sometimes equable, but is  also occa-
 sionally  irregular, or  patched, or streaked, or
 different   in the  layers  or surfaces.   These
 membranes are always opaque ; their free sur-
 face is usually paler and softer than that ad-
 hering to the  pleura,  and  is usually villous or
 reticulated.  The cavity of the pleura contains,
 in addition to this false membrane, a consider-
 able quantity of a slightly  turbid  or flocculent
 fluid, or a light-brown or reddish liquid, bearing
 some relation  to the quantity and character of
 the false  membrane.   When  there is a more
 complete development of blood-vessels in this
 membrane, there  is also a  smaller amount of
 fluid; and where, on  the  other hand,  the  or-
 ganization of the membrane is  imperfect or ar-
 rested, or when the consistent  product  is mere-
 ly that of an  unorganized  coagulum, the fluid
 effusion  is relatively more abundant,  and, as
 Hasse supposes,  with great probability,  much
 less  likely to be absorbed.  It is not unlikely
 that exudations of the latter kind are liable to
 various changes during their retention, causing
 farther alterations in both the  more consistent
 and more  fluid parts, preventing or retarding
 the organization  of the false  membrane, and
 the absorption of the liquid.   In these cases
 the disease is  prolonged, and  does not termi-
 nate favourably until the  adventitious mem-
 brane has become organized and the fluid ab- 
320   PLEUR-V, INFLAMMATION OF THE—Pathological Anatomy  or Pleurisy.
sorbed.  But  in  those  cases in which these
results do not take place, the constitutional
efforts caused by the morbid products, and the
vital  efforts made to resist the  extension of
the changes  which  these products occasion,
produce a febrile  or hectic state of the frame,
which acts upon  the local lesions, and these
again react upon the constitutional disturbance
until  the vital functions are at last arrested.
When the  effused matters are much altered
during retention, or assume a more morbid or
irritating quality, even  the partial absorption
of them causes hectic of a more or less acute
or rapid kind.  Absorption  of such matters is
so constantly attended by  hectic and emacia-
tion, that Dr. Hodgkin,  with much reason, re-
gards the  absence of these symptoms as evi-
dence of its non-existence.  It often does not
proceed steadily,  but remains stationary, until
some intercurrent disease, in no way connect-
ed with the pleuritic malady,  accelerates its
progress.
  117. c.  When  plastic matter or albuminous
lymph is exuded  in a very short period, by the
intensity of the inflammation, it does not enter
into organic union with this membrane, with
which it is only loosely agglutinated, owing
either to its  rapid coagulation, or to  the con-
stitution of the  exudation, or to the  state of
vascular action in the pleura.  The coagulum
then generally assumes the  form of a honey-
combed false  membrane, or it  presents  imbri-
cated layers ;  or it merely consists of irregular
flocculent layers, whence  scattered filaments
run across the cavity of the pleura, while oth-
ers shoot from  the  free  surface, and give an
irregular villous  appearance to this  surface.
These plastic exudations  are  generally soft,
opaque, and of a pale yellow hue.  Along with
the matter forming  these depositions,  a con-
siderable  quantity  of  liquid is also effused,
which is sometimes tinged with the  colouring
matter of the blood, imparting in such cases its
tinge to the whole morbid product.  The more
solid  part  of the exudation surrounds the more
liquid portion, and forms  an envelope  for that
portion ; and being unorganized, and interposed
between the fluid part and  the pleura, prevents
the absorption of that part.  In these circumstan-
ces the disease becomes chronic, if death does
not soon ensue, or assumes the form of empyema.
   118.  d.  The purulent or empyemic form of ef-
fusion may be the result, as Hasse observes,
either of a high degree  of inflammation  at the
outset, or of the introduction  of external air
reacting on the inflamed serous surface and its
product, during  the progress  of the disease.
But may  it  not  also  arise  from consecutive
changes in the vascular action  of the inflamed
membrane, and  in the effused  fluid  independ-
ently of the admission of  the external air .  I
believe this to be the case  in some instances.
Suppuration  of the  pleura, however,  is most
marked where pneumothorax, with violent in-
flammation,  follows  the  bursting of an  ab-
scess, or of a tubercular cavity into the pleu-
ral cavity.  (See art. Pneumothorax.)  In this
case  the pleura  soon  becomes dull and of a
dingy gray, and secretes a thick tenacious, pu-
riform fluid, covering the surface of the mem-
brane, and collecting  in  the most depending
portion of the cavity.   In some instances a I
pure  liquid pus is very abundantly formed, and I
 is often mingled  in  various  proportions with
 coagulable  substances,  especially with  a very
 soft, thin, puriform, false membrane, which are
 either deposited upon or slightly adhere to the
 pleura, or which are mingled with the purulent
 fluid, in the form  of  pellets or flakes.  Unless
 the  pus find a ready outlet, or become seqnes-
 tered within false membranes, this state of the
 disease soon terminates fatally.
   119.  e. Owing  to  the circumstance of the
 pleura  being  inflamed in  different degrees, in
 different portions, or to the occurrence of a
 succession  of attacks, or to the recrudescence
 of a subsiding inflammation, several of the kinds
 of morbid product above described are often met
 with in the  same case.  The most various
 combinations both of consistent exudation, or-
 ganized, organizable, and unorganizable, and
 of liquid effusion, are thus sometimes seen in
 the same subject.   Hasse justly remarks that
 pus, at whatever  period  it may be generated,
 stamps  all  other  substances effused  with its
 own impress.   Plastic organizable exudations
 are thus liquefied  and converted into pus; that
 which is coagulated turns yellow, becomes pu-
 trescent and  flocculent,  and, in like  manner,
 resolves itself, partially  at  least,  into pns.
 This statement,  in  fact, confirms the view
 which I have entertained above (v 73) of the
 not  infrequent  conversion of other and more
 chronic states of  pleurisy into that of a puru-
 lent or empyemic form, independently of the
 admission of the external air.
   120. /. The tubercular form presented by the
 pleuritic products  is one  of the most important,
 and  occurs chiefly in the scrofulous diathesis,
 and  when tubercles at some one period of their
 development  exist in other organs, especially
 in the  lungs.   As the tubercular constitution
 changes the  plastic   products of nutrition in
 particular structures,  even in the circumstances
 of ordinary health, or causes the cytoblaste-
 mata of tubercle to be secreted conjointly with
 normal elements in these structures, so does it
 exert the same  influence in the formative pro-
 cesses  consequent upon inflammatory action.
 When pleurisy  occurs in this constitution, and
 gives rise to the  organizable or first  formff
 product described  (v 115), there are seen, either
 simultaneously  with the incipient formation of
 vessels, or  earlier, dull points as large as pins'
 heads,  scattered through  the gelatinous effu-
 sion ;  and  these  points ere long change into
 granules.   In the  second form of false mem-
 brane (y 116), tubercles likewise often appear
 in the shape of  white, flat granules, distinct
 both in colour and consistency from the rest of
 the  mass.   These granules are inaccessible to
 the  vascularity which soon pervades the or-
 ganizable product.   Professor Hasse  remarks
 the  existence of these granules, even the plas-
 tic substances deposited from purulent  effusion,
 but  he  has  never  met with them in the adven-
 titious deposites which  are not susceptible of
 organization (y 117).  In pleurisy, as well as
 in other diseases, the characteristic influence
 of tubercles is  exerted ;  for, by acting as sub-
 stances alien to the organization, they keep up
 irritation, and the continued secretion of fluid
 and consistent matters; and they impede or
 frustrate the function of absorption.   A por-
I tion, also,  of these effects may be imputed to
I this particular  diathesis,  and to  the  circurc- 
PLEURA, INFLAMMATION OF THE—Pathological Anatomy of  Pleurisy.   321
stance of tubercles in various stages of growth
being generally also present in other organs,
more particularly in the lungs.
  121. g.  The sanguineous state of the prod-
ucts  of pleurisy was particularly noticed by
Laennec   The various grades of reddish  col-
our imparted to pleuritic exudations by the col-
ouring matter  of the blood have already been
slightly mentioned.  Sanguineous coloration of
the fluid effused is most frequent in the tuber-
cular states of pleurisy.  It is only in rare in-
stances that the blood itself exudes into  the
pleural cavity in this  disease;  and when  this
occurrence takes place, little clots are found at
the bottom of  the collected serum, or deposit-
ed between false membranes.   Instances of
the entire effusion, consisting  of pure  blood,
are mentioned by Andral and Hasse ; but these
should be referred rather  to hemorrhage  into
the pleural cavity than to  inflammation of the
pleura.  Even  when blood is effused into  this
cavity it will necessarily produce inflammation;
and hence, in cases where pure blood, or clots
of blood,  are found in  this cavity in connexion
with inflammatory products, it may be difficult
to determine that these are not the products of
an inflammation excited by a primary hemor-
rhage into the  pleural  sac, effused blood gener-
ally causing inflammatory action in the tissues
surrounding it.
   122. h. The  spontaneous evolution of a gase-
ous fluid from the products of pleurisy has been
believed  in by some pathologists,  and denied
by others.  The question  at issue  is,  whether
or not these products  may become so decom-
posed during the life of the patient as to form
a gaseous fluid.   We  know that this  effect is
not  unfrequently observed after death.   Dr.
Hodgkin doubts the possibility of it during  life,
and Andral and Hasse appear very nearly to
agree with him ; for, in  instances  which oc-
curred to them, in which gas seemed to have
been spontaneously evolved from  these prod-
ucts, they admit the possibility  of some perfo-
ration of ihe pleura to have existed, although
they  failed to  detect it.  Although the exuded
matters,  fluid as well  as more consistent, may
long  remain either unchanged, or but slightly
changed, as long as the vital energies  are not
very  much impaired, yet  when  these  energies
are very far reduced, the products of inflam-
matory action are either  insufficiently, or no
longer controlled by them, and various changes
must  ensue.   Some of those changes  may be
ascribed to endosmosis and exosmosis ; others
to the states of vascular action arid of absorp-
tion ; and a portion even to incipient putrefac-
tion ;  but death usually occurs before this last
proceeds far. The ulterior changes of the more
fluid matters effused in pleurisy are as yet not
fully ascertained, especially with reference to
the different grades  of vital power;  and  the
question as to the spontaneous evolution of gas
from  these matters, in the most unfavourable
circumstances  of the  disease, and when vital
power is remarkably reduced, still remains un-
decided.
  123. t. The most important change that takes
place in  the gelatinous and  more consistent
products of pleurisy is their vascular organiza-
tion.   This process has been explained in two
ways.  Dollinoer  and others have supposed
that the exudation, possessing a derived grade
    IN.            21
of vitality from the surface producing it, has
hence the power of producing a movement of
its molecules, of transforming these into blood-
globules, and of developing canals for their cir-
culation independently of any connexion with
the  blood-vessels of the surrounding tissues,
the  circulation in the false membrane  becom-
ing connected with and subject to that in these
tissues only subsequently, and by slow degrees.
This theory  has not been supported by accu-
rate and direct observation, and it has only the
remote and loose analogy of the incubation of
the egg to support it:  a process which possess-
es elements  entirely wanting in the organiza-
tion under consideration.  The other explana-
tion is more obvious, and admits of visual dem-
onstration.   It has  been observed  by Hasse,
Kiernan, Hodgkin, myself, and others, in va-
rious  stages  of its progress ; and it may be
briefly stated, that, wherever vessels had form-
ed  in adventitious membrane, they proved to
be continuations of the  branches ramifying in
the  serous coat, having penetrated the  false
membrane at numerous points, and then branch-
ed out in a stellate manner, or having formed
into partly divergent, partly parallel, fascicular
groups.  In those false  membranes which are
less organizable, or only conditionally so (v 116),
the descriptions of Laennec, Forbes, and Gen-
drin show that a multitude of little red eleva-
tions appear on the serous membrane, like clus-
ters of protruding vessels.   These elevations
impress corresponding pits in the adhering sur-
face of the false membrane, and upon the sur-
faces of these pits appear little arborescent or
stellate extravasations of blood.  By  degrees
these arborescent extravasations become more
strongly marked, and  assume  the appearance
of vascular ramifications. Laennec states that
these ramifications present an outer and softer
layer, formed by  desiccated  blood;  and that
this layer encloses  a small  whitish chord of
coagulated fibrin, apparently hollow in the cen-
tre,  and pervious to the blood stream.  These
thick-walled  canals gradually change into the
natural coats of the vessels, which, pursuing
their course, thus seek to traverse all  the or-
ganizable portions of the false membrane.  Pro-
fessor Hasse remarks, that  some plastic sub-
stances are possessed of so little power of at-
traction over the  capillary  vessels of  the in-
flamed  pleura as neither to form these  little
vascular prominences, nor to occasion  the lit-
tle stellated extravasations  on the new mem-
brane.  These heterogeneous formations go on
irritating the  pleura until another false mem-
brane is thrown out, which,  acting as an inter-
mediate vascular  link, establishes something
approaching to vegetative reciprocity between
the two ; and, being itself devoid of nerves, ob-
viates morbid irritation.
  124. k.  Whatever does not sooner or  later
become assimilated or organized; whatever is
not converted into vascular cellular tissue, or
is not removed by absorption, remains perfect-
ly isolated and encysted, and may, in some in-
stances, be retained for years .without  occa-
sioning any serious symptoms. When the more
fluid parts have been absorbed, the more solid
constituents remain, forming a pap-like mass of
the consistence and aspect of moist cheese, or
of imperfectly-coagulated white of egg.   « Pre-
viously to this, the effused product usually sinks 
322   PLEURA, INFLAMMATION  OF  THE—Pathological  Anatomy of Pleurisy.
to the most dependent part of the cavity of the
pleura, so that the above mass accumulates into
a layer more or less  thick,  between the two
firmly-adhering  and thickened pleurae, poste-
rior to the inferior lobe of the lung."  When
tubercle enters into the combination, and  the
case does  not prove rapidly fatal,  it is occa-
sionally met with as a residue of the aggregate
morbid product in small scattered portions in-
cluded between the pleuritic adhesions. In such
cases, various consecutive changes sometimes
take place, which will be noticed hereafter.
  125. I. When  the fluid,  instead of being re-
moved by absorption, makes its way out of the
pleural cavity, the  lung is  the  part most fre-
quently perforated ; and it is the superior ante-
rior portion of the  organ which is  most com-
monly the  seat of perforation.   Hasss  states
that this  does not  take place where the lung
has suffered compression, but where it has con-
tinued to expand—in the majority of cases, at
the inferior surface of the  upper and  middle
lobes.   Such portions  are commonly attached
by old adhesions to the costal pleura, and form
an arch over  the effusion.   The effusion press-
es against this  arch, until some point  of  the
substance of the lungs and of the pleura soft-
ens, gives way, and allows the fluid to  escape
through the  bronchi.  The  perforation may,
however, take place at the inferior lobe, or at
the base of the lung, especially when protected
from compression by old adhesions, and remain-
ing partially  pervious  to air.   These perfora-
tions  are rounded or oval, are smooth at their
edges, and seldom  exceed two or  three lines
in diameter.  They are generally single.  The
parenchyma  in the vicinity of  the  perforation
or fistula is generally in a state of gray hepat-
ization, or of complete purulent softening. This
change  is usually fatal; but Andral and Hey-
felder  have  met with instances of recovery.
  126. The passage of empyema through the
diaphragm is very  rare.   Andral  and Mohr
have  adduced instances of this  occurrence.  In
these the  fluid, after perforating the diaphragm,
pushed down the peritoneum before it, thereby
preventing effusion into the peritoneal sac.  In
one of Mohr's cases the  diaphragm  was per-
forated near  to the spine, and the pus descend-
ed behind the peritoneum, along the psoas mus-
cle, causing  abscesses and fistulous  openings
in the thigh, extending as  low as the knee.
Gendrin mentions a case in which  the  fluid
made its way into the anterior of the medias-
tinum.   Escape  of the  effusion through  the
thoracic parietes presents  a  better chance of
escape for the patient than the foregoing.  The
chief cause of the spontaneous evacuation of
the fluid of empyema through the bronchi and
thoracic parietes being so often fatal, is  the in-
fluence of the external air upon the diseased
pleura and upon the walls of the fistula, espe-
cially upon the  substance of the lungs.  The
purulent secretion  soon becomes remarkably
fetid, and the air which passes into the cavity
is soon deprived of its oxygen.  Davy found
the air  in pneumothorax to consist of 0 92 of
nitrogen,  and 0 08 of carbonic acid.  The fluid
of empyema generally evolves the odour of
phosphureted and sulphureted hydrogen.
   127. m. The state of the lungs, in cases where
the pleural cavity is surcharged with effusion,
has been  described by several modern writers.
The lung of the affected side suffers the most,
as may be expected, its compression being com-
mensurate with the increase and ascent of the
fluid, until it can no longer expand, and the air
can  scarcely  enter the  partially  compressed
bronchial  tubes.  When the lung  is free from
adhesions, it is pressed upward and forward,
and finally on  all sides towards its roots, when
the bronchi and blood-vessels penetrate.  It
then occupies  the least possible space in front
of the vertebral column ; is flattened and shriv-
elled ;  its  different lobes are mostly adherent;
the parenchyma is inelastic, devoid of crepita-
tion, and almost bloodless ; and generally with-
out tubercles.   When, however, tubercles are
developed in the course of chronic pleurisy, or
are advanced,  having previously  existed —a
thing by no means rare—they are not found in
the most  compressed portions of lung.  The
bronchial  tubes  are usually found  loaded with
a whitish,  tough mucus.  Where adhesions ex-
ist, these generally preserve a portion  of lung
more or less  expanded, the bronchi then re-
maining partially pervious to  the  air,  and tu-
bercles are not unfrequently seen in the par-
tially-expanded portions of lung.
   128. The mode in which compression of the
lung presents itself in those cases in which ad-
hesion between the  opposite surfaces of the
pleura exist has been described by Mohr (op.
cit.,  p. 127).  Out  of  forty-three cases, six of
which were double, the compression and dis-
placement of the lung were once in the direc-
tion from  above, downward ; four times from
behind, forward ; four times from before, back-
ward ; four times from within,  outward;  thir-
teen times from below, upward ; and twenty-
three times from without, inward.
   129. n.  The  appearance and structure of the
adhesions  formed between the lung and costal
pleura, and between the lobes, differ; but they
may be referred to two kinds : First, the cellu-
lar, in which the opposite surfaces are  equally
united by means of a dense cellular tissue; and,
secondly, the filamentous or band-like, separate
bridles or bands, having a smooth, serous sur-
face passing between the two pleural surfaces.
These bands appear identical with the serous
membrane, whose product they are, and into
which they directly pass.  They are often sup-
plied with blood-vessels of considerable size;
and  they  consist of densely stratified  cellular
tissue, with an investment of epithelium cells;
and  they  sometimes  contain, as remarked by
Laennec,   Hasse,  and myself,  a considerable
portion of fat within  this  texture, more espe-
cially in their  centres (see above,  t) 100)  As
shown by  Beclard, Dupuytren, Villerme, and
others, these adhesions may remain during life
without occasioning any sign of disease;  but I
have met  with cases  in which their existence
and situation have been inferred, and the infer-
ence has  proved correct, as shown by  dissec-
tion, years afterward.  They may even disap-
pear in the course of time.  In the latter case
the chords lengthen, become thinner in the mid-
dle, and ultimately rupture, nothing excepting a
whitish, rugose thickening of the p;eura remain-
ing.
   130. The adhesions following  and complica-
ting tubercular disease of the lungs are differ-
ent from  those  observed in primary pleurisy.
They commence at the apex and gradually de 
PLEURA, INFLAMMATION OF THE—Diagnosis.
323
 scend, closely following the course and exten-
 sion of the tubercular disease.  Professor Hasse
 considers these adhesions as being less the re-
 sult of decided inflammation than of a chronic
 irritation, limited in degree, and kept up by the
 proximity of the heterologous product.   The
 result is complete blending of the pulmonary
 with the costal pleura, with lardaceous thick-
 ening, and degeneration of the serous structure.
 Owing to this intimate fusion, the intercostal
 vessels push branches  into the diseased sub-
 stance of the  lung.  In favorable circumstan-
 ces  to the development of inflammation, the
 slight irritation, causing the insensible, or near-
 ly insensible, adhesion of opposite portions of
 the pleura, may amount to actual inflammation,
 rapidly spreading  over the pleura, and throwing
 out diverse products, generally with tubercular
 matter, and passing into chronic pleurisy. Mohr
 calculates the complication of pleurisy with tu-
 bercular diseases of the lungs to be fifteen ca-
 ses out of twenty ; and this appears to be near
 the truth.
   131. o. It is comparatively rare to find pleu-
 ritic  lesions simultaneously in  both  cavities.
 Hasse states, that of thirty-five fatal cases he
 found nine double cases ; and in five of the nine
 one sac was implicated in a minor degree.   He
 considers  both sides of the chest to be almost
 equally prone  to  the disease, with this differ-
 ence, that pleurisy of the left side is both more
 likely to prove fatal in  the acute stage, and
 more apt to pass  into a chronic state ; but he
 adds, of the thirty-five cases just mentioned,
 sixteen were of the left side, and ten of the
 right, the  other cases  being double.  Of fifty-
 six cases observed by Mohr, the  left side was
 the seat thirty-seven times, and the right nine-
 teen times.  The experience of Dr. H. Roe and
 Dr.  Hughes, also, shows  a much greater fre-
 quency of the disease of the left than of the
 right side;  and the  cases which  I have seen,
 since my attention has been directed to the mat-
 ter, also evince a much greater frequency of
 pleurisy of the left side.  In 18461 met with four
 cases of the disease in this side in succession.
   132. MM. Rilliet and Rarthez state, that
 simple pleurisy is more frequently met with in
 the right than in the left side in children; but
 that  pleurisy complicated with pneumonia oc-
 curs oftener in the left; while the simple and
 complicated cases united are more frequently
 seen in the left than  in  the  right.  Of all the
 products of inflammation in this class of sub-
jects, these physicians found  that false mem-
 branes were the most frequent, and these were
 sometimes the only lesion ; next to thpse was
 a turbid serum, a purulent fluid being the most
 rare.

                          {In the right pleura
                            only, 27.
                          In the left only, 38.
                          In the two cavities,
                            14.
In the 79 cases in which ^ T   ,,    . ,.  ,
  there were false mem-   In'he r/fht PIeura
  branes,  they   existed > r  ,,y' !•*.
  alone or with redness |TIn the left alone, 13.
  only, 28 times.         J In both- L
  133 VIII. The Diagnosis of  Pleurisy re-
quires only a  very  brief notice, after  the  full
descriptions which have been given above of
the symptoms, signs, and consequences of the
disease.—a. The greatest difficulties as to diag-
nosis present themselves in cases occurring in
children, and in adults when the  physician has
not observed  the  earlier stages, or when the
pleurisy is latent,  and the quantity of fluid  ef-
fused is not great.   In infants and children un-
der four or five years pleurisy is most frequent-
ly associated  with pneumonia  ;  but after that
age  it  is  often primary  and  uncomplicated.
During infancy, pleurisy  is detected with  great
difficulty;  but  it should be dreaded when the
patient is seized with violent and constant cry-
ing or screaming, restlessness, hot and dry skin,
dry, short cough, and the  appearance of increas-
ed suffering upon being raised to  the erect pos-
ture.   Upon inspection of the  chest, the side
affected does  not  move  so freely as the  other
during respiration, and auscultation detects a
rubbing or creaking sound, which usually con-
tinues longer  than in adults.  In very young
children there are  generally also signs of pneu-
monia,  especially  crepitation, associated  with
these, and occasionally there is evidence, more-
over, of bronchitis.  In older children pleurisy
is also often complicated with pneumonia, and,
in rarer instances,  with pericarditis ;  but  in
these latter, acute  rheumatism is generally also
present, or it has immediately preceded the tho-
racic complication.  The chief difficulty,  how-
ever,  is in distinguishing pleurisy  from pneu-
monia,  and in ascertaining during life the ex-
istence of the association of the  two diseases.
The former usually commences  in children with
dry cough and  acute pain, soon followed by a
bronchial respiration, inspiration  being attend-
ed by a  metallic sound,  while  the  respiratory
sound is rarely much impaired,  unless the dis-
ease is advanced.   Change of  position aggra-
vates the symptoms.  The  febrile symptoms
generally abate from the fourth to the seventh
day ;  and previously the rubbing or  creaking
sound is often heard, especially before effusion
has taken  place ;  but this sound may also  be
present when the  lung is  implicated.   In this
latter case, there are generally  also crepitation
or sub-crepitation, accompanying  bronchial res-
piration  and mucous expectoration, which in
older children is often copious and even tinged
with blood.  When the lungs are thus also  af-
fected, the febrile  symptoms are  usually  more
severe, and continue until the  7th, 8th, or 9th
day, before they abate.
  134. b. In the earliest stage, the pain of pleu-
risy may be mistaken for pleurodynia, or ner-
vous pain in the side; for the  absence of any
distinctive physical sign  at this period, unless
in such cases as may furnish a rubbing or crack-
ing sound, leaves  us without proof of the ex-
istence of the  disease, excepting  that which
may be inferred from short, dry cough, heat of
skin, hardness  or  sharpness of the pulse, and
other febrile symptoms, and these may be very
slight,  or insufficient to indicate the nature  of
the malady.  But  not only may these be  so
slight as to be almost wanting, unless occasion-
ally towards evening, but pain itself may  be
wanting, or be so situated, and so slight, unless
in motion or on exertion, as to render the dis-
ease entirely latent, as stated above (rj 49), ()n.
til the effusion  is so considerable, as it usually
is in a short time,  in these cases,  as to develop
the physical signs  (Y 24). 
324                PLEURA, INFLAMMATION OF THE—Diagnosis.
  135. c. Pleurisy may also be mistaken for con-
solidation of the lung, and this latter for it.   This
mistake is most  likely to be made  when the
pleurisy is attended by a moderate amount of
effusion, the walls and contents of the  chest
not being displaced.  This  lesion of the lung
generally  increases the vocal resonance of the
affected side, whether heard or felt by the hand,
and allows some sound of respiration, which is
generally of a bronchial character, to be heard ;
and it thus may be distinguished from this state
of pleurisy.   " Partial pleurisies confined by ad-
hesions," as Dr. Williams justly observes, "are
less  easily distinguished, because,  where the
lung is adherent, there  may be as much bron-
chophony and respiration as in cases of con-
solidation ;  but, on examination,  these will be
found to be more circumscribed than in the lat-
ter case, all sound being absent in other  parts,
which farther present the signs of enlargement
or displacement of the heart, liver, or mediasti-
num, with fulness of the intercostal spaces, gen-
erally more remarkably than usual.   A similar
irregularity in the shape of the chest will serve
to distinguish pleurisy in the progress of cure
by contraction of the chest,  from the case of a
consolidated lung."   (Op.  Cit.,  p.   122.)  Al-
though I  admit the truthfulness of these re-
marks, as respects many cases, yet others will
occur to which they do not apply, and in which
they cannot assist the diagnosis.  They apply-
chiefly to the more developed and well-defined
cases ; but to others not so  characterized, and
to those which  are more complicated, they will
furnish but slight aids. Indeed, no precise state-
ments can be offered as to the diagnosis of sev-
eral  states  of pleurisy attended by adhesions,
partial effusions, and alterations of the sub-
stance of the lungs, as none apply sufficiently
to these ever-varying states to mark  them with
precision.  The physician's accuracy of diag-
nosis, as regards them, will  depend much upon
the attention with which he has watched the
course of the disease, and upon his  acumen in
detecting, and  his sagacity in  comparing and
estimating signs, symptoms, and almost imper-
ceptible and evanescent phenomena.
  136. d.  Chronic pleurisy is liable to be con-
founded with tuberculous disease of the lung, for
some of the signs of both maladies  are some-
what similar, and the constitutional  symptoms
and affection are often alike.   Indeed, the one
may pass into the  other, or  both  may be  pres-»
ent.   There never is, however, the same amount
of dulness on percussion and absence of respi-
ration in the latter malady as  in  chronic  pleu-
risy ;  while the enlargement  of the side and
displacement of the viscera, attending pleurisy
with very copious effusion and  empyema, nev-
er exist in phthisis.   The puriform state  of the
expectoration, often observed  at an advanced
stage  of chronic  pleurisy, should not mislead
the physician, for  this appearance of the spu-
tum occurs in the last stages of most diseases
of the chest, and  is an attendant upon a sym-
pathetic chronic bronchitis, which gradually su-
pervenes in their advanced  progress, and is in-
dependent of any actual disease of the sub-
stance of the lung.
   137. e.  Protrusion of the intercostals may be
looked upon as the surest sign of empyema; for
it rarely accompanies a very copious and non-
purulent effusion in the acute stage, while it is
generally present when the fluid is purulent, al-
though actually smaller in quantity than before
it assumed this character ; this sign  indicating
rather the kind of fluid than  the quantity, as
justly insisted upon by  Dr. Stokes and Dr. H.
Roe.   It should also be recollected that a small
effusion into the right cavity may, when the pa-
tient is examined in the sitting or standing po-
sition, be mistaken for an enlarged liver, or the
rising of this organ high in the thorax, or this
latter may be mistaken for the former ;  while
the presence of a considerable quantity of fluid
in the left side may not be detected, owing to
an  inflated stomach  having  pushed the dia-
phragm before  or  behind  it,  or  to  the  small
quantity of fluid interposed between  the parie-
tes  and the inflated organ, admitting of a clear
sound upon a strong percussion, although  a doll
sound  may be given out by a very gentle per-
cussion.   The  absence of the vibratory thrill
produced by the voice, and the decubitus, gen-
erally on the affected side ($ 30, et  seq), will
farther determine the seat of effusion.
  138. At  an  advanced period of empyema a
copious expectoration of purulent matter may
occur, and may lead to the inference of the ex-
istence of a pneumonic abscess, or of a tuber-
cular cavity, or, at least, of chronic bronchitis,
of the uncompressed lung.   Instances of this
kind have been noticed by Andral, Stokes, and
Mac Donnell. and upon dissection no such com-
plication could be detected.  But true pulmonic
abscesses are  comparatively rare, and  are not
accompanied with copious expectoration.  The
last writer just named very justly infers that
purulent  expectoration in  empyema, although
attended by quick  pulse, sweating, emaciation,
and other hectic symptoms, is indicative  of tu-
bercular or pneumonic abscess, unless attended
by unequivocal physical signs  of these lesions;
but, on the contrary, it is to be regarded as the
consequence of an  effort of the constitution to
get rid of a large collection of purulent matter
by one of (he ordinary emunctories.
  139. It  should, however, be kept in recollec-
tion that the lung  of  the sound side often ex-
periences, in the course of empyema, conges-
tion of the mucous membrane of its bronchi, oi
fully-developed  bronchitis, often passing into
chronic bronchitis.  In such  cases the acces
sion of chills, rigours, fever, increased difficulty
of breathing, with the physical signs of bronchi-
tis, generally indicate the complication, which
in various degrees is a frequent consequence
of the increased determination of blood that
takes place to the sound lung, owing chiefly to
the compressed and impermeable state of the
lung of the affected side.
  140. When a  circumscribed purulent collec-
tion forms on the left side and advances exter-
nally (" the empyema of necessity"  of French pa-
thologists ($ 52, 56)), it may, owing to the pul-
sations of the heart communicated to it, be mis-
taken  for a thoracic  aneurism, or even  for a
malignant  tumour in  that situation.   Mr Mac
Donnell  has pointed out this circumstance,
and has published some interesting cases illus-
trative of this form of empyema,  which he de-
nominates "pulsating empyema  of necessity"
It may be distinguished from thoracic aneurism,
(a)  by the history of the case; (b) by the dul-
ness extending over the whole side, the pulsa-
tion being felt only in the external tumour; (c) 
PLEURA, INFLAMMATION  OF THE—Prognosis.
325
by the absence of thrill, and of bellows sound ; I
and (d) by the extent and nature of the fluctua-1
tion.   It cannot be mistaken for encephaloid, or
other malignant disease, if the progress of the
disease, and the existing phenomena,  have re-
ceived even tolerable attention.  The absence
of a persistent bronchitis, of a dark expectora-
tion resembling black-current jelly, and the ab-
sence, also, of a  varicose or enlarged state of
the veins of the surface, and of oedema of the
side affected, will assist the diagnosis.
   141.  It was shown  by me in 1815, and  on
subsequent occasions in 1820,  1824 (see Med.
and Phys. Journ., vol.  xliv., p. 530, and Notes
to Richerand's Physiology, p. 626), long before
the subject was noticed by Tiedemann, Gmelin,
Liebig, and others, that, when the functions of
the lungs are in any way impeded, the liver
often performs a vicariously increased function,
thereby preserving the blood from the impure
or morbid state into which it would otherwise
pass.   This increased function of the liver  is
very generally remarked in the course of em-
pyema.  But, in addition to increased function,
there also  not unfrequently supervene conges-
tion, and more or less enlargement of the liver,
owing to the difficult or impeded circulation of
blood through the lungs, and the equally impe-
ded return of it from the hepatic vein.  This en-
larged, or at least congested, state of the liver,
in most cases of empyema of any considerable
duration, should not  be overlooked, or mistaken
for a partial empyema of the right side, which,
however, it may accompany as well as empy-
ema of the left side.   The enlargement of the
liver from congestion, or from impeded and im-
paired  function of the lungs, generally super-
venes to the vicariously increased action of the
organ, and is observed chiefly in the more chron-
ic cases of empyema.
   142. /. The diagnosis between pleurisy with
effusion and hydrothorax, and between empye-
ma and this latter, is by no means easy, unless
the history of the case be well known.  The
circumstance of hydrothorax  being  generally
consequent upon disease of the heart, upon a far
advanced stage of disease of the lungs, especial-
ly congestive pneumonia,  oedema of the lungs,
&e., or upon the last stage of other forms of
dropsy, as ascites,  anasarca, &c, is sufficient
to prevent any difficulty in the great majority of
cases to which the term hydrothorax  is strictly
applicable.  Yet passive effusion may occur, al-
though in comparatively rare instances, either
in one or in both lungs, and be distinguished with
difficulty from the asthenic and latent forms of
pleurisy, more especially when the passive effu-
sion is confined to one side of the chest, which
is seldom  the case when altogether independent
of inflammation of the pleirra.  When dropsy
of the  pleura, however, is caused by disease of"
the lungs,  it is then generally confined to the
same side as the affected lung, or is greatest on
that side.
   143. In most cases, the  chief differences tkat
can be observed between chronic pleurisy or
empyema and hydrothorax are, that the dilata-
tion of the intercostal spaces is comparatively
slight in hydrothorax, while protrusion of them
or of the diaphragm is not observed in this lat-
ter.    Dr.  Stokes  imputes this circumstance
chiefly to the pathological state of the pleura
and the adjoining muscles, and to the puriform
character of the effused fluid; but something
may also be imputed to the amount of effusion,
which is rarely so great in either pleura m pure
hydrothorax as in pleurisy, and hence a change
of sound, varying with the position of the pa-
tient, may generally be recognised in hydrotho-
rax, unless the passive effusion is consequent
upon the existence of several old pleuritic ad-
hesions.  Dr. Stokes  adverts to the  following
diagnosis between empyema and  hydrothorax,
as given by Hippocrates and noticed by La-
ennec :  " You shall know  by this that the chest
contains water, and not pus, if, on applying the
ear during a certain time on the side, you per-
ceive a  noise like that  of boiling vinegar ;"  and
remarks that, when we consider the conditions
of the lung in empyema and hydrothorax, the
diagnosis  of Hippocrates seems much more
accurate than Laennec has admitted.   In em-
pyema the lung is but rarely affected, and  no
rale is  heard, " no sound of boiling vinegar;"
while hydrothorax rarely occurs without more
or less  oedema or congestion of the  lung;  so
that, the presence of liquid in the chest being
admitted, the occurrence of rale would indicate
hydrothorax rather  than empyema.
   144.  IX. Prognosis.—The prognosis of pleu-
risy depends upon the form, state, and progress
of the disease; upon the previous health and age
of the  patient; upon  the  rapidity and amount
of the effusion ; and upon the duration of the
malady, in connexion with the treatment which
has been employed.  The  sthenic forms of the
disease occurring in previously healthy persons,
and  brought early under  treatment, although
serious  in their consequences, and therefore re-
quiring  a most watchful  attention, generally
yield to judicious treatment, especially when
employed promptly, or before effusion into the
pleural  cavity has become abundant.   If, how-
ever, pleurisy have been neglected, or improp-
erly treated ; if it have attacked a cachectic or
broken-down constitution, or assumed an as-
thenic form ; if it have been latent, and hence
existed for some time  before it was recognised;
if it have supervened upon disease of the lungs,
heart,  liver, or peritoneum — more especially
upon tuberculous deposits in the lungs, it is a
most dangerous, and in the latter circumstances
more especially, even fatal malady.
   145.  When the disease attacks a person who
has been exposed to depressing agents; to cold,
humidity, insufficient  nourishment, and anxiety
of mind ; when the effusion increases rapidly,
notwithstanding  the  employment of judicious
means  of cure ;  when it appears in the scrof-
ulous diathesis, or affects the pleura of both
sides, or is attended by purulent expectoration,
emaciation, or night sweats, or when the con-
stitutional symptoms assume the hectic char-
acter ;  when debility increases, and the urine
becomes scanty,  or oedema of the extremities
supervenes ; and especially when these very
unfavourable  symptoms  advance or continue
for some time, the danger should  be considered
as very great, more  particularly in  the  latter
circumstances now enumerated.  The progno-
sis in the complicated, the chronic, and the em-
 pyemic states of the malady is always very un-
 favourable, but more especially when occurring
 in the debilitated, the cachectic, and iutemper-
I ate ; the amount of danger being generally ex-
I treme when the disease has for sume time re- 
326
PLEURA, INFLAMMATION  OF THE—Pleura-pneumonia.
sisted the usual remedies, or when the consti-
tutional powers give way.
   146. In those cases of empyema in which the
matter finds its way through the lungs or exter-
nal parietes of the chest, although the danger is
great, still recovery may take place if the vital
influence be not much impaired, if hectic symp-
toms be  not developed, and if extensive disor-
ganization be not present.   The strength, con-
stitution, and age of the patient, in connexion
with the other circumstances of the case, should
guide opinion  as to  the result.  In the great
majority of instances, however, the spontaneous
evacuation of ihe fluid  affords only temporary
relief, the subsequent discharge and the hectic
fever ultimately sinking the patient.  The pro-
longed retention of the matter,  and the consec-
utive changes  in the lungs and parts adjoining
the fluid collection, before a spontaneous dis-
charge can be effected, generally sink the con-
stitutional powers, and prevent a restoration of
the lesions which have taken place, which are,
however, usually too extensive to admit of res-
toration under any circumstances. Those cases
in which the discharge is procured by operation
admit of a much more favourable prognosis, es-
pecially when  the operation has  not been too
long delayed, or until the alterations of the lungs
and adjoining organs and parts are not rendered
too great  to admit even of a partial removal;
but in these cases the result much depends upon
the peculiarities of the case, and the  circum-
stances under which the operation is performed.
   147. Acute pleurisy seldom proves fatal mere-
ly from the amount of the effusion, until it is
passing, or has passed, into the chronic state;
and  even  then, so rapid a termination  is met
with chiefly in the cachectic,  and in  cases of
double pleurisy, or when previous disease exists
in the lungs or some other viscus.  The rapid
accumulation of the  fluid,  however,  is  a very
unfavourable occurrence in any circumstances
of the case, as it indicates  great defect of con-
stitutional power, and an inability to effect its
removal.  An  opinion  of the result cannot  be
formed correctly in any case of the disease, un-
til the more acute symptoms have subsided, or
until the effects of the means usually employed
for this purpose become apparent; and then the
issue depends much upon the age and constitu-
tion of the patient.   When the sounds of per-
cussion and respiration return, however gradu-
ally, and the other symptoms and signs  disap-
pear, a doubt need not be  entertained  of a fa-
vourable result, especially  if the lungs furnish
no indication of disease.
   148. X. Pleura-pneumonia—Pleuro-pneumo-
nia—Pleuro-pneumonitis—Peripneumonia—i°er-
ipneumony, &c.—or the association of  inflam-
mation of the pleura with that of the substance
of the  lung, is so frequent, that these  distinct
diseases have been very often treated of as one,
and  with the belief that the one does not occur
without the other.   This, however, has been
shown not  to be the case, although they are
frequently  conjoined, as I  have shown above,
and when treating of inflammation of the lungs
(see art. Lungs, $ 73, et seq). The intimate con-
nexion subsisting between inflammations of the
pleura and of the pulmonary parenchyma, and
the frequent complication of these diseases, lead
me further to remark, that pleura-pneumonia pre-
sents itself in practice in three states, which pre-
sent certain  differences in their progress, ac-
cording as either tissue  is prominently aflected:
1st.  Pneumonia associated  with slight pleurisy;
2d. Pleurisy complicated with slight pneumonia;
and, 3d.  Pleura-pneumonia  properly so called, in
which the two affections seem nearly equal in
degree.
   149. i.  Pneumonia associated with slight Pleu-
risy.—In  those cases in which inflammation of
the lung  reaches  to  the pleura,  in  any point,
lymph is  thrown out upon the free  surface of
that portion of pleura ;  but in persons of a pre-
viously healthy constitution,  the lymph effused
is usually in  small quantity, forming  a false
membrane, which  extends no farther than the
portion of pleura covering  the inflamed  or hep-
atized portion of lung immediately underneath.
If the disease be of the sthenic character, or if
it be unconnected  with  cachexia, constitutional
vice, or a contaminated state of the circulating
fluids, the inflammation, thus extending to a por-
tion  only of the  pulmonary pleura, does not
spread over the surface of this membrane, al-
though  the lymph thrown  out will  frequently
excite a corresponding irritation  or  inflamma-
tion  of the  portion of  the costal pleura with
which it  comes in contact,  and  thereby give
rise to adhesions between the opposite surfaces.
If the pneumonia  and consequent hepatization
occupy a  portion only of the  lung, the effusion
on the serous surface is only slight,  consisting
of a sero-albuminous, or sero-puriform exuda-
tion.  But if nearly the whole lung be affected,
then there is often little or no effusion, a very
thin  or imperfect  false membrane only being
seen on  its serous surface, which  is thicker
along the edges and in the interlobular fissures,
and in some other points when the inflammation
had first reached this surface.  This is a very
common form of dry pleurisy, complicated with
pneumonia ; and in this complication the pleu-
risy is merely contingent upon the pneumonia,
and scarcely at all modifies  the severity or prog-
ress  of the primary disease.   M. Laennec re-
marks, that it would be very  difficult to distin-
guish this particular complication from a pleu-
risy with copious effusion, if the patient had not
been seen before this period; the absence  of
the thoracic resonance is here as complete as if
the whole surface  of the lung were covered by
a pleuritic effusion, while the stitch in the side
commonly atlending  the extension of the in-
flammation to the  pleura would farther induce
the belief that the  disease was simple pleurisy.
When, however, the  lung  is completely hepa-
tized, without any attending effusion into the
pleural cavity, there is always a strongly marked
hronchophonisni in different points, and particu-
larly toward the summit and root of the lung:
a sign which never exists  in  the same degree,
or over the same extent, in pleurisy or pleuro-
pneumonia.  If the patient  have been teen from
the origin of the disease, the diagnosis is much
more easy.  If the disease  be pneumonia, crep-
itation will have been heard previously to the
complete  cessation of the respiratory murmur;
and the gradual diminution of the resonance on
percussion, and the supervention of a friction
or rubbing sound,  as described when treating
of the dry form of pleurisy (<> 42, et seq.), will
leave no  doubt of the nature of the affection.
In pleurisy the loss of resonance  is very rapid,
and  exists, if the  lungs have been  previously 
PLEURA, INFLAMMATION OF THE—Treatment of.              327
 healthy and without adhesions, over the whole
 of the affected side.  aSgophonism, moreover,
 is always perceptible, at least for  one or two
 days.
   150. ii. Pleurisy complicated with slight Pneu-
 monia.—If the pleuritic attack be severe, and
 the effusion so rapid and abundant as suddenly
 to compress the lung, it  is not uncommon for
 inflammation of some points of the pulmonary
 substance to occur,  particularly in the  lower
 lobe.   These points sometimes remain distinct
 and of small extent, constituting one of the va-
 rieties of lobular pneumonia.  The pulmonary in-
 flammation is here much modified by the  pleu-
 ritic effusion, as I have  shown in the article
 Lungs (v 73), and it rarely extends much farther
 than  a few lobules, and  still more rarely ad-
 vances to suppuration.   This complication can
 only take place early in the attack, and before
 the effusion and consequent compression of the
 lung have become very considerable ; as a lung
 greatly compressed is hardly susceptible of in-
 flammation, the symptoms and signs of this com-
 plication are described in the article  now re-
 ferred to (t) 75).
   151. iii. Pleuro-pneumonia, properly so called.—
 The association of an inflammation of the whole
 or part of the pleura, with considerable effusion,
 and of a  severe pneumonia, is not so frequent-
 ly met with as either of the two complications
 just mentioned.    M. Laennec remarks, that
 pleurisy conjoined with pneumonia does not in-
 crease the danger of the latter;  on  the contra-
 ry, it lessens the danger, as above stated, by
 compressing the lung.  On the other hand, the
 pneumonia at first augments the danger of the
 pleurisy, which is rarely fatal in the acute stage;
 but it favours a more rapid absorption of the
 effusion, by preventing this from becoming as
 copious as in simple pleurisy, the inflammation
 rendering the lung less compressible. Hence
 pleuro-pneumonia, caterit paribus,  may be re-
 garded as less dangerous than either simple
 pleurisy or simple pneumonia.
   152. Pleuro-pneumonia is recognised by the
 union of the signs of pleurisy and of pneumonia ;
 and some of these signs are even more perma-
 nent  in this complication than in either of the
 simple affections; for they mutually impede
 and retard each other's progress when these in-
 flammations are conjoined.  The crepitation on
 the one hand, and the oegophony on the other,
 are thus often heard  up to the period of conva-
 lescence.  In cases of this kind, oegophony is
 seldom simple ; it is perceptible only at the root
 of the lung, around the lower angle of the scap-
 ula ; and, from the vicinity of the  large bron-
 chial trunks, and the density of the pulmonary
 substance, it is usually combined with marked
 bronchophony.  This conjunction of these two
 signs  Laennec has likened to the squeaking of
 Punchinello.
  153. XI. Treatment.—i.  History  of the
 Treatment of Pleurisy.—(a) Among the sev-
 eral means advised by the older writers for the
cure of pleurisy,  blood-letting was  considered
 of the first importance ; but there  are various
 circumstances which  have been noticed in con-
 nexion with it by these writers that deserve  a
 brief  notice.   Hippocrates  advised bleeding
 "addeliquiumanimi."  Aret.sus insisted upon
the necessity of early and repeated venesection,
but cautioned against  carrying it so  far as to
 produce syncope.  He distinctly stated the na-
 ture and seat of the disease, and remarked that
 it was neither sporadic nor epidemic.  Aetius
 was the first to  point out some of the condi-
 tions which indicate the impropriety of having
 recourse to  blood-letting, and imputed  these
 conditions to indigestion and crudities of the
 stomach.   C/elius Aurelianus and other Meth-
 odists advised blood-letting, but condemned the
 practice of carrying  it to the length of causing
 syncope.   Alexander  Trallianus  seems  to
 have been  the first to advise local depletion for
 this disease, according to the manner of cup-
 ping then in use.   Avicenna, and  other Arabi-
 an physicians, generally had recourse to vene-
 section and cupping,  and the rest of the  anti-
 phlogistic plan.
   154. The question as to the greater efficacy
 of bleeding from the same side as that affected
 in pleurisy, or from the opposite side, was agi-
 tated at a  very early period.  The Greek and
 Latin authorities  were divided in opinion as to
 this question.   Hippocrates, Galen, and  Cel-
 sus advised bleeding from the arm of the affect-
 ed side ; while .\ret/eus, a\etius, and Celius
 Aurelianus directed it from the opposite  side.
 The discussion was carried down by the Arabi-
 ans, who, however, generally bled from the arm
 of the unaffected side ;  and by the writers' of
 the fifteenth, sixteenth,  and seventeenth  cen-
 turies, some of whom, as Amatus Lusitanus,
 Vesalius,  Trincavelli,  Ruland, Saillans,
 Wipacher, Rodriguez,  Bertin,  and  others,
 discussed the subject as one of the utmost im-
 portance.
   155. Other  circumstances, of greater  mo-
 ment than this, were at last noticed in connex-
 ion with bleeding for pleurisy, by Sydenham,
 Callisen,  Baglivi,  and  others,  who insisted
 upon  the injurious tendency  of  bleeding  in
 cachectic  and asthenic states of the disease,
 or when the blood did not present a buffed or
 cupped appearance.   Mursinna,  Stoll,  and
 many  recent writers have likewise cautioned
 against bleeding  in these cases, as well as  in
 those which present a putrid character, or a bil-
 ious in connexion with an asthenic diathesis;
 and have  likewise warned the inexperienced
 against repeating venesection, or  carrying  it
 too far merely because the blood was buffed:
 a caution of no small importance.
   156. There can be no doubt of pleurisy being
 much more prevalent at some seasons or  in
 certain years than at others, and thus assuming,
 according to the circumstances of season or lo-
 cality, more or less of an endemic, or an epidemic
 form ;  and there is no less doubt of the charac-
 ter of the disease varying remarkably at differ-
 ent periods and in distinct localities; it being, in
 one or the other, of a much more phlogisticand
acute form than in the rest, or assuming even
 an asthenic or latent character.   And hence,
 indeed, may arise the fact that  blood-letting
 and other parts of the antiphlogistic treatment
 have been advised with very different degrees
of boldness by different writers.   We find that
since the days of Galen, prejudices existed in
Rome  against large bleedings in this and other
acute diseases; and these were very probably
well founded,  in  respect of that  and all other
large cities in ancient times, as they are as re-
gards this city and other large towns at the pres
ent day.  The opinions of medical writers are 
328              PLEURA, INFLAMMATION OF THE—Treatment of.
too generally based upon the narrow or pecu-
liar circumstances of their own practice, either
previously to or at the  time of their writing;
and all have neither the inclination nor the time
to acknowledge the change of opinions which
farther experience and more diversified oppor-
tunities have occasioned.  We find that Dover,
Cleghorn, Huxham, and many others advised
very large, prompt, and repeated venesection ;
and  that  Riverius, Le  Mercier, Stoll, and
Sims recommended that it should be performed
in both arms at the same time.  A more enlight-
ened experience, and more diversified opportu-
nities of observation, have now demonstrated
that this  practice may have been appropriate in
many of the circumstances in which these wri-
ters had recourse to it;  but that there are oth-
er circumstances, in respect not only of  the in-
dividual,  but also of the season, locality, and
epidemic constitution, which render it altogeth-
er unsuitable  and  injurious; while  there are
certain conditions of the disease which  I have
endeavoured to point out, that require very dif-
ferent or even  opposite measures.  In the more
doubtful circumstances of the case, or when the
propriety  of bleeding from the  arm, or  of the
repetition of such  bleeding, admits of dispute,
the application of leeches to the side, as advi-
sed by Zacutus Lusitanus, Sarcome, Schmuck-
er, and Hufeland, should be resorted to.
  157. (b) Emetics  were formerly much  resort-
ed to, but they are now  but little employed for
the cure of pleurisy.  They, however, have had
the sanction  of Riverius, Ruland,  Blegnv,
Mursinna, Morgagni, Wright,  Stoll, Tissot,
Ackermann, and Schelhammer ;  and I can add
that, when they are discreetly prescribed, they
are important aids  in the treatment of most of
the forms of the disease.  They should  not be
exhibited  until after bleeding has been resorted
to in the more phlogistic cases.   They will often
relieve the dyspnoea and oppression  attending
the stage  of effusion, and promote absorption,
when judiciously selected and associated with
other means which are suited  to the circum-
stances of the case.  Purgatives are much less
beneficial than emetics  in this  disease.   Very
active purging is seldom requisite, unless when
there are accumulations of excretions and mor-
bid secretions to remove ; but it is always ne-
cessary freely to promote the secreting and ex-
creting actions of the abdominal viscera.  Con-
formably with this principle, diuretics are  gen-
erally beneficial, especially at an  advanced pe-
riod of the disease, or when effusion has taken
place, and when conjoined with  cooling diapho-
retics or  other appropriate measures.
  158. (c) Mercurials, especially calomel, in full
or even  very  large doses in the more acute
cases, with antimonials, or opium, or  with both,
according to circumstances, are  often, in this as
well as in other inflammations of serous mem-
branes, of the greatest advantage.  They have
been  much  recommended by Lind,  Wright,
Finch, Hamilton,  and others, and the  experi-
ence of recent writers has confirmed the state-
ments of  their predecessors.  The active exhi-
bition of calomel, either  alone or in the  combi-
nations now mentioned,  is even more necessa-
ry in the early stages of pleuritis than in those
of pneumonia ; and, in the more advanced sta-
ges, or when effusion has taken place, either this
or some other mercurial preparation, conjoined
with diaphoretics or diuretics, and aided by ex
ternal  rubefacients  and derivents,  is  of the
greatest benefit.  I have often given  the bi-
chlorate in small doses, either thus associated,
or with other tonics and alteratives, as cincho-
na, sarza, &c, with marked benefit, at  an ad-
vanced stage of the disease, and more especial-
ly of the latent and asthenic forms.
   159. (d) Antimonials are  not so beneficial in
pleurisy as  in pneumonia,  yet they have  long
possessed a high reputation in the former dis-
ease, and have been much confided in by a\gric-
ola, Millar, Brocklesby,  Belfour, Laennec,
and many others.  Of  these preparations the
kermes mineral and  tartar emetic have been
most employed, although the empirical powder
of James and  others  have also been prescri-
bed with advantage.   The kermes mineral was
recommended by Von  Mertens, Bang, Sims,
Montral, Colombier,  &c, in  doses of  one
fourth  or one third of a grain  given every two
or three hours, while  the tartar emetic was
adopted by Callisen,  Millar,  Belfour,  Laen-
nec, and numerous modern writers.   Antimo-
nials have rarely been confided in alone for the
cure of pleurisy, but have usually been prescri-
bed in aid of vascular depletions, and for the re-
duction of vascular action  and the promotion
of perspiration ;  the substances most beneficial-
ly conjoined with them  being  mercurials, opi-
ates, and other sedatives, or cooling diaphoret-
ics and diuretics, more particularly the solution
of the acetate of ammonia,  or of the nitrate of
potash, and the nitric ether or the spirits of ni-
tric ether.
  160.  (e)  Opium and  other  narcotics have
been used by several  writers, but generally in
combination with other medicines, according to
the stage of the disease and circumstances of
the case,  and with the intention  of allaying
pain, and  of promoting the operation of the
substances with which  they were conjoined;
as with calomel by Hamilton, to determine the
constitutional operation  of this medicine; with
ipecacuanha and nitre by Dover, to determine
the diaphoretic action of these substances, or
with diuretics to ensure their operation on the
kidneys.  Opium was much  praised by Ko«-
tum for pleurisy ; and certainly, in conjunction
with calomel  or other  mercurials, and with
an antimonial preparation, or  in the form of
Dover's powder, as I have advised it in other
inflammations of serous surfaces, it is of great
service, especially  after blood-letting in  the
more phlogistic cases ; and with alteratives, or
diaphoretics, or  mercurials, &c, in the more
advanced stages.
  161.  (/) Of other medicines which have been
resorted to in pleurisy, there are few which de-
serve a particular notice.  Camphor has been
much praised by Baglivi, Grimm, Tissot, Gro-
elmann, and Schelhammer, especially in con-
junction with  nitre.  I have  prescribed  this
medicine very often in the more asthenic  forms,
and  in advanced  stages of the more sthenic
stages of the disease, and frequently with great
benefit, but  generally with  a mercurial  altera-
tive, or other substances, according to the cir-
cumstances of the case.   Ammonia was  em-
ployed  by Chalmers; Hoffmann's ether, and
other  stimulants, by Tissot ;  and benzoin by
Hoffmann ; but they are serviceable chiefly in
asthenic forms and contingent conditions of the 
PLEURA, INFLAMMATION OF THE—Treatment  of Acute.
329
disease.  I may add, that aconite was recom-
mended by Gebel, in combination with an an-
timonial medicine for the  rheumatic form or
complication of the  disease,  in which  form,
also, arnica was much used by several German
writers.
  162.  (g) The inhalation of warm vapour was
advised for pleurisy by Hippocrates, and of nu-
merous forms of warm, medicated vapours, by
modern writers.  I, however, much doubt their
efficacy, unless as adjuvants, in this disease, in
which,  as well as  in peripneumonia, this prac-
tice should not be overlooked, especially in cold
and dry states of the atmosphere.  In these cir-
cumstances of weather and of disease, I have
had recourse to it  on  numerous occasions.  In
a case  attended in 1826, by Dr. T. Gordon, Sir
J. Annesley, and myself, the vapour of boiling
water was introduced into  the apartment, and
within  the curtains of the bed, by means of a
tube leading from a  boiler  on the fire of the
room.  As to the use of medicated vapours, I
need add nothing to what I have stated respect-
ing bronchitis (see art. Bronchi, y 98, et seq.), as
much of what I have there  advanced is  appli-
cable to pleurisy as well as to pneumonia and
bronchitis, and to most of these complications.
  163.  (h) Demulcent and oleaginous medicines
were very generally employed by both ancient
and modern writers,  in expectation of obtain-
ing a soothing effect from  them as regarded
the pain  and  the  cough of  pleurisy, and as a
vehicle for more  active substances.   Linseed
oil, and decoctions, and almond oil, were chiefly
thus prescribed by  Sydenham,  Lange,  Spin-
dler, and others, and  were often  associated
with camphor,  opium, and other sedatives  by
Gilibert, De Haen, Kortum,  and numerous
more recent authors.  Many other demulcents
and mucilaginous preparations have been used,
as the  decoctum althaa, &c, but they require
no  farther notice at this place.
   164.  (i) Numerous external means were ad-
vised for  pleurisy by most  writers, from Hip-
pocrates to this time.   Warm fomentations of
various kinds, and both humid  and dry, were
much  employed ;  and  even topical cold, by
evaporating lotions,  or by means  of  ice or
snow,  as advised by Bartholinus, was even
resorted  to.   Of this latter but few modern
physicians will form a favourable opinion, al-
though certain analogical facts may be adduced
in its favour.   Sinapisms, and other rubefacient
applications to the side affected, were advised
by Celsus and others of the ancients, as well
as by  the Arabian and modern writers; and
they are  certainly of more  or less benefit,  ac-
cording to the knowledge by which a recourse
to them is guided.  The most beneficial rube-
facient, however, which can be employed, the
most appropriate  to all circumstances of the
disease, and the least liable to be injurious in
any, is  the spirit of turpentine, in the form either
of epithem, or of liniment, or of embrocation,
or conjoined  with  oil, or camphor, ammonia,
and oil with opium ;  and repeated or renewed
according to the  effects produced,  and to the
peculiarities and complications of the case.
   165. (k)  Vesicants over the part  affected
were  recommended  by Amatds  Lusitanus,
Conradi, Brocklesby, Gardanne, Grimm, Tho-
mann,  De  Haen,  Tralles, and Engei.haet.
But they should be prescribed  only after  bleed-
ing in the more sthenic or phlogistic cases ;  be
large, and repeated even oftener than once in
the more chronic states of the disease ; and be
aided by mercurials, diuretics, and  alteratives,
according to circumstances.   The  propriety
of applying them over the affected part, espe-
cially when there is reason  to suppose that the
costal pleura is inflamed, and when the patient
is thin or emaciated, may be reasonably ques-
tioned.  In these circumstances, 1 have gener-
ally directed them to be applied, either more
or less below the seat of pain, or on the oppo-
site side.  In  the more asthenic and chronic
forms of the disease, a repetition of them, gen-
erally in quick succession,  in  different parts
of the thorax, are often of great service, Plum-
mer's pill, with ipecacuanha and opium, being
given at night, and small doses of the iodide
of potassium and liquor potassae, with sarsapa-
rilla, being taken during the day.  The repeat-
ed application of moxas  to  the affected side
has been a common practice from the earliest
ages in Eastern countries,  and has been fre-
quently had recourse to in Europe by modern
physicians  with  considerable  advantage  in
chronic cases of the disease. In these cases,
as well as during convalescence from acute at-
tacks, I have often prescribed  a large  plaster
to be kept applied upon the affected side, con-
sisting either of the emplastrum ammoniacum
cum hydrargyro,  or of a combination  of this
with the emplastrum picis compositum.
  166. ii. Treatment advised by the Author.
—The intentions  of cure  are  nearly the same
for the several forms of pleurisy, although each
form requires a more or less marked modifica-
tion of the plan and of  the means  by which
these intentions are to be fulfilled.   The first
object is to arrest the progress of the  inflam-
mation ; the second, to promote  the removal of
the  products  and the consequences of the in-
flammation ; and the third,  to enable the con-
stitutional powers to resist, in the more chronic
cases, the injurious influence of the structural
changes produced, and, if possible, to counter-
act or overcome them.
  167. A. In sthenic acute Pleurisy, the ob-
vious indication is to arrest the progress of the
inflammation by the means recommended  for
other inflammations of this character affecting
other serous tissues, namely, by blood-letting to
an amount which the age and  constitution of
the patient, the hardness of the pulse, and the
duration of the attack will suggest.   If the pa-
tient be robust, if the disease has not advanced
so far as to give rise to great effusion, and if
the pulse be hard and inspiration painful, gen-
eral  bleeding should be promptly resorted  to,
and carried sufficiently far to relieve the respi-
ration, and to make a decided impression on
the  pulse, without,  however,  producing full
syncope, for the reasons stated in the article
Blood (see § 64, et seq.).  Contemporaneously,
or nearly so, with the blood-letting,  a full dose
of calomel, antimony, or ipecacuanha  and opium,
should be given, taking care that the dose of
the  antimony or ipecacuanha  should  not  be
such as to occasion vomiting.  The effect of
these I have so frequently shown to be  such
as will  promote the good effects of vascular
depletion, and often prevent the necessity of
repeating this measure, that I  need not here
recur to the subject.  If,  however, pain on in- 
330   PLEURA, INFLAMMATION OF THE—Treatment of Asthenic and Latent.
spiration, or when coughing, or hardness of the
pulse, should return, blood-letting ought to be
repeated, and the other medicines just  named
again be exhibited  after  the operation.  In
some cases, more especially if the patient be
not very robust or be not plethoric, local deple-
tion, by means of cupping a short distance from
the spine, or of leeches near  the  part, may be
employed in  place of the second  venesection ;
and, in more  robust and plethoric  persons, after
the second blood-letting,  if  the  pulse  should
rise, and the  febrile symptoms increase.  The
application of leeches should be followed by a
succession of warm poultices, or several folds
of warm, moist cloths or flannels, covered by
dry napkins.
  168.  It will generally be  requisite to give
some purgative medicine, in  order to keep down
febrile   reaction,  and  derive the circulation
from the seat of  disease.  But this medicine
should not interfere with the effects of those
just recommended, and therefore it  ought  not
to be given until  some hours afterward ; and,
during its operation, care  should be taken to
prevent the free perspiration, usually produced
by the medicines  previously given, from being
checked.   The  purgative  operation may be
farther promoted, if it be required, by enemata,
more especially such as contain the oleum ter-
ebinthinae, or may be left  to them alone, par-
ticularly when  the bowels are  not confined.
In addition to the means now advised, suitable
diaphoretics should be given at  short intervals.
The most generally appropriate are those which
consist of the liquor ammoniae acetatis, spiritus
aetheris  nitrici, and either the vinum antimonii
tartarizati or vinum ipecacuanhae, with cam-
phor water.  To these may  be added  other
medicines, such as digitalis or hyoscyamus, or
both, as circumstances  may suggest ; or a
preparation of colchicum may be substituted
for*the antimony or ipecacuanha, but its oper-
ation should be carefully watched.
  169.  In this form of the disease,  and more
especially if  it have made considerable prog-
ress before it came under  treatment, the rep-
etition of the calomel with James's powder, or
with ipecacuanha and opium, becomes  neces-
sary. The frequency of their exhibition should
depend  upon the dose prescribed and the ur-
gency of the case.   I have  usually directed  full
or large doses, particularly of the calomel or
opium, at intervals of six, eight, ten, or  twelve
hours,  and  the  saline medicine,  mentioned
above, to be  taken in  the  intervals, until  the
gums indicate a slight  affection, or the  evacu-
ations assume a green or very dark hue.
  170.  The above treatment will generally ac-
complish the first intention, and the latter part
of it partly fulfil the second.   But it may hap-
pen that, when we have happily arrived thus
far, exposure to a current of air, or  some  un-
toward  circumstance, may occasion  a relapse,
or a recrudescence of the disease ;  and the phy-
sician will then propose to himself this ques-
tion, Ought  general  blood-letting now to be
resorted to, or should local  depletion be con-
fided in .  In this state of the case he will duly
consider the amount and effects of the previous
vascular depletions, the duration of the dis-
ease, and the probable amount of effusion, the
existing states of the pulse and of respiration,
the  pain and other symptoms, in connexion
with the age and  constitution of the patient,
and decide accordingly.  But, if a due estima-
tion of all  these prevent  him from  venturing
upon  general blood-letting, he will  decide in
favor  of the application of leeches, the number
varying with the exigencies of the case;  and
he may even see occasion to repeat them, and
to follow them with the  warm poultices  and
fomentations already advised ($ 167).
  171. In order to prevent the farther progress
of the disease and its consequences, as well as
to remove its more  immediate results, addi-
tional means are  often required,  more espe-
cially after the inflammatory or acute symp-
toms  are reduced.  At first the turpentine tpi-
them may be applied over the  affected side, or
folds of warm flannel moistened with  this sub-
stance,  or  with   embrocations containing a
large  proportion of it (see Form. 295, et seq.).
These may even suffice, and prevent the neces-
sity of having recourse to other  means;  but
if they do  not produce a decidedly beneficial
effect in  the course of twenty-four or thirty-six
hours, or little  more, they should  be  replaced
by a large blister,  which will generally produce
its effects in about six hours, when it should
be removed, and  the part be covered with a
large  warm bread-and-water  poultice.  This
ought to  be frequently renewed.  It will rarely
fail to procure  a free discharge from the blis-
tered  surface.
  172. If the disease has made considerable
progress, or if the effusion is considerable, it
will generally be  requisite to keep up a slight
mercurial effect on the gums, and to repeat  the
blister either over  or near the part.  But in no
instance  should the blisters, or the vesicating
tissues  employed  in their stead, be  applied
longer than six or  eight hours ; they should be
then replaced by  warm poultices, which will
cause them to rise, and prevent the inflamma-
tion produced by them from extending below
the integuments.   In some instances, particu-
larly in those which have  proved  most obsti-
nate, and when no mercurial effect  has been
produced, I have directed  the blistered surface
to be dressed with the mild  mercurial oint-
ment, or with this in  part, and have generally
seen benefit derived from the measure.  If the
disease be not cured by the above treatment—
a contingency  which generally arises from
some  complication or pre-existing affection, or
from the advanced progress of the malady be-
fore it came under treatment, or from a con-
stitutional vice, as the scrofulous >  tubercular
—it then assumes the chronic form, to which
attention will be more particularly directed in
the sequel.
   173.   B.  The   asthenic and  the  latent
States  of Pleurisy (§ 47-50) are  often ad-
vanced to a more or less copious effusion be-
fore they come  under treatment; and  for  this
reason,  and still  more from the state of the
disease,  they rarely admit of general blood-let-
ting, unless they are seen at a very early stage,
and the  asthenic diathesis is not very promi-
nent.   An intimate knowledge of morbid ac-
tions, conjoined with close observation and an
experienced recourse to remedial  agents, can
in no circumstances be more  advantageously
evinced  than in  the course of treating these
and the preceding  forms of pleurisy—in deter-
mining,  in the sthenic, how far to carry,  and 
PLEURA, INFLAMMATION OF THE—Treatment of Asthenic and Chronic.   331
 how often to repeat, vascular depletion, and in
 the asthenic and latent as to the propriety of
 adopting  this practice, and as  to the  manner
 and the extent of carrying it out when it is
 determined upon.   It should entirely depend
 upon  the  state of the pulse, the age and con-
 stitution of the patient, and the  progress of the
 disease, whether a moderate blood-letting or
 leeches be prescribed.  Cases may occur when
 both may  be required, and others where neither
 is admissible, owing to the depression  of vital
 power, and the great amount of fluid effusion
 which had taken place before the disease had
 come under treatment.
   174. In these states—in those in which vas-
 cular  depletions  have been practiced, as well
 as in those in which they are  inadmissible—
 recourse  should be had,  in a prompt and effi-
 cient  manner, to alterative and diuretic reme-
 dies.  If the effused fluid be not inferred to be
 of the puriform character—a state of the effused
 fluid very  rarely observed  in an early period,
 even of the asthenic  and latent forms  of the
 malady—calomel should be given, with opium
 and small quantities of camphor, twice or thrice
 a day ; the infusion of digitalis, with the nitrate
 of potash, the spiritus aetheris nitrici and oxy-
 mel of squills, being taken in the intervals, in
 doses which the peculiarities of the  case will
 suggest.   The digitalis will be  more certainly
 beneficial  if it be given at first in as large doses
 as may be prudently exhibited, each dose, after
 the second or third, being diminished.  The
 terebinthinate epithem or embrocation should,
 at the same time, be applied over the affected
 side, and be renewed according  to the effect.
   175. In  cases of longer duration—when the
 disease  has existed two or three weeks—and
 when the  quantity of fluid effused is considera-
 ble, acute  or inflammatory symptoms  having
 subsided,  the treatment should partly depend
 upon  the  means which had already been em-
 ployed.  If the patient be seen for the first time,
 the internal  and  external remedies just .now
 mentioned should be resorted to; but if these
 or similar agents have been employed without
 avail, the pilula hydrarg. chloridi comp., with
 the pilula  scillae and digitalis, may be given night
 and morning, and two or three doses of the  io-
 dide of potassium  in solution with the spiritus
 aetheris nitrici, or some other diuretic,  in the
 course of the day.  Blisters should not, at the
 same time, be overlooked ;  they may be repeat-
 ed, according to circumstances, in the manner
 already recommended, in order  to obtain their
 most beneficial effects, and to secure a free dis-
 charge from them.  They  are certainly bene-
 ficial,  but  not to the extent stated by some  re-
 cent writers.  In some instances I have pre-
 scribed the iodide of mercury internally, with small
 doses  of squills and digitalis, with seeming ad-
 vantage ; and  in others directed the iodide of
 lead to be used externally in the form of an oint-
 ment, according to the  following formula, a
 small piece of it being well rubbed over the  af-
 fected side every night, or both night and morn-
 ing, the side being covered afterward by a piece
 of flannel:
 No. 325. Plumbi lodidi, 3j ; Unguenti Hvdrarg. mitiori.
 •t Adipit prepar., M 3vj.  Misce bene, et fiat unguentum.
   176. The effects of iodide of potassium in this
disease are very uncertain.  In some  I have
found  it very serviceable,  in others of doubtful
 advantage; and in a few I have considered it
 prejudicial.  I have employed it in dropsical dis-
 eases of all kinds for very many years, since
 the time of its first preparation, and can, there-
 fore, say, from considerable experience, that its
 effects should be carefully observed in the as-
 thenic and latent forms of this disease ;  for, in
 some of the more extreme of these, it may prove,
 as I  have found it in two or three cases, dis-
 tressingly  depressing, although given in very
 small doses.  In these cases the iodide of iron,
 taken in sirup of sarza, may prove more service-
 able,  especially when aided by the continued
 application of the emplastrum ammoniaci cum
 hydrargyro, or by a plaster consisting  of equal
 parts of this, and the emplastrum picis  comp.
 In most cases of the disease, these last means
 will prove of great service in promoting the
 absorption of the fluid  during early convales-
 cence, or when the fluid is partly removed.  At
 this period change of air—especially to a mild,
 pure, and dry air, or  to the sea-side, in a shel-
 tered situation, and suitable diet and regimen—
 avoiding vascular excitement, yet sufficiently
 supporting the powers of life, should always be
 recommended.
   177. It is  not unusual to observe, in the more
 asthenic cases of pleurisy especially, an abun-
 dant and rapidly-increasing effusion, occasion-
 ing the greatest distress, and even threatening
 the dissolution of the patient, by its pressure on,
 and displacement of the lungs, heart, and large
 vessels, notwithstanding a judicious  recourse
 to internal and external means.  When this re-
 sult is met with, more especially in very deli-
cate or scrofulous persons, or  in the  asthenic
and latent states of the disease, the remedies
already noticed having proved inefficacious, no
farther time should be lost before recourse be
had to paracentesis thoracis, to the removal of
the fluid through an opening made in the pari-
etes of the chest.   It is obvious that,  as soon
as the medical  treatment proves  itself  ineffi-
cacious, this operation  should  be  resorted to,
for delay will diminish the  chances of success
from its performance.   As this operation is also
required  in the  chronic states  of the  disease,
more  especially  for empyema,  it will be more
particularly noticed hereafter.
  178. C. Partial and double Pleurisy (v 51-
62) require but little modification of the treat-
ment  already advised, which should be adapted
to the peculiar  features of individual cases.
Where the  symptoms are  acute, and at the
same  time of the sthenic character, the anti-
phlogistic means should be employed accord-
 ingly, and with  due  reference  to each feature
of the case.   When  they partake more of the
asthenic form, the measures mentioned in con-
nexion with it then  are  requisite.  It may be
remarked that, while partial pleurisy more gen-
erally  presents  the  former character, double
pleurisy commonly possesses most of the lat-
ter, and especially requires prompt and efficient
treatment, which, however, is in no way differ-
ent from that which  has been already  advised.
  179. D. Chronic Pleurisy and  Empyema.—
a. If the  disease have become chronic before
treatment has been  employed, then the dura-
tion of the  disease,  the amount  and probable
nature of the  effusion, and the urgency of the
symptoms will  suggest  the measures which
should be adopted.  If the malady have become 
332          PLEURA, INFLAMMATION  OF THE—Tkbatment of Empyema.
chronic, owing to the failure of the means re-
sorted to, or to the constitution of the patient,
or to both causes conjoined, as usually observ-
ed, the question  may still be entertained as to
what may be farther tried.   In the former cir-
cumstances, if the indications above stated (y
137, et seq.) as to the purulent nature of the ef-
fusion be not present, and if the duration of the
disease have not  been above two or three  weeks,
then the internal and  external treatment ad-
vised above (§ 174-177) may be tried—prompt-
ly and efficiently—before recourse shall  be had
to 'paracentesis thoracis.   If, however, protrusion
of the intercostal spaces, hectic and other symp-
toms  indicate a puriform state of the  pleural
collection, no time should be lost before  resort-
ing to this operation.  In the latter circumstan-
ces referred to, especially when the treatment
has been judicious,  no appropriate and efficient
means having been overlooked, the operation
is equally required, whatever may be the na-
ture of  the  fluid collection, although, perhaps,
it may be more  urgently called for when indi-
cations  of a purulent character are present; for
where these indications exist no other  means
will save the patient.   The several writers who
agree in the propriety of having recourse to this
operation—especially Larrey, J. P. Frank, La-
ennec,  Forbes,  Bell,  Elliotson, Williams,
Davis,  and H.  Roe—advise  its performance
when the  effusion proceeds  so  rapidly as to
threaten the life of the patient, or when it ei-
ther increases or remains stationary under the
use  of  the means already recommended,  al-
though  the dyspnoea may not  be urgent or the
danger  immediate,  for the continuance of the
morbid collection and the compressed state of
the lungs may prevent this organ from recov-
ering its functions.   Dr. H. Roe justly remarks,
that " for empyema paracentesis should always
be performed the moment the nature of the case
is ascertained.  For serous effusions occurring
in persons of scrofulous habits, or very delicate
health,  after pleuritic  attacks, for the  cure of
which the necessary treatment has either fail-
ed or been neglected,  paracentesis will gener-
ally be  required."  (P. 208.)
   180.  b. There are certain conditions requisite
to the success of the operation.  It is most im-
portant that it  should be performed before ei-
ther  the vital powers of the patient  are too
much reduced, or the thoracic viscera have un-
 dergone serious organic lesions.  It is chiefly
when the lung still possesses the power of ex-
 panding after the pressure upon it is withdrawn,
 that  a  cure can be effected without deformity
 of the side.  If, however, the operation be de-
 layed until the lung has become atrophied, con-
 densed, or bound down by adhesions, so as to
 be incapable of expanding sufficiently  to meet
 the ribs, either  the vacuum will be rapidly re-
 filled with fluid, or  the shoulder will be depress-
 ed and the side contracted.   This last change
 seldom occurs  immediately after an operation,
 although it takes place gradually, and to a great
 extent, when the fluid is absorbed.   The reac-
 cumulation of the  fluid will, therefore,  be most
 likely to occur when the lung  is incapable of ex-
 panding sufficiently after the operation.   When
 this  is the case, a space must necessarily inter-
  vene between  the surfaces of the pleura, and
  either  the fluid is thereby prevented from being
  draw n off during the operation, or it is replaced
by atmospheric air, which is always  injurious
to the pleural surfaces, and occasions a more
puriform, and often an offensive renewal of the
effusion, and the aggravation of both  the local
and  constitutional symptoms,  exhausting and
ultimately destroying the  patient.   These con-
sequences sufficiently show the propriety of an
early recourse to  the operation, but  they  are
not satisfactory reasons for the neglect of it al-
together, as urged by those who object to  the
performance of it.
   181. When the operation is performed suffi-
ciently early, even in the most rapid and urgent
cases of empyema, the removal of the puriform
collection allows the lung to expand, and  the
upper portions of the pleura to come in contact,
and  ultimately to adhere ; and  the  adhesion
gradually extends  as the fluid is removed, until
the opposite surfaces become agglutinated; and
a cure is thus effected by the obliteration of the
cavity throughout, or nearly  so.   In order to
secure this  desirable result, it would be most
important to  determine, were it possible, the
exact  period when  the operation ought to be
resorted to—when an operation would prevent
the  accession of those changes which  usually
become irremediable.  It is manifest that, wbea
indications appear of a puriform state of the col-
lection, no  delay  should  occur; and that, in
many  cases, it might be of advantage to ascer-
tain, by means of the exploring needle, the ex-
act nature of the effusion.  If it be found that
the  fluid is 6erous,  then  Dr. H. Roe believes
that we may wait till the end of the third week,
in hopes that medical treatment may  cause ab-
sorption ; and, if it does not, that the  operation
should not  be longer deferred ; for he  consid-
ers, and I think justly, that the operation should
not  be postponed to a later period,  lest organic
changes in the thoracic  viscera may become
irremediable, and that it is, therefore, better
that it should be performed too soon, than that
this risk  should be incurred  by delay.  Cases
 are  recorded  of patients  who had  been tapped
successfully for pleuritic  effusions of  several
months' duration ; but there was no proof that
 the  lungs expanded to  their full dimensions in
 those cases, and  that the recovery was com-
 plete.  Dr. Roe states, that no case has occur-
 red  to him in which the patient was perfectly
 cured  when the operation  was delayed until  five
 or six weeks from the commencement  of effu-
 sion.   The non-expansion of the lung in these
 circumstances has always given rise  to the in-
 troduction  of more or less air into the cavity,
 in the cases which have come under  my obser-
 vation, however carefully  the exclusion of  it
 had been attempted ; and the patient has usu-
 ally sunk from a reaccumulation of a fetid pu-
 Tulent secretion, or survived with  a considera-
 ble  loss of lung.
   182. c. The operation being manifestly neces-
 sary,  in the circumstances now stated, and in
 performance not  admitting of delay, the man-
 ner and the situation in which it is  most advan-
 tageously performed requires some considera-
 tion.   The situation in which the opening iato
 the chest should be made has been pointed out
 by  Laennec, and  it has been  generally adopted
 by later authorities.  He recommends the soace
 between the fifth and sixth ribs, a little behind
 the digitations of the serratus major, as being
 the most dependent point in the horizontal po- 
PLEURA, INFLAMMATION OF THE—Treatment of Empyema.          333
 sition, generally the freest from adhesion, and
 the seat of the greatest quantity of fluid.  In
 this situation the operation  was performed in
 all the cases recorded by Dr. H. Roe.
   183 The manner of performing this operation
 has recently received due attention.   Former-
 ly surgeons advised  operations  implicating se-
 rous surfaces with a perfect indifference to the
 action of the air upon those surfaces.  But the
 injurious action of the atmospheric air  upon se-
 rous or shut cavities especially, and indeed upon
 other  surfaces or parts denuded  of their epithe-
 lia, or separated from their natural connexions,
 is now acknowledged by every enlightened ob-
 server.  This is evidenced by the inflammato-
 ry irritation, terminating, in weak or unhealthy
 constitutions particularly, in  offensive purulent
 discharges,  and acute  hectic fever.   Of the
 rAree following modes of performing paracentesis
 thoracis,  the  one which should be adopted may
 be inferred from what I have just stated.   Ac-
 cording  to one  plan, an incision is made  into
 an intercostal space, the fluid is evacuated at
 once, and the wound left open.   Another meth-
 od is to  make an opening into the pleural cav-
 ity with  a trochar, to keep the wound  open by
 introducing a canula, or a catheter, or gum-elas-
 tic tube, by which  the fluid is to pass off grad-
 ually.  The third mode  consists  in making an
 opening  by a trochar or otherwise, and allow-
 ing as much  of the fluid to flow  out as will es-
 cape without admitting  the air, and in immedi-
 ately closing the opening.   This last method is
 that which I would recommend, from observa-
 tion of the  results of these  several methods,
 and for  the  following reasons:  First. When
 the  air,  even in small quantity, comes  in  con-
 tact, either with the pleural surface, or with
 the false membrane formed on this surface, the
 state of morbid action  and the  fluid secreted
 are still  farther removed from the natural and
 healthy  conditions, and rendered more injuri-
 ous to the economy, and much less capable of
 restoration to states compatible with the  con-
 tinuance of life.  Secondly. The continued ac-
 cess of  the air will give rise to the thickening
 of the false membrane, and thereby prevent the
 lung from expanding, while it will render  the
 secretion at  first purulent, and afterward offen-
 sive and irritating to the surfaces containing it,
 and consecutively most contaminating to  the
 circulation and whole frame.  Thirdly. The op-
 eration performed so as to prevent the intro-
 duction  of the  air, although  often required to
 be repeated  at successive periods, closing the
 wound carefully in the intervals, admits o=f the
 gradual agglutination of the  opposite surfaces
 of the  pleura, does not interfere  with the con-
 tingent absorption of the remaining fluid, and
 is  compatible with the  continued recourse to
 medical treatment appropriately to the peculiar
 features  of the case.
   184.  I agree so entirely with what Dr. Will-
 iams has  stated as to the manner in which this
 operation should be performed, that I here adopt
 his recommendation : "The spot for the intro-
 duction of the trocar should be determined
 with due reference to the physical signs; care-
 fully avoiding every part where,  or near which
 there is sound of respiration, voice, or not  per-
 fect  dulness  on  percussion.  ' A  projection or
 fluctuation of an intercostal space give  greater
eligibility to a spot;  and these circumstances
  present  themselves most frequently at the in-
  ferior lateral parts of the chest, from the third
  to the seventh rib, where, also, the soft walls
  of the chest are as thin as anywhere.  In all
  cases it is a proper precaution to pass a groov-
  ed needle first, as recommended by Dr. T. Da-
  vies ;  for this at once determines the pressure
  of the fluid, its  quality, and the thickness of
  the walls which contain it at that spot."   The
  upper margin of the fifth  or  sixth rib  offers
  most commonly the most favourable situation,
  avoiding, of course, the immediate vicinity of
  the known arteries and nerves, and especially
  of the heart, with  reference to displacement,
  etc.  " The patient should be lying on his back,
  inclining to the  affected side, and not more
  raised than is necessary to  the state of his
  breathing.  The  skin should be  drawn  aside,
  so that the puncture through it may not, after
  the trocar is withdrawn, correspond with that
  of the pleura, but form a valvular orifice.  The
  trocar should not be pushed in farther than is
  necessary to clear the parietes, but the canula
  may be pushed farther after the stilette is with-
  drawn, and its sides should have several holes
  in them.   As soon as  the stilette is withdrawn,
  steady pressure  should be applied  by  a  band-
  age,  or by the hands of an assistant, to depress
  the shoulder and  sides, and to push up the dia-
  phragm on the  affected side  to promote  the
 flow  of liquid, and to prevent the introduction
 of air through the orifice during any sudden or
 forcible act of inspiration.  For the same rea-
 son,  during a fit  of coughing, if there appear
 any tendency to intermission in the stream of
 fluid, the  orifice should be closed by the finger.
 The pressure should be steadily increased as
 the liquid flows ; and if the stream should stop,
 a probe may be passed  through the canula, to
 clear it of clots of lymph or other obstructing
 matter ; but if still no more flows, a compress,
 or, if the liquid  is  purulent, a large  poultice
 should be placed on the  orifice ; and then, and
 not till then, the pressure on the walls of  the
 chest  may  be  discontinued.  The  result will
 be, that the walls of the chest, expanding by
 their  own elasticity  on the removal of  the,
 pressure,  will draw air into  the compressed
 lung,  which, being thus  inflated,  will begin to
 resume its part in the function of respiration
 and circulation, and will thus promote  the  ab-
 sorption of the rest of the fluid, and improve
 the condition  of the whole system.  Even if
 the fluid should reaccumulate, the  temporary
 expansion of the lung will have  served to  re-
 store  its natural properties, so that, when an-
 other quantity of fluid is again  withdrawn, the
 organ will be better prepared for  a restoration
 of its  functions."   (P. 28.)
   185. Performed in the manner thus judicious-
 ly advised by Dr. Williams, the  operation is
 free from risk, and will seldom fail to give  re-
 lief.  If the collection be purulent, it will often
 be necessary to repeat  the operation several
 times ; but if it be serous, one tapping, which
 will more or less expand the lung, will often be
 sufficient  to give  a turn to the disease, the
 complete removal of the effused fluid being ef-
 fected by  nature,  aided  by  appropriate reme-
 dies.   When the  fluid is purulent, Dr. Will-
iams recommends  the injection of warm water
with the view of displacing it; but, instead of
doing this with a single tube, it should be done 
334         PLEURA, INFLAMMATION OF THE—Treatment  of Empyema.
through a double-tubed canula, the tube for in-
jection being cautiously carried two or three
inches into the chest,  while the evacuating
tube is merely long enough to pass through the
walls.  If warm distilled water be then  thrown
in by a syringe through the longer tube, it will
drive the matter off through the shorter tube,
and in this way the morbid secretion  will be
displaced by water,  which is much more likely
to be absorbed.  If,  after repeated evacuations,
there be  no apparent disposition to the expan-
sion of the lung or  contraction of the chest,
and matter continues to be secreted, the writer
now quoted advises a recourse to medicated
injections, " such as a very weak solution of
nitrate of silver, or chloride of soda."  I  have
no experience of medicated injections in these
circumstances; but I see no reason against a
cautious  recourse to them.   The  pleural sac
may be treated, in these cases,  as an abscess ;
and, if the discharge be unhealthy, we should
endeavour to correct it, and to  promote the
healing of the diseased surface  by such means
as are found beneficial  in  analogous circum-
stances.   When the discharge  is fetid, it  may
be washed out, in the way just  advised, by an-
tiseptic injections, especially by chlorinated so-
lutions, or fluids  containing creasote.   "The
same practice may be advantageously pursued
when the matter has pointed, and opened spon-
taneously, leaving a fistula which may remain
open for months, or even years.  Dr. Townsend
mentions the remarkable case of Dr. Wandel-
stadt, who had been tapped thirteen years be-
fore, since which time the wound had remained
open, and discharged daily from half a  drachm
to four ounces.  The diseased  side was much
contracted, and did not move on breathing, yet
he could  blow the flute, walk fast, and actively
perform his professional duties."
  186. I  believe that the Hippocratic  method
of evacuating the  fluid  at  successive times,
preventing the access of air, and closing the
orifice in the intervals, is the best, because it
gives the lungs time to expand, and prevents
those changes in the inflamed membranes, and
in the products of inflammation still  retained
in the pleura, that the admission of air would
certainly produce.  The practice of leaving the
orifice open, and especially of leaving a canula
in it, is attended by this mischief, namely, that
the free  access of air to the cavity either re-
kindles the inflammation of the pleura, of which j
the effusion had in great measure caused the i
resolution, or changes the character of the in- J
flammation still remaining from an adhesive to
a suppurating form, and ultimately even de- j
composes the matter which  is formed.  I have
generally observed, when the access of air was
allowed,  that  the fetor  of the  discharge  was
most manifest in two or three days, and  that
all the constitutional, and even the local, symp-
toms were aggravated.
  187. Several recent writers, who have advo-
cated the propriety of operating in the circum-
stances  already stated, have not sufficiently
recognised the importance of excluding the air,
and have considered that, because it has been
shown by the experiments of Nysten and  oth-
ers that  air introduced into the cavity of the
healthy pleura is removed in a short time by
absorption without  manifest detriment, no in-
jury need be expected from its admission after
this operation.   But circumstances are differ-
ent as regards these experiments and the oper-
ation for this disease ;  besides, what has been
inferred from ii priori reasoning and from anal-
ogy has been proved by the experience of sev-
eral candid  observers, namely,  that, although
air may not affect a serous surface, when only
temporarily  brought in contact with this sur-
face, it will certainly  influence it, if allowed
free communication with it;  that, when this
surface is inflamed already, the admission of
air aggravates, and changes to an unfavourable
form that inflammation;  and that  the air acts
also injuriously upon the products of inflamma-
tion, both the  consistent and fluid; changes
their characters, decomposes  them, and ren-
ders them more contaminating to the surround-
ing tissues.  To prevent the injurious influence
of air, it has been recommended to  perform the
operation under water, and while  the  patient
is immersed  in a warm bath.   In  certain cir-
cumstances, and more especially in the  more
prolonged cases, this expedient deserves atten-
tion, and even adoption.
   188. Some writers have advised fluid injec-
tions into the pleural cavity, with  the view of
expelling both  the diseased effusion and the
air which may have been introduced ; and it is
not improbable  that pure or distilled water, of
the proper temperature,  thus introduced, the
orifice  being accurately closed afterward, may
have a beneficial effect, and  be absorbed, al-
though the morbid fluid was not absorbed, ow-
ing to its nature.  If this measure  were adopt-
ed, it should be employed in such a manner as
to wash  out the morbid  matter as entirely as
possible; and  the fluid  allowed  to  remain
should not be so much as might  prevent the
lung from expanding, if it still possessed this
power.   Of the success  of medicated injec-
tions in  these cases, the evidence is not  suffi-
ciently conclusive.  Dr. Williams  states that
Sir P. Crampton used with success an injec-
tion of a weak solution of chloride of lime; but
all stimulating  injection  must necessarily in-
crease or perpetuate  the  inflammatory action
in the surface, and thereby prove  an obstacle
to the expansion of the lung, and to the attain-
ment  of the end  proposed by  the injection,
namely, the arrest of the effusion  and  the ad-
hesion of the opposite surfaces.  In some in-
stances,  however, the injurious effect may not
result,  while the beneficial effects may follow;
and,  therefore,  such injections may be  cau-
tiously resorted to after other means have fail-
ed, and in the circumstances  hereafter to be
noticed ($ 189).   In this state of the disease,
and on occasions which the experienced phy-
sician will duly appreciate, he will  agree with
Celsus in considering that the " A^nceps reme-
dium melius est quam nullum."
   189.  In order to obtain the  re-expansion of
the lung, so  much to be desired after the oper-
ation for empyema, and at the same time to
increase  the discharge of the accumulated fluid,
it has been  advised by  Laennec and others to
apply a cupping-glass with an  exhausting' syr-
inge over the puncture.  Some advantage might
accrue from this expedient, if carefully perform-
ed ; but it is not unattended by risk, both  from
injuring the lung by forcibly expanding  it, and
from allowing air to rush in through the open-
ing upon removing the exhausting apparatus. 
PLEURA, INFLAMMATION OF THE-Treatment  of Complications  of.
335
If these dangers could be sufficiently guarded
against, the expedient might prove of service.
The latter might be prevented, and the former
could hardly be considered so great as to pre-
vent a cautious recourse to it.
  190. D. The Complications of Pleurisy ne-
cessarily involve the same principles of treat-
ment as have been above developed—(a) The
most frequent complication, namely, that  with
pneumonia, forming pleuro-pneumonia (v 93, 148,
et seq.), requires very nearly the  same treat-
ment as I have recommended for either of the
diseases when  occurring simply? due  regard
being paid to the existing diathesis or states
of vascular reaction and vital resistance.   In
this complication, however, and more especial-
ly when the sthenic character is manifest, the
preparations of antimony, especially tartar emet-
ic, are  more frequently beneficial  than  in un-
complicated pleurisy;  but they should be ex-
hibited after blood-letting, and in  the manner
advised for pneumonia (see Lungs, Inflamma-
tion of, y 96), or in conjunction with calomel
and opium, as above prescribed (y 167, 169);
the other internal and external means advised
for these maladies being employed as the cir-
cumstances of the case will suggest.
  191.  (b) When pleurisy complicates eruptive
or continued fevers (y 94), then the treatment
must necessarily depend upon, 1st. The char-
acter or state of the fever;  2d. The period of
the fever at  which it occurs ; and, 3d. The
states of vital energy and vascular action char-
acterising it.  In these  complications, the as-
thenic diathesis  should generally be suspected,
unless the character of the prevailing epidemic
constitution and of the existing symptoms indi-
cate the contrary, and  the  plan of cure sug-
gested  above for the  asthenic  or cachectic
forms of pleurisy (y 47, et seq.) ought therefore
to be  entertained, with such modification as
the features  of individual cases may require.
It very frequently happens that the  local dis-
ease is either  not detected in these circum-
stances, or proceeds so insidiously and latently
as to elude even close observation, until it has
advanced far, or given rise to considerable ef-
fusion, and  can  admit  only of  the curative
means which have been already recommended
for the latent, the advanced, or  the  chronic
states of the malady, as the case may be (y 173,
et seq).  In  these complications I have  seen
great advantage derived from the terebinthina-
ted epithems or  embrocations, and  the  other
external remedies mentioned above (y 171,175).
  192  (c) The partial, adhesive,  and  chronic
states  of pleurisy which so generally  compli-
cate the advanced stages of tubercular consump-
tion  (Y  95)  fall more  legitimately under  the
treatment of that malady ;  but I  may here re-
mark, that the pleurisy which thus supervenes
is not always attended  by tubercular deposits,
either  upon the pleura or in the false  mem-
brane ;  although it is sometimes thus accompa-
nied, more especially in the scrofulous diathe-
sis, and in persons who have been exposed to
depressing agents, as anxiety of  mind, insuffi-
cient nourishment and clothing, and deprivation
of air, exercise, and sunshine.   In  these cir-
cumstances, also, pericarditis may farther com-
plicate  the malady and  present  a tubercular
character (y 96).   In both these forms of com-
plication the  friction sound  is often heard on
auscultation, and then the nature of the mis-
chief may be inferred with tolerable certainty,
especially in  the  circumstances just  stated.
The treatment cannot be expected to be satis-
factory in these cases, some of which  are at-
tended by either more or less anaemia or ca-
chexia ; but life may be prolonged for  a very
considerable  period, even if it may not be sa-
ved, by a judicious recourse to chalybeate prep-
arations, more especially to the iodide  of iron
with sarza, alternating  this course with very
minute doses of the bi-chloride of mercury, pre-
scribed in tonic decoctions or tinctures, &c.
  193.  (d) In the complication of pleurisy with
hepatitis (y 98), and in that with peritonitis (y 99,
100), the associated malady usually presents an
acute character, which may pass into the chron-
ic form if not promptly and actively treated.  In
these complicated states of disease, the means
which are most serviceable are not materially
different from those advised for the acute form
of either of these uncomplicated diseases.  It
is  generally of great importance to bring the
system under the influence of mercury before
effusion takes place or proceeds far; and this
may be done by either the internal or the ex-
ternal use of the mineral, or by both modes, ac-
cording to circumstances.  In a case of remark-
able urgency,  to which I was recently called, a
large blister was applied somewhat below the
seat of suffering, after blood-letting was  carried
as far as appeared prudent; free vesication was
promoted by warm poultices ; and, after  the cu-
ticle was removed, the  mild  mercurial oint-
ment was applied, and covered  by a warm
hread-and-water poultice.  The most beneficial
results were soon afterward observed, and the
patient rapidly recovered.  In these complica-
tions, the terebinthinate epithems and  embro-
cation, advised above (y 171), are often of great
service, when judiciously employed and aided
by the additional means which the state of the
case will suggest.
   194.  In some of the  complications of pleu-
risy just noticed, paracentesis  thoracis can fur-
 nish only temporary relief; in others  it  may be
 most beneficial, while in a few it cannot be at-
 tempted with any sufficient prospect of advan-
 tage.  It is not merely the complication which
 ought to be considered, but also every circum-
 stance connected with the case, and more  es-
 pecially those connected with  the primary mal-
 ady, of which the pleuritic attack is the conse-
quence.   When this operation appears at all ad-
missible in any of these associations, it should
be resorted to as early as possible ;  for the sev-
eral lesions mentioned above (,  101) may soon
be caused by  the pressure of  the effused fluid,
 and farther complicate a disease which an oper-
ation promptly performed might have removed.
   195.  E. In the  Dark Races (y 102) pleurisy
should be treated as I have advised for the as-
thenic and complicated forms  already consider-
ed.  Whether it assumes an acute or a chronic
character in  these  races, I have always seen it
more or less  latent, complicated, and consecu-
tive, more especially of tubercles of the lungs ;
tubercles having been found also on the surface
of, or  below the pleura, or  in the  false mem-
branes after death  (y 102).  When the effusion
is great, paracentesis should be early employed.
The few cases of this  disease which  I have
 seen in these races have not  been so much 
336
PLEURA, STRUCTURAL LESIONS OF THE—Description.
benefited by treatment as the natives of cold
or temperate climates; but this was partly at-
tributed  to the unfavourable circumstances in
which they were  placed, and to the influence
of a temperature and climate different from that
to which they are suited by their organization.
   196. F. Pleurisy in Infants and Children
(y 103) requires the same measures as I have
advised  for adults, due reference being had to
age and  to the susceptibility of the influence
of certain remedies  connected with  infancy.
In this class of subjects, pleurisy is most fre-
quently consecutive and  complicated, and the
treatment  should be  prescribed  accordingly.
For very young children especially, some reme-
dies which are most beneficial for adults with
this disease should either not  be  employed  at
all, or with great caution.   The chief of these
are opium and other narcotics, tartar emetic,
and blisters; but calomel may be given freely
without risk, with small doses of James's pow-
der, vascular depletions being promptly employ-
ed, and to an extent which the circumstances
of the case will warrant.  The terebinthinate
epithem  or embrocation will prove of great ser-
vice, and will be attended by no risk, unless the
utmost neglect be evinced. If the application of
a blister  be considered advisable, with the view
of obtaining a discharge from the external pari-
etes of the  chest, it should not be continued
longer than three or four hours, oruntil slight
redness of the surface is  caused by it, when a
warm  bread-and-water poultice should be ap-
plied,  which will usually produce  vesication
without  subsequent risk, if due  attention be
paid to the case.
  197. In the acute stage of the malady, the
treatment now advised, aided  by diaphoretics
and diuretics, should mainly be trusted to ;  hut,
as the chronic stage advances, and particularly
as effusion increases,  the iodide of potassium
may be  prescribed,  with liquor  potassaj  and
some  preparation of sarza, or with the addition
also of a diuretic ; the terebinthinate liniment,
or a liniment containing the iodine of lead, or
iodine of potassium, being occasionally applied
to the  side, or the emplastrum ammoniaci cum
hydrargyro, or  equal parts of this plaster and
of the emplastrum picis comp.  If the patient
evince a  marked debility, or cachexia, anaemia,
or constitutional vice in the chronic stage, the
iodide of iron should be given in the sirup of sar-
za, and change of air, especially to the sea-side,
be recommended; the external applications just
mentioned,  or  the frequent sponging  of the
surface with warm salt-water,  or with a toler-
ably strong solution of bay-salt  in warm  wa-
ter, or the use of these alternately, being also
resorted  to.   If effusion  be considerable, es-
pecially  if the patient live in a  large  town,
change of air to the country, aided by suitable
alterative and diuretic medicine, will generally
remove the disease, unless it have become com-
plicated,  or the vital powers be very depressed,
and the constitution cachectic.
  198. Treatment, judiciously directed, is gen-
eralr/much more efficacious in this class of pa-
tients than in persons advanced in age, or even
in adults; and the more serious consequences
of the disease, as empyema, with or without
fistulous  opening, should not be considered
hopeless, unless complicated  disorganization
exists.  Whenever  the effusion appears to be
puriform, no delay in resorting to paracentesis
thoracis should take  place in children, more
than in adults ;  and in the former especially, it
is hardly ever too late to perform  this opera-
tion, particularly  when  the effusion is of this
kind.
   199.  iii.  Diet and Regimen—It is almost un-
necessary to add  anything on  this  topic, as it
must be evident that both the diet  and the re-
gimen  should be  strictly antiphlogistic during
the acute stage, more especially when  the dis-
ease presents a sthenic character.   As effusion
advances, or becomes chronic, and especially if
vital resistance be weak, it will often be neces-
sary to  support the powers of life with such
means as will the least  excite  vascular action
or accelerate respiration, and at the same time
tend to increase the natural secretions and ex-
cretions.  This  becomes the more requisite in
the scrofulous diathesis, or when the effusion
is puriform, and attempts to discharge and pre-
vent the return of the effusion are being made.
But there is no aid to a judicious treatment that
deserves more general  adoption  than  change
of climate, especially to the sea-side, to a mild
air, and to  a dry  situation.  A person  who is
recovering from pleurisy should guard, both du-
ring convalescence  and for a long time after-
ward,  against  currents of cold air; against
wet, cold, or damp feet;  and against errors in
diet;  and  he ought more especially to avoid
standing upon cold stones, or floor-cloth, or in
damp  places.   His shoes  ought also  to be
changed after walking,  immediately upon re-
turning home.
  200.  XII. Structural Changes of the Pleu-
ra NOT NECESSARILY ARISING  FROM  INFLAMMA-
TION.
    Classif.—IV.  Class.   II. Order.  (Au-
       thor in Preface.)
  1.  Defin.—Lesions of the pleura not necessa-
rily depending upon, although frequently associa-
ted with, inflammatory  action,  but often arising
from diathesis, or constitutional vice  or contami-
nation, and seldom attended by distinct signs, al-
though their presence sometimes may  be inferred
from the history of the case, and from  various lo-
cal and general symptoms.
  201.  i. Description.—I have  so fully descri-
bed those lesions of the pleura  resulting from
inflammation (y  112, et seq.), that I cannot far-
ther advert to them than to briefly notice some
of their associations  with  those  alterations
about to be considered.   Certain lesions which
I  shall  point out doubtless  originate, in most
cases, if not in all, in inflammatory action; but
they subsequently undergo changes, which may
be referred to morbid  nutrition, this nutrition
giving  rise either to a transformation of  the tis-
sue to one of a different nature :  to the transition
of this  tissue to another different from it,  but not
foreign to  the economy, or to the production of a
structure altogether adventitious to the  healthy
frame.   It is thus that we perceive, as a con-
sequence of pleuritis, and owing to  the states
and grades of action, and to the conditions of
the constitution, cartilaginous or ossific depos-
its or transformations of the pleura in some
cases;  and, in the course of this disease, ow-
ing to  constitutional vice, tubercular deposits
either beneath the pleura, or in the albuminous
or fibrinous deposits, or false membranes on the
free surface of this membrane.   The former le- 
PLEURA, STRUCTURAL LESIONS OF THE—Description.
337
 sions most probably originate in  inflammatory
 action or irritation,  the morbid nutrition pro-
 ceeding as this action subsides ;  but the latter
 lesion is either coetaneous with the inflamma-
 tion, or excites it, or is a consequence of it, in
 the scrofulous or tubercular diathesis.  The
 lesions  more immediately as well as remotely
 consequent  upon inflammation of the pleura
 have been described  above (y 112, et seq.), with
 the exception of gangrene, ulceration, and perfo-
 ration of this  membrane, of which I  proceed
 to take farther notice.
  202. A. Gangrene  of the pleura occurs only
 on very rare occasions, and chiefly as a conse-
 quence  of either  gangrene  of the subjacent
 lung,  or abscess  of this  organ, or  external to
 the costal pleura.  A sphacelated s|ate of  the
 pleura may also occur in an advanced stage of
 chronic pleurisy or empyema in the form of
 gangrenous  ulcers, as remarked  by Laennec,
 Baron, and Chomel, but this is very rare.  Gan-
 grene of the pleura is generally limited to a small
 space, and presents the appearances of irregu-
 lar patches of a brownish green, livid,  or very
 dark hue, that softens, ulcerates, and passes
 into a dark-grayish, dirty, and irregular surface,
 exhaling a fetid odour.   Around these patches,
 indications of inflammatory action, with certain
 of the more usual consequences of this action,
 are generally observed.
  203. B. Ulceration and perforation of the pleura
 are not infrequently met with, and are noticed,
 especially as regards their chief consequences,
 under the head of chronic pleurisy, and in the
 article Pneumathorax.  They may take  place
 under a variety  of circumstances, especially
 when they commence,_ as  more  frequently is
 the case, in the attacked surface of the pleura,
 perforation proceeding from  this  surface  in-
 ward.   In cases  of  abscess, or of tubercular
 softening and  ulceration, or of gangrene of a
 superficial portion of the  lung, softening and
 ulceration of the pleura covering this portion
 thus supervene, and sometimes go on to perfo-
 ration.  Haemorrhage from injury or disease of
 a  blood-vessel,  or  pulmonary  apoplexy, may
 cause rupture of the pleura at the nearest point
 to the seat  of effusion.  Either  ulceration or
 perforation, or rupture of the pleura, may like-
 wise be caused by abscess seated in some place
external to this membrane, as an abscess of  the
lungs,  liver,  &c.; or by hydatids, cysts,  tu-
mours, aneurisms, and injuries of any adjoin-
ing structure or part.  In all these circumstan-
ces the perforation commences in the attacked
surface, and advances into the pleural cavity ;
but  it may proceed from within outward;  but
this is very rarely the case unless in general or
partial empyema, when the matter is evacuated
either through  the lungs or at some part of the
thoracic parietes, as already described (y 87-92).
  204. C. Effusions into the Cavity of the Pleura.
—Those which depend chiefly on inflammatory
action have been described above (y 115, etseq.),
and have been shown to consist of serous, sero-
albuminous, or plastic products, which may un-
dergo various changes of puriform matter, and
more rarely of a sanguineous or sero-sanguine-
ous fluid. Those which take place independent-
ly of  inflammation are simple  serous  or wa-
tery effusive haemorrhages, and the passage,
owing generally to perforation  or rupture  of
the pleura, of gaseous fluids, or of purulent, gan-
    III.             22
 grenous, tuberculous, or cancerous matters into
 the cavity.
   205. (a) Watery effusions, or passive serous
 effusions,  require  no  farther notice than they
 have already received when treating of dropsy
 of the pleural cavity, they being usually inde-
 pendent of disease of the pleura itself (see art.
 Dropsy, y 158, et seq.).
   206. (b) Hamorrhagic effusions into this cav-
 ity, or hamathorax, may proceed from a haemor-
 rhagic form of inflammatory action implicating
 this  membrane, characterized by deficient vital
 powers and a morbid  state of the blood itself;
 or from loss of tone of this surface and of the
 capillaries ramified to it;  or from this slate
 conjoined  with an haemorrhagic tendency,  or
 from rupture of an aneurism, or injury or dis-
 ease of some vessel adjoining or involving the
 pleura.  In  the  former states, the  effusion,
 whether altogether sanguineous, which is very
 rarely the case, or sanguineo-serous, is an ex-
 udation from a greater or less extent of the
 pleural surface, this surface being more or less
 concerned in causing the effusion.   In the lat-
 ter this surface is generally healthy, the blood-
 vessels subjacent  or adjoining  it being princi-
 pally affected.  When blood is effused into the
 cavity  of  the  pleura,  inflammation  is  usually
 thereby produced ; and generally with a rapid-
 ity according to the quantity and purity of the
 blood effused, the  resulting phenomena varying
 with the condition of the patient and circum-
 stances in which he is placed.
   207. (c) The  effusion of gaseous  fluids into
 the cavity of the pleura is considered in the ar-
 ticle Pneumathorax, and of purulent collections I
 have already treated.   Tubercular and cancerous
 productions often  form within the  pleura, but
 they also  appear external to it, as well as in-
 volve its structure, as  will be shown in the se-
 quel.  The passage of gangrenous, carious, ich-
 orous, or  other morbid products, from disor-
 ganization of an adjoining part  into the cavity
 of the pleura, may likewise occur in the man-
 ner already stated ; but, when this takes place,
 inflammation is thereby rapidly eAxerted through-
 out the serous surface.   Simple cysts and hy-
 datids are  rarely or never  formed  within the
 pleural cavity,  and are rarely developed exter-
 nally to it, or, at least, in such situations as al-
 low them to find their way into  this cavity.
   208. D. Cartilaginous and osseous formations,
 or transformations of  the pleura, are not very
 rarely met with.   In  some  instances  these
 changes appear to  exist immediately under or
 external to the pleura, or on its attacked sur-
 face,  the membrane retaining its natural struc-
 ture and polished surface.  In others they seem
 more entirely to involve the pleura, as if arising
 from  thickening and induration  of this tissue,
 and advancing  through the fibro-cartilaginous
 state  to osseous transformation  ; and in°some
 cases they are  confined entirely, or  in part, to
 the false membranes or adhesions  formed'on
 or between the pleural  surfaces.  They evi-
 dently result, as noticed above (y 201), from  a
 state  of chronic inflammation or irritation that
 has passed into morbid nutrition, the fibro-car-
 tilaginous condition beingintermediate between
simple thickening with induration and ossifica-
tion.  They have been found of various grades
of thickness, from a line or two to an inch  and
seated in  or  upon  either the  costal, the'dia 
338     PLEURA, STRUCTURAL LESIONS

phragmatic, or the pulmonary pleura, and in
some cases in the false membranes existing be-
tween and connecting these.   In some instan-
ces the transformation  is neither altogether
cartilaginous nor entirely osseous, bony mat-
ter, in  lamellae, or in irregular forms, and in
detached patches, existing between the layers
of cartilage, or otherwise irregularly deposited.
  209.  These productions are found either in
the form of smooth plates or lamellae, or in that
of irregular nodules, or  they present a rough
surface, with irregular acuminations or points.
They are never met with to  any considerable
extent in connexion with the pulmonary pleu-
ra, without  the subjacent lung being more or
less consolidated.  In rare instances, they have
assumed a  rounded, oval, or globular form, ei-
ther with bases of varying sizes, or with nar- j
row and short peduncles, their surfaces  being
smooth and shining, as if still covered by the
pleura.  These nodules  may be single, or sev-
eral may exist in the same case, their magni-
tude varying from that  of a  pea to that of a
large cherry.
  210.  E. Fatty appendages have  been found
attached to the free  surface of the pleura, but
very rarely, at least entirely unconnected with
adhesions between the opposite surfaces.  I
have met with  these  appendages in  several
cases,  but in all they appear to have been de-
veloped by the formation of  fat underneath a
portion of false membrane, and between it and
the pleura, the false membrane having been of
old date.  In some cases, old adhesions, hav-
ing a polished serous surface, and a thick or
rounded form, have consisted, excepting their
surfaces, entirely of fat.
   211. F.  Tubercles may be formed  either on
the attached surfaces of the pleura in the sub-
serous cellular tissue, or in the pleural cavity.
In the former situation  they  chiefly consist of
numerous small granulations  under the pulmo-
nary pleura ; and sometimes they form more
considerable masses developed beneath the cos-
tal pleura, and causing elevations of the pleural
surface.  Tubercles  are never found within the
pleural  cavity, unless in connexion with false
membranes or adhesions, and infiltrating or
studding these, as described above (y 120), thus
constituting the tubercular form of pleurisy.  But
they may exist in both situations in  the  same
case, as well as in the lungs and adjoining mem-
branes, as  the  pericardium, peritoneum, &c.
Tubercles may be formed underneath or upon
the attached surface of the pleura, as just de-
scribed, and may advance even farther in their
development without any evidence of inflamma-
tory action in their seats or vicinity. But the cir-
cumstance of their constant coexistence with
certain of the products of inflammation, when
they are found within the pleural cavity, or upon
the free or internal surface of the  pleura, sug-
gests the question, whether they are the cause or
the result of inflammation in the tubercular di-
athesis.  That they are merely one of the prod-
ucts of inflammation in this diathesis, are exu-
ded, in a rudimental state, with the lymph pro-
duced  by the inflammation, and are further de-
veloped as the organization and other changes
of that lymph advance, are circumstances ren-
dered  probable by their constant  coexistence
with these products; while the opposite doctrine,
that they are the  causes of the inflammation,
 OF  THE—Symptoms  and Signs  of.

and  of the consequent exudation  of lymph in
which they are  enveloped, necessarily allows
that  they are  first thrown out or formed upon
the free serous surface, where they excite  the
irritation and inflammation, with  its conse-
quences found in connexion with them.   Now
if they are thus formed on the free serous sur-
face, before  inflammation is  developed, it is
reasonable to infer that they should be found,
in some instances, before this effect is pro-
duced, or produced to an extent rendering the
cause doubtful;  but this has hitherto not been
remarked (see y  120).
  212.   G.  The  several forms  of malignant  or
cancerous degenerations have been observed  in-
volving the pleura, but generally consecutively,
never primarily.  These lesions, whether schir-
rous, carcinomatous, encephaloid, or fungo-
haematoid, when they implicate the pleura, are
consequent upon their existence in some other
part  of the  economy, most frequently in the
mamma, in the axillary glands, or in some oth-
er situation in the vicinity.  They first extend
to the subjacent cellular tissue, causing an  ir-
regular  thickening and  induration, with their
characteristic forms of degeneration of this tis-
sue,  and an irregularity or unevenness of the
serous surface,  which  ultimately becomes va-
riously changed in color and consistence, ac-
cording to the form and progress of the mala-
dy, until it altogether loses its natural hue, and
is altogether involved  in the malignant struc-
ture, .^t this advanced stage the  surface and
cavity of the  pleura generally present more or
less  of a turbid, dirty,  ichorous, or sero-san-
guineous fluid, which is sometimes also offen-
sive, or of a peculiar odour.
  313.  ii. Symptoms and Signs of Structural
Change of the Pleura.—The symptoms and
signs of these changes  are mostly the  same as
have been described above as indicating the
progress and  advanced stages of inflammation
of this membrane.   Those changes, which are
essentially the  result  of inflammation, most
necessarily present these  symptoms and signs
which,  in connexion with the history of the
case, usually show the nature, if not always
the  exact extent,  of the disease.  But those
lesions  which consist  of adventitious forma-
tions, as regards either the situation or the
economy, frequently advance without  any dis-
tinct symptom or sign  from which their exist-
ence may be  inferred.
  214. (a) Gangrene of the pleura (y 202) being
met  with chiefly as a consequence  of gangrene
of a  portion of the lung, is preceded by the indi-
cations  of this occurrence.   When the symp-
toms of gangrene of the lungs (see Lungs, ,
173-175) are followed  by an  acute pain in the
side, painful  cough  and inspiration, extreme
anxiety and depression, followed generally  by
all the usual symptoms of the  utmost vital ex-
haustion, then this lesion may be inferred.  The
physical signs may consist merely of dulness in
percussion, of greater or less extent, with ab-
sence of the respiratory sound.
  215. (b) Ulceration of the pleura (y 203) is an-
nounced only when it has terminated in perfo-
ration.   If the ulceration  has proceeded from
the  attached  surface  into the cavity  of the
pleura, the passage  of  the  matters, whether
gangrenous,  puriform,  tuberculous, aeriform,
&c,  the patient very suddenly  experiences 
PLEURA, STRUCTURAL LESIONS OF THE—Treatment.
339
 acute pain  in the  side, with  oppression, dysp-
 noea, and anxiety ; and if air passes rapidly into
 the pleural  cavity, these latter symptoms  are
 not only sudden, but also extreme, and are at-
 tended by the physical  signs of pneumathorax.
 When ulceration, followed by perforation, takes
 an opposite  course, proceeding from the inter-
 nal cavity externally, as stated above (y 203),
 then the  symptoms already described (§ 87, et
 seq.) as attending  empyema, when terminating
 in this way, are usually observed.
   216. (c) Acute or inflammatory effusions into
 the pleural cavity have  been  already fully no-
 ticed (y 204-207)  as  respects  the  symptoms
 and signs they produce, and  passive effusions
 into this  cavity have been elsewhere treated
 of (see art. Dropsy, y 158, et seq.).  Effusion of
 blood into this cavity, kamathorax, unless when
 it occurs from rupture of an aneurism, or from
 external injury, is a rare occurrence, as shown
 when treating of hemorrhage into the pleural
 cavity (see art. Hemorrhage, y 277).  As a pure
 exudation in this situation, it is very rarely met
 with, although  the exhalation of a greater  or
 less proportion of red  particles with the serum
 of the blood, in some extreme cases of asthen-
 ic acute pleurisy,  or  of cachectic pleurisy, is
 not very infrequent, and constitutes the hamor-
 rhagic pleurisy of Laennec  Hamalhorax—or
 the  effusion of blood into  the pleural cavity,
 analogous to the haemorrhages, active or pas-
 sive, of other organs or surfaces—is so rare,
 that the phenomena  attending or consequent
 upon it have not been satisfactorily  observed,
 and they are hence imperfectly described.   But,
 whether the blood poured out in this  situation
 be  a primary  lesion, or consecutive  of some
 other, or of local injury,  I cannot view it, with
 M. Laennec, as an occurrence devoid of im-
 portance,  as regards its  effects upon  the  pleu-
 ral cavity, or believe that the  blood effused  in
 this situation will be absorbed without produ-
 cing inflammation in this cavity.  My experi-
 ence has proved that, although absorption does
 take place,  inflammatory  action, varying  in
 character and intensity with the circumstances
 of the patient, is the most frequent result, as I
 have already shown (y 206).   It must be ad-
 mitted that  effusion  of  blood into the pleura
 will produce similar symptoms to those result-
 ing from other effusions to the same amount.
 But  it will be  generally observed that indica-
 tions—either local  or constitutional,  or both__
 of inflammatory action of the  pleura will soon-
 er or later supervene ; and that the products  of
 this  inflammation,  mingled with altered  and
 nearly absorbed blood in  the pleural cavity, will
give  rise to peculiar appearances, on examina-
tion after death, more distinctive of the imme-
diately antecedent inflammation, than of the
haemorrhage which developed the inflamma-
tion.  I have nothing to add at this place  to
 what I have stated above respecting  the symp-
toms and signs of purulent or of other effusion
 into the pleura (y 63, etseq.), and have advanced
 in the  art. Pneumathorax, when noticing the
 combination of aeriform and fluid effusions into
 this cavity.
  217. (ji)  Cartilaginous and ossific formations  in
the pleura are not  indicated  by symptoms  or
signs during life. They  are merely contingent
 changes, occurring  after chronic pleurisy, and
 are met with chiefly in persons who have lived
 for a considerable time after such attacks, with
 more or less disorder of the respiratory func-
 tions, and probably with dulness on percussion,
 or with imperfect or absent respiratory mur-
 mur; and although their existence may possi-
 bly be in some instances suspected during life,
 they are unattended by any peculiar symptom
 or indication.
   218. (e) Tubercles formed immediately beneath
 the pleura, occasioning  small or irregular ele-
 vations of the membrane (y 211), without much
 effusion,  are generally attended by a rubbing
 sound during respiration ; but if effusion exist,
 or if the  tubercles be deposited in false mem-
 branes, their presence can  be suspected only,
 and chiefly from the coexistence of the pleu-
 ritic  lesion with  tubercular  consumption, or
 from the occurrence of this  lesion in the scrof-
 ulous diathesis.   Tubercular  formations are
 most frequently found in one side only,  in the
 same case, but they may exist in both cavities;
 and they may be present in both the pleura and
 in the pericardium.   When this latter compli-
 cation occurs, without much effusion within the
 pericardium, there is generally  a cardiac rub-
 bing sound in connexion with a similar  sound
 during respiration.
   219. (/) Cancerous or malignant alterations in
 the pleura may be inferred from  the  gradual,
 nearly latent, and chronic or sub-acute form, in
 which the pleuritic affection supervenes upon
 malignant diseases of the mamma, or in the
 vicinity of the thorax;  and  from the  presence
 of symptoms and physical signs similar to those
 attending tubercular formations in this  mem-
 brane. The rubbing  sound generally continues
 for a considerable  period, and until the subse-
 quent effusion becomes copious ; and the pleu-
 ritic symptoms appear chiefly when the cachexia
 attending the cancerous malady is well marked,
 and the system manifests more or less of the
 usual accompanying  anaemia.
  220. iii. Treatment.—The treatment of the
organic lesions of the pleura now passed  under
 review,  should be  directed entirely by the cir-
cumstances of  the case, and  by the evidence
 furnished  of their individual existence, and of
 their morbid associations.—(a) If there be rea-
son to infer the supervention of gangrene of this
membrane, treatment is then very rarely of any
farther avail than to prolong existence for a few
 hours, or at most a day or two ; and this object
can be attained only  by the exhibition of resto-
ratives,  &c.,  as camphor,  ammonia,  quinine,
myrrh, ammoniacum, &c. ; for, although recov-
ery from gangrene of the substance of the lungs
 may take  place by the aid of these or similar
 means, it is very rarely  procured when this le-
sion has extended to the pleura.
  221. (b) a\s to  the treatment of ulceration and
 perforation of, and effusions  into, the pleura,  I
can add nothing to what I have recommended
to  be done for the more  advanced stages, and
 more chronic forms  of pleurisy  (y 63,  et seq.),
 for which, however, and more especially for the
 more simple states of effusion, the means there
 advised, when judiciously administered, will be
 often  very successfully employed, especially
 when aided by a free use of the acetate of pot-
 ash, so as to act manifestly both  upon the bow-
 els and  kidneys;  and by the external means
 above mentioned (y 175, et seq).   If the causes
 and circumstances of the disease lead to the 
340
PLEURA—Bibliography  and References.—PLEURODYNIA.
inference  that much  blood is effused into the
pleural cavity, or that this fluid constitutes the
larger part of the effusion,  I believe that the
operation  for empyema should  not  be delayed,
otherwise inflammation, if it have  not already
appeared,  will certainly supervene, in a form
not readily removed by treatment, inasmuch  as
the blood,  or at  least its unabsorbed  portion,
will remain to perpetuate the  disease, and fa-
vour the occurrence of consecutive lesions.
   222. (c)  The treatment of the other organic
lesions of  the pleura  promises  but  few advan-
tages when their presence are  even presumed.
Tubercles are very rarely  present  in this mem-
brane, without  existing in still greater abun-
dance, and often in advanced states, in the lungs
or other structures.    Hence  the treatment re-
quires to  be  directed in  many cases more  to
these organs  than to this special lesion; and,
even when the features of the case warrant the
direction of remedies principally to this seat  of
disease, it will be difficult to suggesto thers more
likely to be beneficial  than those advised above
for chronic pleurisy (y 175-179).  The mistura
ferri composita, the  iodide  of potassium, the
iodide of iron, the liquor potassae with tonic in-
fusions and sarsaparilla, or these variously com-
bined, or conjoined with such other substances
as the peculiar circumstances  of the case will
suggest,  are most  generally   appropriate  for
these lesions, as  well as  for  the effusions  into
the pleural cavity, by which  these  lesions are
often attended, especially when aided by suita-
ble  means for the promotion  of the alimentary
and renal  evacuations, and by  external  deriva-
tives.

  Biblioo. and Refer.—Hippocrates, Tlrfi Toroiv, Ac,
Opera, p. 414 ; et Tlepi rav Eitoj ILiOwv, Op., p. 515, 534.
—Galen, De Loc. Affect.,  1. v.,  ch. 3.—Celsus, 1. iv., ch. 6.
—Areteeus,  Cur. Acut., 1.  i., ch. 10.—Altius, viii., 76.—
Alexander Tral., vi. i.—Oribasius, Synopsis, Ac, ix , 7, 8.
— Actuarial, Method. Med., iv., 4. — Calius Aurelianus,
M"rl». Acut., 1. ii., 13.—Octavius Horatianus, ii., 4.— Mar-
cellus, De Medicam., 24.—Serapion,  u., 21.—Mesue,  De
AEgTit. Pect.,7.—Avicenna, Canon, 1. iii.. 10,4.—Haly Ab-
bas, Theor.. ix., 21; Pract., vi.,  13.—Rhases, Divis..  54.—
Paulus jEgineta, 1. iii., ch. 33. (Transl. by F. Adams, for
Sydenham Society, p. 496.)—F. Bonafides, De Cura I'leu-
ritidis per Ven<£sectionem. 4to.  Venet., 1533.—A.  Jurinus,
De Duratione Plenrit. perVenaisectionem,4to.  Basil., 1527.
— V. Benedictus, De Pleuritide Liber, 4io.  Venet., 1536.—
/. F. Arma, De Pleuritide, 8vo.  Ferrnra, 1549.—P. Brxsso,
Apologia de Incisioue Verne in Pleuritide, Svo.  Paris, 1558.
—Trincavelli, De Vena secanda in  Pleuritide, 8vo.  Pat.,
1563.— V. HalUri, Bilil. Med. Pr., t. ii.. p. 46— Vesalius, in
ibid., t. ii., p. 32.—W. Builtyn.  Regimen against the Pleu-
risy, 8vo.  Lond., 1562.—F. Cassanus, De Vena;  Sectione
in Pleurit., 12mo.  Patav., 1564.—J. Wyer, Obsvrvationuni
rararum Liber, de Scorb.  Pestilenti,  Angina, Pleuritide,
Peripneumonia, Ac, 4to.  Basil., 1567.—F. Cigalini, Epist.
de Oxymellis Usu in Pleurit., Svo.   Tigur..  1592.—R. Mo-
reau.De Missione Sanguinis in Pleuritide, 8vo.  Paris, 1622;
pt De Loco  affecto in Pleuritide, 8va  Paris, 1641.—M.
Ruland, Utrum in omni Pleur. Venndextri Cubiti secanda?
Svo.  Basil., 1627.—Amatus Lusitanus, Cur., cent, i., Nos.
12, 53, 59.—.V.  Wright, Theses Mediae de Pleur. Vera,
4to, 1635.—Ballonius, Opera, t.  i., p. 24 ; t. iv., p. 313.—V.
Martinii, Opuscula de Vesirantibus, de Orfhopnrea Pleuri-
tidis, Ac, 4to, 1636.—Zacutus  Lusitanus, Med. Pr. Hist.,
1. ii.;  et Prax. Admir., 1. i., obs.  104.— V. Baromus,  De
Pleuropneumonia Flaminiam Populantur infestante,  4to.
Forol., 1635.—G. Ballonius, Liber de Rheumatismoet Pleu-
ritide Dorsali, 4to.  Paris, 1642.—Riverius, Observ., cent.
ii., No. 63.—B. Baldi. De Loco affecto in Pleuritide, b>u.
Rome, 1643.—A. Cleti, Circa Partem  affectum Pleuritide,
8vo.  Rom., 1643 —Diemerbroeck, Anat., 1. ii., c. 13, p. 309;
et Disp. de  Morb. Thoracis, No. 1.—Bartholinus, De Vsu
Nivis Medico, ch. 26.—Prosper Alpinus, De Med. jEgypt.,
1. iii., cap. 4.—A. Banda, Discours contre PAbus des Saig-
n*es, qui  pronve que la Saignee n'est pas I'unique ni le
plus assure remede des Pleurisies, 8vo.  Sedan, 1672.—
Sydenham, Opera Edit. Societ.  Sydenhami, Svo. p. 244.—
 Willis, Phannac. Ration., p. ii., sect, i., c. 8.—J. S. Knisel,
Historia Pleuritidis et Abscessus Pectoris,  4lo.   Tubing.,
1630.—C. Yon Compen, Collectanea Theraneutico de Pleq.
ritide  et Apoplexia, S*o.  Breda.  1692.—F. H. a Fonseca,
Pletirologia, de Pleuritide ejusque Curatione, 4to.  Lisb.,
1701.— .4. Pascali, Observat. de Pleuritide,  4to.  VeueL,
1"02.—Bonet, Sepulchetum, 1. iv., s. i., observ. 3,2(1, 45.
— F. Hoffmann, De  Pleuritide et Peripneumonia, Opera
Suppl., t. i ,  p. 165.—Baglivi, Prax., 1. i.. Opera, p. 35.—
J. B.  Verna, Prmceps Morbor. Acutor. Pleuritis, 4lo.  Ve-
net., 1713.—A. Camerarius, et J.  G. Seeger, De Pleuritide
Maligna; in  Halleri, Disp. ad Med., Ac, vol. u.—Fnead
Comment, de Feb., No. v.— Giffard, in Philosoph. Trans.'
No. 395.—/. Tennent, Epistle to Dt. Mead, concerning to*
Epidemical Diseases of Virginia, particularly Pleurisy aid
Peiipneumony. 4c, 12mo.  Edin., 1742.—Dover, Legacy
Ac, p. 144.—Huxham. Opera, t. ii., p. 168.—J. N. BouiOet,
Meuiotre sur les Pleuropneumonias Epidemiques, 4u>, 1759!
—Morgagni, De  Sed.  et  Cans. Morb., Ep. xx. et  xii.—
Wright, in Med. Facts and Observations, vol. vii., art.  i.—
G. V. Zeviani, Della Rachitide,  et della  Pleuritide,  4to.
V-rona, 1761.—aV. Flemyng, On Adhesions of the Longs hi
the Pleura. Svo.   Lond., 1762.—Chalmers, On the Weather
and Dis. of South Carolina, vol. ii., p. 106—Berlin, An in
Pleuritide Sanguis mittendus e Brachio Lateris affecti, 8ro
Paris, 1763.—D. W.  Triller, De Pleur. .^Estiva; in  Opus-
ciil  vol. i., 4to.   Lips., 1766.-CJ*^Aom, On the Disease)
of Minorca, &c, p.  238.-Mursinna, Von  Faulfiebem, p.
154.—B.  L. Trallea, Commentatio de Usu  Vesicantiura in
Pleuritide, 8vo.   Bresl., 1776—S. Musgrave, Gulstonian
Lectures^ Ac, on the Pleurisy and  Peripneumonia, Svo.
  „".' !• '9—fta«<rf, m Act. Reg. Soc. Med. Hann.,t  iii.,
p. 246, et t. iv., p  216.—Bang, in  ibid., t. i., p.  IO.-Cstfi-
sen. in ibid., t. i., p. 60.—De Haen, Rat. Med. Pr., t. n.,ch.
2.—Hamilton, in Edin. Med. Comment., Ac, vol. ix., p. ".-
Thomann, Anaales VVirceb., t. i., p.  9.—C. Strack, Nova
Theona Pleuritidis, Ac, 8vo.  Mogunt..  17s6- Vi.ri-.riw,
De Signis Diagnosticis er Prognostics PleuntiJis, <kc.,4to.
Giess., 1786.—.V. Stoll. Rat. Med. Pr., t. ii., p. 368;  t.  iii.,
p. 54, 115 ; t vii., p. 182.—Sims. Observations, Ac. p. 45.
—Millar, Observations on the Prevailing Diseases of Greal
Britain, p. 20.—F. Fiorani. Suggi0 s„na Pleur. Biliosa Ep-
            .   Firenz.,  1792.-G. J. Maschkt, Histom
idemica,  bvo.
 Litis de Loco Vemesectionis in Pleur., 4to.  Hal. 179J.—
 Portal, in Mem. de l'-Acad. des Sciences a Pans, 1789- et
 Sur le Traitement de plusieurs Malad., Ac, t. ii'., p. 54.—
 Gebrl, in Hufeland's N. Journ. der Pract. Arzneyk., t. i.,
 p. 180.—Conradi, in  ibid., t.  \ii., ». 763— C. Racine, Re-
 cherches sur la Pleuresie et la  Penpneumonie latent*
 Chromque, 8vo.  Paris, 1803— Pmel el Bricheteau, in Diet.
 des Sciences Mdd., t. xlm., p. 185.—G. Andral, Clinique
 Medicale, t. in., Svo.  Paris, 1826.-CAo.ie/, Dtct.de Med.,
 t. xvii.—Law, Cyclop,  of Pract. Med., vol.  iii  p  337 —
 Andral, Archives Generales de Med., t. ai., p."246.  (On
 Inflammation of the  Diaphragmatic Pleurt')—Bonnet, in
 ibid., t. xxi., p. 86.—Schmidtmunn, Observat. Med., t. i., p.
 104.—jf. Gintrac, Le Diagnostic des  Affectiois Aigiies'et
 Chroniques des Organes Thorachiques. &w.  Lond.  1886.
 —T. H. Laennec, Treat, on Dis. of the Chest, At.; transl.
 by J. Forbes, 3d ed.. Svo.  Lond., 1 !>29, p. 426.-7. Houston,
 Descrip. Catal. of Prepar. in the Mus. of Coll. of Sorg. in
 Ireland, vol. ii., Pathology, p.  171.— M. Histz, Recherches
I Cliniques surquelques Pointsdn Diagnosticde la Pleuresie;
 dans Archives Gener. de Medecine, 2d ser., t.  xiii., p. 171,
 1836.— Heufelder, Sur la Pleur. Chron.  et l'Enipyema; in
 ibid., 3d ser.. t. v.. p.  59, 1839.— Cruveilhier, Diet, de Mai
 et Chirurg. Prat., t. iii., 8vo.  Paris, 1835.—TV. Stokes, A
 Treatise ou the Diagnosis and  Treatment of Diseases of the
 Chest, 8vo.  DuLl., 1837, p. 459 ; Lancet, No.  619, p. 4M.
 —C. J. B.  Williams, The Pathology and Diagnosis of Dis-
 eases of the Chest.  &c, 4th ed., 8vo.  Lond .1840, p. 103,
 and Library of  Medicine, vol. iii., p. 10s.  Med. Gazette,
 March, and Apr. 28, 1838, p. 2. 161.— Watson, in Med. Ga-
 zette, Jau. 27, 1838, p. 696 — Wilson, in ibid., June 10,1637,
 p. 395.— Porral,  Journ. Hebdom.  de Med.,  t.  iii., p. 215.
 (Hamorrhagic Pleuritis, and  Hamorrhage into Pericardi-
 um.)—Graves. Clinical Medicine, Ac, p. 792. — Greene,
 Dublin Journal  of the Medical Sciences, vol. xvn., p. 27S.
 — R. L. Mac Donnell, On Empyema; in ibid., vol. xxv., p.
 1.  (An excellent Memoir.)—P. C. A. Louis, Researches on
 Phthisis, Anatomical. Pathological, and Therapeutical, 2d
 edit.;  transl. by  W. H.  Walshe for the Sydenham Society,
 8vo.  London, 1844, p.  276.—C. E. Hasse, An  Anatomical
 Description of the  Diseases of the Organs of Circulation
 and Respiration; transl. by W. E. Swaine for the Syden-
| ham Society. 8vo.   Lond., 1846, p. 181.—C. RtkitanM,
 Handbuch der Pathologischen Anatomie, 8vo.  Wien., 184J,
I b. iii.,  p. 43.—G. Williamson, Catal. of Prepar. in Museum
I of Army Med. Dep. Fort Pitt, Ac, Svo. Lond., 1845, p.
 96.—J. Paget, Descrip. Catal. of Anat. Museum of St. Bar-
 tholomew's Hospital,  8vo.   Lond.. 1846, p. 282.
i   [For Am. Bib., see various works on the Theory and Pme-
I tice of Med. and Pathology, referred to onder  Pneumonia,
 Phthisis, Ac. ; also various Am. Med. Journals, passim.]

 PLEURODYNIA.—Synon. Pleuralgia, Pleuro-

    dynia (from n'kevpd, the side, and biirvn, pain) 
PLEURODYNIA—Causes of—Description—Diagnosis.
341
   Pleuritis spuria, pseudo-plturitis.   Neuralgia
   thoracica, Pleurodyne, Auct. Var.  Dolor late-
   ris.  Rkeumatismus Pectoris, Naumann.  Pleu-
   rodynie, Point de Cdte, Fausse Pleurisie, Fr.
   Der Seitenschmerz, derfalsche Seitenstich, Ger.
     Classif.—I. Class,  IV. Order (Author).
   1. Defin.—Pain in the  side, usually occurring
 and ceasing suddenly, independently of any phys-
 ical sign of inflammation of the pleura, and gen-
 erally connected with rheumatic, neuralgic, or hys-
 terical affection.
   2. Pleurodynia and pleuralgia are names in no
 way applicable to  the  painful affection under
 consideration, inasmuch as there is no evidence
 in favour of the pleura being at all implicated in
 it, unless it change its nature, or superinduce
 or pass into  pleurisy.  If, however, the  word
 nXevpa be viewed, as it was by the ancients, as
 meaning the side, without reference  to any par-
 ticular part or structure of the side, these terms
 will appear much less objectionable.   That this
 affection is not always rheumatism of the chest,
 as implied in the name given to it by Naumanx,
 is a fact which experience will soon teach  the
 inexperienced.  Nor should it be viewed, as it
 has been by M. Jolly and others, as inflamma-
 tion of one or more of the muscles of the tho-
 rax.   But it is often connected with rheuma-
 tism, either in some other part of the body, or
 with the rheumatic diathesis; and  it may be
 converted or pass into inflammation of the  pleu-
 ra, or of the  pericardium, owing either to the
 predisposition  and  constitution of the patient,
 or to injudicious treatment.   When it thus pre-
 sents a rheumatic character, then it is to be
 viewed and treated as I have advised in the ar-
ticle Rheumatism,  although it is by  no  means
demonstrated, however frequently it has  been
assumed, that the pain constituting the  princi-
pal feature of the disorder is caused by an  af-
 fection of the intercostal muscles,  or  of the
 fibrous fascia lining the chest.
   3. I. Causes.—Persons of a nervous, suscep-
 tible, or irritable temperament; of the rheumatic
 and hysterical diathesis ; those who are exposed
 to atmospheric vicissitudes, to currents  of cold
 air, to marshy or humid exhalations, or to cold
 or wet in any way, and those who live in damp,
 cold, and low houses, or in cellars, <fcc, are the
 most liable lo experience those rheumatic and
 neuralgic affections in the  side which have
 generally  received  the name of pleurodynia.
 Owing to the greater exposure of males  than
 females to these causes, the former are most
liable to them;  and adults and aged persons
are more frequently affected than children and
young persons.  But all  the causes of inordi-
nate excitement, and of exhaustion or direct
depression of the nervous system, both predis-
pose to, and more  immediately occasion, pain-
ful affections, in  either side, as well  as in other
parts of the body.  Owing to the prevalence of
the above causes,  especially those which pro-
ceed from season, climate, and the soil and wa-
ter of a locality, pleuralgic affections may be
so prevalent as to be endemic, but they can rare-
ly be considered as epidemic, or as being so
generally prevalent, even in those localities, as
to deserve that character.
  4. II. Description.—Pleurodynia varies much
in character  with the causes which  produce it,
and according as it occurs in a rheumatic, neu-
ralgic, or hysterical diathesis, or presents either
 of these forms.—(a) In the first of these forms,
 it may be either acute or chronic ; in the former
 it is sudden, severe, lancinating, increased upon
 pressure,  even upon the slightest pressure or
 contraction of the  affected muscles.   It often
 ceases as suddenly as it appeared, the pain shift-
 ing, or having shifted, to some other part.  This
 more acute state of the affection is frequently
 attended by more or less fever, and the other
 phenomena of acute rheumatism.  The chron-
 ic state  is generally prolonged for many days,
 sometimes subsiding altogether for a time,  and
 then suddenly recurring either in the same place,
 or in the vicinity.   It occasionally ceases  du-
 ring the  day, and recurs at night; or it disap-
 pears when warm,in bed, to return at some pe-
 riod of the day.  The pain is exacerbated du-
 ring respiration ;  but this  may  take place ei-
 ther during  inspiration or  expiration  only or
 chiefly,  according as  the muscles and  nerves
 supplying be inspiratory or expiratory.   Cough-
 ing, sneezing, and all movements which affect
 the  muscles, occasion a sharp or cutting pain
 of the  part.
  5. (b)  The hysterical and neuralgic forms of
 pleurodynia are more manifestly seated in  the
 sentient  nerves than the rheumatic, and are re-
 ferred  chiefly to some part between the ster-
 num and spine.  They are often connected with
 irritation about the origin of the dorsal  nerves,
 or in the ganglionated roots of these nerves;
 this irritation, whether functional or inflamma-
 tory, being either  seated  there, or reflected
 thence from the renal or  sexual  ganglia, or
 nerves, or  from the uterus and ovaria.  These
 forms of pleurodynia are much more frequent
 in adult females than in males ; in the nervous
 and irritable temperament;  in persons who are
 subjects of anaemia, or who are liable to irregu-
 lar determinations or distributions of blood; and
 in those especially about the period of the cata-
 menia, and when this discharge is irregular, dif-
 ficult, scanty, or interrupted.  (See art.  Hys-
 teria, y 78, et seq., and Neuralgia, *■ 89, el seq.)
  6. (c) Occasionally cases occur in which the
 pain cannot  be referred either to rheumatism
or to any neuralgic  or hysterical  condition, but
rather to disorder of some one of the digestive
viscera; to either the stomach, the duodenum,
the colon,  or the liver.  In these  cases flatu-
lence is a very prominent symptom, the pleuro-
dynia being entirely sympathetic of the disten-
 tion or irritation caused by  the flatus contain-
 ed in one or more of these viscera.   But, in  ad-
 dition to  this symptom, other indications of dis-
 order of  the  digestive organs are usually pres-
 ent, especially  a loaded tongue,  the edges  be-
 ing red or flabby ;   an irregular and flatulent
 state of the bowels; and an unhealthy condition
 of the secretions and excretions.  These symp-
 toms are, however, often present in the other
 forms of  pleurodynia, but they exist in this gen-
 erally in  a very prominent manner, and without
 any evidence of rheumatism, or of hysteria hav-
 ing been  previously complained of.
  7. III. The Diagnosis  of pleurodynia rests
 upon, 1st, the phenomena immediately connect-
 ed with  the painful affection;  and, 2d,  the ab-
 sence of the symptoms and physical signs  of
 pleuritic, pericardiac,  and  pulmonary disease
 If pleurodynia  occur in  connexion with rheu-
 matism or in the rheumatic diathesis, or if the
 patient be subject to any form of hysterical  af- 
342
PNEUMATHORAX—Pathology of.
fection, or furnisn any indication of spinal irri- j
tation, or he liable to disorder of the catainenial
discharge, then  it may be suspected that the
pain is independent of inflammation of the pleu-
ra or lungs : but the suspicion can  be confirm-
ed only  by a careful examination of the chest
by percussion and auscultation, and by the ab-
sence of the physical signs attending inflamma-
tory or structural diseases of the thoracic vis-
cera.   The  negative  evidence  thus furnished,
the absence of many of the  rational symptoms
of these diseases, the manifest nervous.or rheu-
matic, or dyspeptic character of the affection,
and the several causes or circumstances which
appear to have produced it, will generally guide
the careful observer to a correct  conclusion as
to its nature and morbid relations.
  8. IV. The Treatment should depend upon
the conclusion thus arrived at.  If the affection
be manifestly rheumatic, the treatment advised
for Rheumatism is required ; and if the patient
be  young,  robust, plethoric, &c,  a moderate
bleeding from the arm, or  the application of
leeches to the  side, may precede other reme-
dies.  When the  pain seems to depend upon
disorder of  the digestive organs, or upon bilia-
ry or other colluvies,  then a  suitable but smart
emetic, followed, after an interval, by cholo-
gogue aperients, by a warm bath, and by di-
aphoretics,  will  generally remove it.  As this
affection is  merely the manifestation of a dis-
order seated more internally or deeply, the sup-
pression of it by external applications  should
be  avoided until  the primary affection is re-
moved by a treatment directed to it entirely or
chiefly ; and when all disordered secretions and
excretions are removed, and when the functions
and tone of the digestive organs are restored,
then whatever of painful affection  may remain
may be treated by rubefacient and anodyne em-
brocations or applications,  by  tonics, and  the
other means advised for Neuralgia. The treat-
ment should in  every respect be directed  con-
formably  with the morbid relations which the
case  may present. The very  general connex-
ion existing, in  females, between this affection
and disorder  of the catamenia requires  that
treatment should be more especially directed to
the removal of that disorder.  In this form of
the affection, as well as in every other, the in-
tentions and means  of cure should have for
their objects the precise origin of this  and of
its associated  evils,  and the  removal  of the
source  of them just adverted to ; for as long as
it exists the symptomatic effects will recur again
 and again,  or whenever circumstances favour
their evolution.
  Bibliog. and R.EFER.—D. G. A. Richter, Die Specielle
 Therapie, b. i., p. 407.—Chamberet, in Diet, des  Sciences
 Medicales, vpl. xliii., p. 217.—J. Jolly, in Diet, de Med. et
 Chirurg. Prat., art. Pleurodynie. — Williams, in Lib. of
 Pract. Med., vol. iii., p. 134.
 PNEUMATHORAX. —Synon.  Pneumothorax,
   Itard.  Pneumathorax (from  Ilvei^a, air, and
   tiufiat;, the chest).  Pneumatothorax.; die Luft-
   Irust, Germ.   Pneumothorax, Fr.
     Classif.—IV. Class, II.  Order (see Pref-
     ace).
    1. 'Defin.—The presence  of air in the pleural
 cavity,  occasioning collapse or compression of the
 lung, extreme dyspnaa  and  anxiety, and obvious
 physical phenomena.
    2. I. Pathology of.—Pneumathorax is the
consequence of lesions,  generally of both the
lungs and the pleura, or rather of the lung im-
plicating the pleura, allowing the irruption of
air into the  pleural cavity, and thereby sudden-
ly occasioning severe circumscribed pain in one
side, great anxiety, and extreme dyspneea.  It
may occur at any period of the course of phthi-
sis ;  and, as in one case in my practice, it may
even  take place before the  patient has com-
plained, or had recourse to medical aid.  This
dangerous and generally fatal result of pulmo-
nary  tubercles has  attracted attention  only in
modern times.  It is usually developed as fol-
lows :
   3.  (a) A tubercular cavity may extend to the
pleura, inflame, and ultimately  perforate this
membrane,  before adhesions have formed be-
tween the opposite  surfaces, and thus  the air
will pass into the cavity of the pleura.   This is
the most common way in which pneumathorax
occurs.—(b) One or more tubercles may form
so close to the pleura as to perforate this mem-
brane, and open into a minute bronchus, in the
course of softening, even at  an early period of
the pulmonary disease, and without having pro-
duced a limited inflammation of  the pleura, or
adhesion of the opposite surfaces, at least in a
sufficient degree to prevent the passage of air
into  the cavity of the  pleura.  This, however,
does  not  occur so frequently as the former;
yet  I  have met with two  cases.—(e)  In the
course of partial pleurisy, the absorption of the
contained fluid may leave a void, which is not
occupied either by a contraction of the parietes
of the chest or by  the  lung, which continues
either condensed, or bound down by adhesions
or false membranes.  This vacuum, which may
be either  very small or more considerable, con-
tains air secreted by the surfaces, by which the
fluid  was absorbed.   Dr. Williams  mentions
two cases of this  kind ;  but  this  is a rare form
of pneumathorax.—(d)  It has been  supposed
that the products  of pleurisy may undergo such
changes as will develop a gaseous fluid, espe-
cially in the more cachectic states of the dis-
ease,  and at an advanced period, or shortly be-
fore death.   Without denying the possibility of
this occurrence before death, it may be admit-
ted to take  place, in some instances, soon after
death. There is  not, however,  sufficient evi-
dence of this  change in the effused fluids in
pleurisy having supervened during life to allow
of its  being ranked as a variety of pneumatho-
rax.—(e) Air may also be present in the cavity
of the pleura, owing  to a  fistulous   opening
through the parietes of the chest, or in conse-
quence of  a fistulous .communication between
this cavity and the bronchi  on the one hand,
and the external surface on  the other.
   4. The intimate adhesions  which usually form
between  the pleura covering the tuberculated
portion of  lung and the costal  pleura  obviate
the  occurrence of  pneumathorax ;  yet when
these adhesions either  do not take place, or
when they are either incomplete or not  inti-
mate, and the  softened tubercles or the extend-
ing  ulceration perforates the  pleura, then the
air  passes  into the cavity,  distends  it, com-
presses the lung, and gives rise to the symp-
toms and physical signs of this organic mischief.
 Most frequently the resulting  perforations are
 small, consisting  of an oval aperture, or small
! fissure, three or four  lines long, frequently in 
PNEUMATHORAX—Symptoms of.
343
 the midst of a soft, dirty, grayish, or yellowish
 texture, which is easily torn.   There is usual-
 ly only one perforation ; but several in the same
 case have sometimes been met with.   The per-
 foration occurs in about five sixths of the cases
 near the angles of the  third or fourth ribs; that
 is, in a  place corresponding with that where
 pain was felt, and  where  pleuritic adhesions,
 when not  general, commonly terminate.   In
 other cases it is more  or less distant from the
 apex of the lung ; but it very rarely takes place
 at the apex, owing to the frequency of adhe-
 sions in this situation.
   5. Perforation of the pleura, occasioning pneu-
 rnathorax, is much more frequent on the left
 than on the right side.  This is probably owing
 to the somewhat more frequent occurrence, and
 the  more advanced progress, of tubercular ul-
 ceration in the left than in  the right lung.  Dr.
 Reynaud found, in forty cases of perforation,
 ascertained  by post-mortem examination, that
 this lesion was twenty-seven times on the left
 side, and thirteen  times on the right; and  in
 ten  similar cases, not  demonstrated  by  exam-
 ination after death, the left side was affected
 in six cases,  and the right in four.  Dr.  Hasse
 met with pneumathorax nine times on the left
 and seven times on the right  side.   M. Louis
 observed this lesion seven times on the left
 side, out of the first eight cases which occurred
 to him.
   6. The perforation generally  depends upon
 the  progress of ulceration, usually tubercular,
 very rarely gangrenous, through the  pleura.
 In ordinary circumstances,  when ulceration ap-
 proaches the pleura, inflammation, with the ex-
 udation of plastic  lymph, supervenes at that
 part of this membrane which is nearest the ul-
 cerated cavity, and protects that part of it, ei-
 ther by  covering it with a thick false mem-
 brane, or by uniting it  to the opposite surface
 by this medium.   If a firm  adhesion of the sur-
 faces has formed, and the ulceration proceeds,
 perforation  of both the pleura and the false
 membrane takes place without  being followed
 by pneumathorax ; and even the parietes of the
 chest may ultimately be perforated,  the adhe-
 sions of the pleural surfaces around the fistu-
 lous perforation preventing the  air from pass-
 ing into the cavity of the pleura.  But in other
 cases, especially when either vital power and
 resistance are weak, or the lymph thrown out
 is of an unhealthy or unorganizable character,
 and hence neither  false membranes  nor inti-
 mate adhesions are formed, or  are not formed
 in a state sufficient to protect the ulcerated sur-
 face, the air passes into the cavity of the pleu-
 ra, at one or more points, upon sudden efforts,
 or severe fits of cough.   Ulceration may ad-
 vance until the pleura  is nearly perforated, ei-
 ther without the  production  of a false mem-
 brane or of adhesion, or with these in a more
 or less incomplete  state, when  a severe fit  of
 coughing, or  a forced inspiration, or some  ef-
 fort, or even  an external  injury, causes the
 thinned or ulcerated point to give way sudden-
 ly, and induces all the symptoms and signs of
 pneumathorax.
  7. II. Symptoms  and Signs.—A. Symptoms.
—The effects of the perforation are immediate
 and  consecutive.—(a) The immediate effect is to
admit air more or less rapidly into the cavity
of the pleura, which permits the lung to as-
 sume that state of collapse to which its natural
 contractile property would reduce it, by equal-
 izing the atmospheric pressure within and with-
 out It.   In addition to the introduction of air
 and the  dyspnoea thus rapidly produced, the
 sensibility of the part is generally also sudden-
 ly and severely excited, and, with the extreme
 dyspnoea and pain, great  anxiety  is felt.  The
 connexion between the lesions and the symp-
 toms is  remarkably striking.  The pain corre-
 sponds with  the rupture of the thinned portion
 of pleura and the irruption of the tuberculous
 matter into the pleura, and is caused by these
 occurrences ; while the threatened suffocation
 and anxiety are the effects of the rapid passage
 of air and of some fluid matter into the pleural
 cavity.  Therefore, when  acute pain, oppressed
 breathing, extreme anxiety, and the symptoms
 of acute pleurisy  display  themselves  suddenly
 in one  side  of the chest of a tubercular or
 phthisical patient, we may suspect the occur-
 rence of perforation of the pleura, and ascertain
 the presence  of pneumathorax by examining
 the chest.
  8. (b)  The  consecutive effects  of perforation
 vary  in different cases.  Although perforation
 of the pleura  will  not fail to allow air to pass
 into the  cavity, yet the size and  other condi-
 tions of  the opening modify the amount of air
 introduced and  the  effects which follow.   If
 the perforation  be very small,  or if it  be  so
 placed that the walls of the chest close it upon
 expiration, or if it  be below the level of the ef-
 fused fluid, or if the opening be of such a form
 as to become valvular, and to close the aper-
 ture on expiration, air will pass into the cavity
 in accumulating quantity, and occasion an in-
 creased  compression of the lung;  and even
 suffocation in the  course  of a few hours, and
 before many  of the consequences  observed, in
 cases of longer duration, can take place.  When,
 however, the termination of the mischief is not
 so rapid, the  presence of air in a cavity neither
 accustomed to, nor organized for it, and of the
 matters which pass along  with the air from the
 ulcerated cavity, excite with more or less ra-
 pidity great irritation and inflammation  of the
 pleura, attended by acute pain, dry  cough, dysp-
 noea, spasms  of the intercostal muscles ; quick,
 weak, or irregular pulse; heat of  skin, and all
 the symptoms of acute pleurisy, with the phys-
 ical signs of pneumathorax (y 11), and of liquid
 effusion accompanying the air contained in the
 pleural sac.
  9. When the aperture,  by which air passes
 into the cavity of  the pleura, is  large, there is
 a frequent renewal of the air in this cavity; for
 the lung  is kept in a state merely of collapse,
 and not of forcible compression ; the air pass-
 ing out of the cavity, as well  as passing in, to
 a partial  amount.   The consequences are, a
 more  copious purulent secretion  takes place
 from the pleural surface, and this secretion al-
 ways  becomes more or  less fetid if it cont'inue
 for some time.  The foregoing symptoms, how-
 ever, are not of themselves sufficient  to show
 the existence of pneumathorax ; for, notwith-
standing  the sudden supervention of acute pain
 in the side, with oppressive dyspncea and anx-
 iety, and  although, in some instances,  these
symptoms  may be instantly felt after  a  fit of
coughing, or  upon exertion when the patient
has felt as if something had given way in the 
344
PNEUMATHORAX—Physical Signs of.
 pained place, still all  these  phenomena may
 exist in some acute cases of pleurisy, without
 any perforation ; while, on the other hand, per-
 foration  and pneumathorax  may take  place
 without any very acute or suddenly developed
 symptoms, although this is seldom observed.
 The physical signs, therefore, are chiefly to be
 depended upon  for the diagnosis of this lesion.
   10. When the quantity of air which is passed
 into  the pleural cavity is great, if there be  no
 adhesions between the opposite surfaces of the
 pleura, or if these adhesions be inconsiderable
 or admit of being much stretched, the lung is
 compressed and forced against or towards the
 spinal column.  At the same time, the thoracic
 parietes on the  affected side are distended, the
 ribs  separated,  the diaphragm depressed, and
 the mediastinum pushed to the opposite side.
 The  widening  of the intercostal spaces, the
 rounding and dilatation of the parietes, the
 much less degree of motion during respiration,
 and the much greater dimensions of the affect-
 ed side upon admeasurement, sufficiently indi-
 cate  the distention of the pleural cavity by the
 accumulation of a fluid ;  the nature of the fluid,
 whether gaseous or liquid, being  readily indi-
 cated by  the physical signs.  The viscera are
 also displaced by the contained air. The heart
 and mediastinum are pushed to the right side,
 if the left be  the seat  of lesion ; and towards
 the left axilla, if the right is so affected, and if
 the air be in great quantity, while the liver and
 stomach are pushed downward ;  the upper re-
 gions of  the  abdomen  sometimes protruding
 more or less.
   11. B. The Physical Signs are the most im-
 portant of the consecutive effects of pneumatho-
 rax, and are generally  very distinctive.   The
 air contained in the pleural cavity gives the
 walls of the chest a greater degree of resonance
 on percussion than when the  structure of the
 lung is naturally distended with air. According
 as the quantity  of air is great, so is the sound
 produced  by percussion the more hollow or
 drum-like, owing.to the farther removal of the
 collapsed or compressed lung from the parietes
 of the chest, and to the diminished entrance of
 air into the lung.   Hence pneumathorax may
 instantly be detected by a remarkable contrast
 of physical signs, namely, by a very hollow or
 clear sound on percussion of the affected side,
 with little or no vesicular sound  of respiration,
 while the healthy side  gives a duller sound on
 percussion,  but  a much more distinct respira-
 tory murmur.
  12. Perforation of the pleura, and its conse-
 quences, pneumathorax, and the  effusion of
 fluid,  give rise to other phenomena which are
 farther diagnostic of these lesions.   These are
 the sounds which have been termed the metallic
 tinkling sound,  the amphoric  sound, and the
 sound of fluctuation.
  13.  (a) Metallic tinkling has been  variously
 accounted for by several writers, but none of
 the explanations, and some of them have been
 sufficiently singular, and others equally labori-
ous, appear satisfactory.   This sound is heard
 most  distinctly when the pleura is perforated,
 when much  air is enclosed in the pleural cavi-
ty, and when there is also some fluid effused
It  seems to proceed from the air passing, du-
ring inspiration,  through the pleural orifice of
the perforation, which, being partially obstruct-
 ed by fluid or mucus, occasions a noise similar
 to that produced by the breaking of a bubble of
 air contained by an albuminous  or other fluii,
 and the vibrations, being propagated through
 the enclosed air, give rise to the  clink, or metal-
 lic sound or tinkling in question.  According to
 this explanation, although perforation of  the
 pleura most commonly  causes  this  sound, it
 may,  nevertheless, be heard in  other circum-
 stances in which air is contained in the pleural
 cavity, provided that, during respiration,  the
 air in  struggling through  a fluid forms bubbles,
 which, breaking on the  surface of the  fluid,
 causes a vibration which is propagated through-
 out the included air.   From this it will follow,
 that whatever occasions  such a  degree of mo-
 tion of the parietes of the chest, even percus-
 sion during the physical examination of this
 cavity, may occasionally develop this sound,
 which has  so long puzzled many stethoscopists,
 which has  mystified others, and which has con-
 cerned some but little who  have paraded the
 stethoscope as a most serviceable instrument
 of charlatanry and humbug.
   14. (b) The tinkling sound may thus present
 several modifications.  Where the  perforation
 is protected or obstructed by its position against
 the walls of the  chest or  below the level of the
 fluid, the tinkling may not be heard unless upon
 coughing or taking a full inspiration, so as to
 cause  bubbles to be formed in  the affused fluid.
 But the smallness of the  perforation, provided
 that air passes through, will not prevent or ob-
 scure the sound, as Dr. Williams  has supposed.
 " When the orifice is  large  and  free, the  air
 will pass in and out in ordinary breathing, and
 will produce in its vicinity a sound like that of
 blowing into the mouth  of a  glass bottle," or
 the bung-hole of a small  cask, and hence this
 sound has been called amphoric. In these cases
 the diseased lung is merely collapsed, not com-
 pressed by the accumulation of air in the  cav-
 ity as when the  perforation  is small, and  as it
 is described above (y 8-10).
  15.  The tinkling or metallic sound may  be
 heard only in certain parts of the chest;  only
 where the  lung is non-adherent, and where the
 effused liquid does not reach; only where a
 cavity is distended by air so as to  give the
 parietes of the cavity a certain degree of ten-
 sion, and to furnish the condition upon which
 the sound chiefly depends.  In the sitting pos-
 ture, this sound  is heard  best about the mam-
 ma, and lower part of the axilla  and scapula;
 but in  those cases in which the  accumulation
 of air and the distention of the parietes are the
 greatest, it may be heard in every part of the
 affected side ;  while in others, where the  col-
 lection of air is  small, it  may  be heard only  at
 one spot.
  16.  When there is a liquid effused into the
 pleural cavity as well as air contained in it, the
diagnosis is generally easy.  Percussion shows
 the level to which  the liquid rises, according
 as it varies with the position of the patient.
 The motions of the liquid, also, especially upon
 coughing, will also  often  give evidence of the
 presence of air  in the cavity. Dr. Williams
 has stated  that,  -'on change of posture and  on
 coughing, the liquid will  sometimes drop from
 the parts which have just  been immersed ; and
 the sound of this will exhibit the metallic ring-
 ing in  so distinct a manner, that it resembles 
                   PNEUMATHORAX—Prc

the note which a  glass  or porcelain  vessel
yields when struck."   (P. 132.)  I think that
Dr. Williams  is mistaken in  this ;  for, how-
ever change of position may produce this sound,
whether as I have explained it or otherwise, I
am certain  that no dropping takes place, or can
possibly take  place, in the physical circum-
stances  of  the parts ; but that, in all changes
of position  which can possibly be made, how-
ever extreme or opposite,  the fluid will merely
run down the  parietes of the cavity, without
dropping in any part.
  17. (c) If the patient be shaken forcibly, or if
he give  the trunk a jerk, or an abrupt turn  or
shake, the  sound, which was first mentioned
by Hippocrates as resembling the splashing  of
water, will  be distinctly heard.  This sign has
been aptly termed Hippocratic fluctuation, and is
heard when the ear is applied to the side at the
time of succussion; the tinkling sound being also
heard  to accompany or to follow it, as the air
bubbles break on the surface of the fluid or  at
the pleural  orifice of the perforation.  Fluctua-
tion or splashing is  best  heard when there  is
much air in the cavity and a moderate or con-
siderable quantity of liquid.   Percussion will
frequently indicate the  proportions, if carefully
performed.
   18. III. The Prognosis of pneumathorax  is
very unfavourable, not  so  much as regards the
 Cresence of the air in the pleural cavity  as the
 isions of which it is the consequence.   Pneu-
mathorax most frequently, especially when su-
pervening at an advanced stage of tubercular
consumption, rapidly hastens a fatal termina-
tion ; but in more favourable circumstances,  or
earlier stages of that malady, life may be pro-
longed for some indefinite time after its occur-
rence ; rarely, however, for a longer period than
a few months.   Dr.  Houghton  has recorded a
case of a bricklayer who lived eighteen months
after perforation had taken place, and who might
have lived longer if he had not imprudently ex-
posed himself in his business, for the signs of a
cavity had disappeared, the side had contracted,
and his general health had much improved. Dr.
Stokes  has adduced the case of a gentleman
who lived for many  months, and who generally
heard a splashing noise in his chest when on
horseback.  Cambalusier and Laennec refer to
cases which they consider to  have recovered,
but upon insufficient evidence.  Dr. Williams
states, that he has seen " two cases leave the
hospital  with  the impression  that  they were
nearly well, having gained  flesh  and lost the
worst phthisical symptoms after the first severe
consequences of the perforation had subsided."
(P. 133.)  My experience leads me to conclude,
that, when  the tuberculous disease is limited,
when  perforation occurs at an early stage  of
that disease, and when the constitutional pow-
ers of the patient are not  much impaired—cir-
cumstances in which perforation rarely takes
place—then life may be prolonged for a consid-
erable period, if a cure even may not be effect-
ed. For it is  not impossible  for a superficial
tubercle, or very small cavity, to perforate the
pleura, and, by such perforation, or the rupture
of the nearly perforated pleura, to allow the pas-
sage of air  into the pleural cavity, the compres-
sion of the lung, and the exudation of lymph upon
the surface of the perforated membrane, favour-
ing the diminution or oblite:ation of the  cavity,
gnosis and Treatment of.                345

 and the occlusion, or even the cicatrization of
 the aperture.  In  these circumstances, there-
 fore, it is not unreasonable to hope for a con-
 siderable prolongation of life,  even although
 complete recovery may not take place.   M. La-
 ennec has adduced an  instance in which the
 patient lived six years after pneumathorax ap-
 peared ; and M. Chomel has considered perfect
 recovery not impossible,  the parietes  of the
 chest falling inward, as in recovery from cer-
 tain cases of empyema (see Pleura, y 78).
   19. IV. Treatment.—This should vary with
 the several circumstances under which perfo-
 ration or rupture of the pleura and the  passage
 of air into  the pleural cavity take place, with
 the period which has  elapsed since the occur-
 rence,  and  with  the existing state of the pa-
 tient.  When the  perforation and passage of
 air into the cavity have just occurred, the pa-
 tient often presents many of the indications of
 having received a vital shock ; he is pale, anx-
 ious, faint, feeble, and  depressed physically and
 morally.  At the same time, he complains of op-
 pressive dyspnoea and  pain, and his pulse is rap-
 id and feeble.  In this state lowering measures
 would be dangerous.   Gentle restoratives, with
 opiates, are chiefly indicated, as camphor or am-
 monia, with morphia; but reaction often occurs,
 if the accumulation of air and  the suffocative
 dyspnoea (v 8, et seq.) prevent not its superven-
 tion.  Nevertheless, the irritation and inflam-
 mation of the pleura produced by the air are gen-
 erally attended by some indication of reaction
 after some hours, although this may be imper-
 fect, or but slightly developed.  The pain which
 is complained of should not be considered as a
 proof either of the presence or the amount of
 inflammation, or even of irritation of the pleu-
 ra, for it is often  greatest  immediately upon
 the perforation and passage of air into the pleu-
 ra, and before inflammation is developed by the
 occurrence.  Besides, it is often occasioned by
 the stretching of adhesions which had existed,
 and is thus, as well as in other circumstances,
 independent of inflammatory action.   Still we
 should be prepared for the supervention of in-
 flammatory irritation  of the pleura  soon after
 the air has acted upon this surface, especially
 if the atmosphere at the time be cold and dry ;
 and this complication  of inflammation with the
 pneumathorax will be  more certainly indicated
 by the states of the  pulse, skin, and tongue
 than by the amount of pain.   If the pulse be-
 come hard or constricted, the skin dry,  and
 warmer over the affected side, or if the parie-
 tes of the side are tender  or sore upon pres-
 sure or percussion, and if the patient be young,
 robust, or plethoric, or of the  sanguine tem-
 perament, then blood-letting, general or local,
 the latter most frequently, but the former in
 some instances, and both  in others, especially
 in  the circumstances just stated ;  antimonials,
 mercurials, and opiates; cooling  diaphoretics,
 aperients, and external derivatives and coun-
 ter-irritants, as advised for inflammations of the
 pleura, are the means chiefly to be relied on.  But
 these means should be directed with due atten-
 tion to the peculiarities of individual cases, as
 insisted upon in the preceding article.
   20. Instantly upon the occurrence of this le-
 sion—within even a few minutes of it, as I have
 seen in one instance—but at any indefinite pe-
 riod afterward, the quantity of air drawn into 
346
POISONS—Definition.
the pleural cavity may be so great, and the dis- I
tention of the parietes of the side so very con-
siderable, as  to suggest reasonable fears of al-
most immediate suffocation, not only from com-
plete compression  of the lung of the affected
side, but also from a less compression of that
of the other side.   In these circumstances, exit
should be given to the air by puncturing the pa-
rietes of the thorax.   I am aware that the pro-
priety of resorting to this mode of relief has
been questioned ;  but an instantly impending
fatal result has to be averted ; and in some  in-
stances it may be  averted  for a considerable
time, almost  always  for a short time, and pos-
sibly for months, or even years, by  resorting to
this operation.  I believe that recourse to this
operation should  not be delayed when pneuma-
thorax has occurred at an early period of phthi-
sis, or when  the  patient is young, not greatly
reduced,  or while  he has not advanced very
nearly to a probable termination of a disease
which would  certainly end fatally,  even if per-
foration of the pleura had not taken place. The
pain and risk of the operation are nothing in com-
parison with  the continued distress experien-
ced during the  pneumathorax;  and although
relief may be only temporary, the  operation
may be repeated several times without increas-
ing the risk of life, but, on the contrary, greatly
diminishing it.*
   21. It  is unnecessary to remark farther  re-
specting  the  treatment of pneumathorax, inas-
much  as the means which have been  recom-
mended for chronic pleurisy and empyema  are
generally applicable also  for the more compli-
cated malady which  has just now been consid-
ered, due regard being had to the peculiar fea-
tures of individual cases.   (See art. Pleura,  y
 175, et seq.)
   Biblioo. and Refer.—B.  Af. hard, Dissert, sur le
 Pneumothorax ou les Congestions gazeuses qui se forment
dans la Poitrine. Paris, Svo, An. xi.—R. T. Laennec, Trea-
 tise on the Dis. of the Chest, &c.; transl. by /. Forbes,
 Svo.  London, 1829, p. 499.—J. Forbes, Original Cases, with
 Dissections and Observations  illustrating the Use of the
 Stethoscope and Percussion in the Diagnosis of Dis. of the
 Chest, 8vo.  Lond., 1824.—Rayer, Archives Gener. de Med-
 ecine, t. xvii., p. 345.—Various Cases illustrative of Pneu-
 mathorax.  See t. v., p. IT et 321 ; t. vi.. p. 104 ; t. viii., p.
 456.—Liltri, in Journ. Hebdomad, de Medecine, &c,  t. i.,
 p. 49.—Lenoir,  in ibid., t. i., p. 312.—Lenormand,  in ibid.,
 t. ii., p. 293.  (A Case in which Recovery appeared to  have
 taken place.)—Duncan, in Edin. Med. and Surg. Journ., vol.
 xxvui., p. 302.  (Chiefly Cases  illustrating the association
 of Empyema and Pneumathorax.)—Gerard, in Med.  and
 Chirurg. Review, Oct., 1S36, p. 562.— W. Stokes,  Treatise
 on Dis. of the  Chest, &c, Svo.  Dub)., 1837, p. 527; and
 Dublm Journ-  of Med. Sciences, Sept., 1840.—C. /. B.
 Williams, On the Path, and Diag. of Dis of the Chest, p.
 125 ; and Lib. of Pract. Med., vol. iii., p.  130.—A. M. Saus-
  * In 1833, a case of pneumathorax occurred in my prac-
tice, at an early stage of phthisis ; the patient being young
and r.obust, and not having lost flesh or strength. The na-
ture of the mischief was prominently characterized: the
heart was pushed remarkably far to the right side ; and the
rational and physical signs were all marked and extreme ;
the dyspnoea and distress were great.  I advised that an
opening should be made for the exit of the air; and the
friends of the patient desired that Sir A. Cooper should
make it.  We met a few hours afterward ;  he admitted his
ignorance of the nature of the lesion.  I fully explained the
cause of the symptoms, and of their extreme  urgency; but
he refused to perform the operation, stated that he had
never  performed it with the view of letting out air, and
that he would not now do any thing so novel, although he
would have been ready to undertake it when he was a much
younger man.  Having heard Sir Astley's determination,
the patient's friends would not allow the operation lobe re-
sorted to by any one else ; and the  patient died, asphyxied,
a few hours afterward.   The operation, if it had been re-
sorted to in this case, might have  prolonged life far a very
considerable period.
sier, Recherches sur le Pneumothorax et les Maladies qui
le produisent, les Perforations Pulmonaires en particulier,
Svo.  Pans, l8il.—Chomel. in Diet, de Mt'd., 2d edit., art.
Pneumothorax.—P. C. A. Louis,  Researches on Phthisis,
&c. ; transl. by H". H. Walshe (or the Sydenham Society,
p. 328.  (See, also, Biblioo. and  Refer, to art Pleura.)
POISONS—Poisoning—Poisoned—Symptoms
  and Treatment  of.
     Classif.—General and Special Pathol-
       ogy and Therapeutics.
Poisons may be defined to be substances which
  act  injuriously upon the human body.  The
  number of  substances which  may be com-
  prised under this definition, even in the pres-
  ent state of our knowledge  of the productions
  of the three kingdoms of nature, is very great;
  and many  of these,  owing either to their
  weak  powers,  or to the imperfect state of
  our knowledge of their  effects,  will receive
  only a slight notice,  or be  entirely overlook-
  ed.   It  should, however, be recollected that
  there are many substances which act injuri-
  ously when improperly  employed either as
  articles of food  or  as medical agents;  this
  improper employment having reference rath-
  er to  the quantity used, and the conditions
  of the  frame  in  which  it  is employed, than
  to the injurious nature of the substance.  The
  definition, therefore, may be extended as fol-
  lows :  Substances which  exert a deleterious in-
  fluence on the  human frame, when taken inter-
  nally or applied  externally,  as  regards either
  their nature or the quantity of them employed;
  or which tend, in either respect, to destroy life
  when thus used.
   1. While  the word  poison refers to the sub-
stance exerting the deleterious influence, poi-
soning is the commission  of the injurious  act,
and poisoned  is  the state or effect resulting
from the substance or agent employed.  These
words may thus be viewed  as referring respect-
ively to the  agent,  the act, and actor,  and  the
effects or  pathological  states produced by  the
poisonous agent.   It is obvious that the inves-
tigation of the first and second of these, with
due precision, belongs to legal medicine or medi-
cal jurisprudence, and  that  it  consequently does
not fall within the scope of  my work.   I have
only briefly to consider the symptoms and effects
of poisons—the  pathological states  produced by
substances, whose injurious effects  have been
observed  and recorded by medical authorities,
and the best means of preventing, counteracting,
or  removing  these  states.  Before, however, I
venture  to discuss the pathological effects  of
 individual poisons,  and the treatment of these
effects, I shall briefly consider, 1st.  The modes
in  which poisons are employed or exhibited.   2d.
 The action of poisons.   3d.  The channels through
which poisons act in producing their effects.  4th.
 The general  effects of poisons;  and, 5th.   The
 special operation of poisons.*
  " The following Synopsis will show the extent of consid-
eration which a due discussioD of the subject now before
me ought to comprise.  My limits, as well as the scope of
the work, will  admit only of a hasty view of the several
topics here  enumerated:
1. Modes in which Poisons are employed or exhib-
  ited.
   i. To the Respiratory organs—Inhaled or Inspired.
  ii. Taken into the stomach.
  iii. Applied externally—(a) The cuticle not having been
       removed-
     (b) To a surface the cuticle of which has been remo-
       ved.
     (c) Introduced by or into a wound. 
POISONS—Their Modes of Action.
347
  2.  I. The Modes in which Poisoning takes
place, whether the act is felonious, intentional,
or accidental—whether it is suicidal or from in-
tentional exposure to the agent—are more di-
verse than may appear on a hasty view of the
matter ; and the effects produced and the treat-
ment required are thus equally diversified :  1st.
Several gases, vapours, or fumes of volatile or va-
porizable substances have been intentionally exhibit-
ed, or accidentally inhaled, so as either to arrest the
respiratory actions, or to impede or obstruct, or oth-
erwise influence the changes produced in the blood
by respiration, as well as those changes of func-
tion, and  sometimes  even  also of organization,
which take place cither primarily or consecutively
in the nervous centres.  Several vapours or fumes,
medicinal as well  as poisonous, may be inhaled
into the lungs with the view of producing cer-
tain anticipated  effects.   Some   of  these  are
thus employed more  or less beneficially.   Oth-
ers are more obviously injurious, or even fatal;
and a few have recently been directed to pur-
poses which are considered beneficial, after the
very superficial  and empirical view which has
hitherto been bestowed upon this mode of  em-
ploying them.   The vapours of several  sub-
stances possess the  power not only of imped-
ing the changes produced in the blood by the
air during respiration, but also of altering the
physical characters of the blood  itself and the
    (d) Injected into blood-vessels.
 iv. Injected into the larger bowels.
  v. Introduced or injected into the sexual organs,
 vi. Injected into the urinary organs.
II. The action of Poisons.
  i. Poisons act locally and primarily.
  ii. Remotely and consecutively.
 iii. Both locally and remotely.
 iv. Chemically.
III. Channels through which Poisons act.
  i. Primarily and locally.
    a. On the nerves of the part.
    b. On the capillaries and vessels of the part, and tho
        contained fluids.
    c. On the irritability of the tissues.
    d. On the general structure  of the  part.
  ii. Sympathetically, or by nervous influence ; or through
      tho  media of the organic aud animal systems of
      nerves.
 iii. Organically,  or by imbibition or endosmose, and ab-
      sorption; or through the medium of the circulating
      fluids.
IV. General Effects of Poisons.
   i. Depressing nervous influence  and vascular action;
      lowering vital power.
  ii. Inordinately exciting nervous influence, either organic
      or animal.
  iii. Inordinately exciting vascular action.
  iv. Exciting nervous influence  and vascular action; ex-
      citing vital power.
  v. Exhausting  nervous influence; or exhausting vital
      energy.
  vi. Altering nervous influence and vital power.
 vii. Producing a succession of two or more of these states
      or effects.
V. Special operation of Poisons.
   i. Abstracting the animal caloric or depressing the ca-
      lorific process in a part, or throughout the body.
   ii. Benumbing, depressing, or suppressing sensibility,
      or the organic nervous influence.
  iii. Paralyzing involuntary motion and voluntary move-
      ments.       ,       ....
  iv. Softening, liquefying, or dissolving one or more tis-
      sues or textures.
   v.  Irritating particular organs or parts.
  vi. Astringing and increasing the tone or vital cohesion
      of certain  tissues.       ,......,•,   e  ,
  vii. Diminishing or increasing  the irritability of contrac-
      tile parts.
 viii. Augmenting certain secretions and excretions.
  ix.  Stimulating the ganglial, spinal, or sensory nerves.
   x Altering the vital actions-the secretions and nutn-
    ' ■ tion of particular organs or textures, according to
      the  substance employed, and the mode of employ-
      ment.
state of the nervous functions.   These altera-
tions of the blood and nervous systems are pro-
duced not only immediately upon the blood cir-
culating in the capillaries of the air cells, and
upon the organic nerves supplying the respira-
tory organs, but  also consecutively, owing to
the passage of the vapour to some  amount into
the circulation, and to the actual admixture of
it in the blood, and to its action on this fluid and
on the nervous centres.  The vapours of alcohol,
of all strong spirituous liquors, of most ethe-
real fluids, of spirits of turpentine, and several
volatile oils, produce a more rapid effect when
inhaled in more or less concentrated states than
when these substances are taken into the stom-
ach ; and if the vapour inhaled  be much con-
centrated, or if the inhalation be continued for
some time, the changes produced in the  blood,
and the effects on the nervous system, are such
as to endanger or to destroy life.   This more
immediate and intense effect arises chiefly from
the extent of  surface upon  which the vapour
acts, and  from the rapid imbibition of fumes or
vapours by  the  respiratory mucous  surface.
But  this  subject will be  more  fully shown in
the sequel, when the special operation of cer-
tain injurious  agents is considered.  Most of
its pathological and therapeutical relations are
discussed in the article jVsphyxia.
  3. 2d. The most frequent  way in which poi-
sons are exhibited is that  by  the mouth,  the inju-
rious substance being taken into the stomach ei-
ther alone, or simply diluted, or in  the drink or
food.  It  is obvious that the symptoms and the
effects of any poison are much modified by the
state of dilution or of admixture with aliment-
ary  articles  when thus exhibited, and by the
condition of the stomach at the time, especial-
ly as regards the nature and amount of the con-
tents of this viscus.  The state of the consti-
tution and of the health, and other circumstan-
ces  connected with the  person poisoned, as
well as with the  agent employed,  also materi-
ally influence the effects produced in different
cases by any  individual  poison, although the
quantity exhibited is the same.   The rejection
by vomiting of a portion of the poison,  the time
that  has  elapsed from  the moment of exhibi-
tion, the  amount and character of the evacua-
tions it may have produced, and the precise na-
ture  and character of the effects  observed at
the period when the patient has been first seen
by the physician, require, both individually and
in  connexion, to be duly considered  by him,
the  inferences which he must promptly draw
from these being made the basis  of the most
prompt measures of aid.   The  digestive  mu-
cous surface being protected by a mucous se-
cretion, and by the secretions  furnished  by the
collatitious viscera, and frequently containing
more or  less partially-digested matters, in ad-
dition to the vehicle of the poisonous substance,
an injurious effect is  produced upon  it much
less readily in many instances, owing  to these
circumstances, as well as to the nature of the
poison employed, than upon some other parts
where the poison is more rapidly absorbed and
carried into the circulation.  Besides, the inju-
rious substance  is often in great  part thrown
off the stomach, or passed through the bowels;
and  that which remains, by irritating and in-
flaming the  villous surface, is thereby  prevent-
ed from being absorbed, or so entirely absorbed 
348
POISONS—Their Modes  of  Action.
 as  it might otherwise be, into the circulating
 fluids, absorption, imbibition, and endosmosis
 not  so readily taking  place  in  these  circum-
 stances as in others.  Nevertheless, the  inju-
 rious impression  made by the substance taken
 into the stomach upon the  nervous systems,
 and especially upon the organic  or ganglial,
 may continue or may increase, and be  extend-
 ed  to  several of the collatitious  viscera, and
 even to remote  organs, as  the brain, spinal
 cord, heart, lungs, and kidneys—to the former
 by  nervous communication,  and to the latter
 partly by this channel, and partly through that
 of the blood and vascular system,  either mode
 of operation  predominating in  different cases,
 according to the poison which has been taken.
 I need not, however, dilate farther on this top-
 ic, as it will receive numerous illustrations  in
 the sequel.
  4. 3d. When poisons are applied to the external
 surface of the body, the effects are contingent
 upon the state of the cuticle, which forms an
 efficient protection  against injurious substan-
 ces, excepting such as are most  irritating or
 virulent; and even many of these latter are in-
 operative, unless they are allowed to  remain
 applied to the surface for a considerable time.
 —(a) The  protective power  of the cuticle varies
 in different temperaments and constitutions,
 substances which produce little  or no effect
 when applied to the cutaneous surface of one
 person rapidly affecting others when thus  em-
 ployed. This difference most probably depends
 upon the varying grades of density, thickness,
 &c, of the cuticle, and possibly, also, upon the
 vascularity and sensibility of  the subjacent tis-
 sues.
  5. (b) Poisonous  substances, applied to the
 skin after the cuticle is removed, or even to a mu-
 cous surface, but more particularly to this  sur-
 face when its epithelium is detached, produce
 their effects with great rapidity, the period va-
 rying, however, with the situation,  the dura-
 tion of contact, and the nature and state of the
 substance.   The  effects  depend upon  the na-
 ture and intensity of the impression made upon
 the tissue, upon the sensibility and vascularity
 of the part, upon the rapidity and  amount of
 imbibition and absorption, and upon  several
 other circumstances, which will be more fully
 set forth hereafter.
  6. (c) When a poison is inserted in a wound,
 the effects will be nearly co-ordinate with those
 which result from its application to a  surface
 deprived of its cuticle or epithelium, some va-
riation, probably, resulting from the nature and
Situation of the wound, and upon the degree in
which the injury may favour the retention, and
the situation facilitate the absorption of the
poison.
  7.  (d) The passage of the poison into a vein,
or the injection of it into a vessel, is  produc-
tive of the most rapid effects, relatively to the
operation  of the  particular agent  employed ;
for not only is a local effect thereby produced,
but the poison, being directly carried into the
 circulation, operates, according to its  nature,
 both upon the blood and  vascular  system, and
upon the nervous centres, and the vital and ex-
 creting organs.
  7*. (e) When a poisonous substance is  em-
 ployed externally in  either of the modes now
indicated, the  effects depend principally upon
 its nature.  Numerous specific or other animal
 poisons, and several virulent vegetable poisons,
 are thus inoculated ; and diffusive or septic in-
 flammation and destruction of the cellular tis-
 sue, erysipelas,  the  contagious exanthemata
 and fevers, inflammations  of the lymphatics,
 veins, arteries, and glands, various specific dis-
 eases, as rabies, smallpox, &c, and other viru-
 lent maladies, in which the  organic nervous
 energy is depressed or annihilated, and the cir-
 culating fluids are contaminated, are thereby
 produced.   The  inoculation of most of these
 poisons is accidental, but it  may be intentional
 —felonious or suicidal.  Certain of these poi-
 sons, when allowed to remain in contact with
 the surface, may  produce  their usual effects,
 although the cuticle or epithelium  is entire ;
 but when they are brought in  contact with  an
 abraded surface, or introduced into a punctured
 or  incised  wound, the effects are  rapid, and
 vary in character with  the nature of the poison,
 and the affection of the constituent tissues  of
 the part injured, some occasioning a septic con-
 tamination—a solution and disorganization  of
 the cellular tissue, which rapidly spreads, and
 poisons the circulating fluids ; others affecting
 the veins, and producing asthenic and spread-
 ing inflammation  of them,  with  all its worst
 consequences; several inflaming  the  absorb-
 ents and absorbent glands ;  and certain others
 implicating two or more of these, and often  the
 nerves, arteries, and other structures in  addi-
tion, the secondary and more  remote effects
 being still more complicated, and the ultimate
results being often speedily fatal.   Numerous
illustrations of what I have now advanced will
appear in the sequel, when certain animal poi-
sons come under consideration, and may be ad-
duced from the history of infectious and conta-
gious maladies.
  8. 4th. Poisons may be  injected into the  large
bowels, either accidentally or intentionally, and
produce in this situation their peculiar and even
fatal effeets.  Even  certain of them  may  be
thus employed medicinally, and,  owing either
to the  ignorance of the prescriber of their in-
fluence in this situation, especially in some dis-
eases and states of vital power and action, or
to idiosyncrasy of constitution, their operation
may be most dangerous  or even fatal.  Some
injurious substances, when taken into the stom-
ach and mixed with the aliments, are some-
what changed by the action of the secretions,
while the primary impression produced by them
is thereby  impaired  or modified,  and the ab-
sorption of them is delayed or prevented, if, in-
deed, they be not instantly thnwn off by  vom-
iting ;  but there are many which, when thrown
up into the large bowels, act more rapidly and
more virulently  than  if  they had  been taken
into the stomach, owing to rapid absorption
often taking place in the large bowels, and  to
the circumstance  of their being less likely to
 be changed in this situation.
  9. ftth. Poisons  have been  introduced into  the
sexual  organs, especially of the female, where
they have produced their local as well as con-
stitutional  effects, the  former  of these effects
 being severe according to the nature and quan-
 tity of the substance thus  employed, and  the
 latter depending upon the same circumstances.
 This mode of poisoning,  as well as the next,
  10. 6th.  The injection of poisons into the uri- 
POISONS—Their Modes  of  Action.
349
nary passages, is  of rare  occurrence ; it has,
however, been employed  both feloniously and
accidentally;  while the treatment  of several
maladies of the sexual and urinary organs, by
means of injections of various stimulating, as-
tringent, tonic, or acrid substances, has caused,
either directly or  indirectly, most injurious, or
even fatal results, especially when these have
been resorted to  in cases to which they were
inappropriate.
  11.  II. Of the .Action of Poisons.—Poisons,
according to  the  definition of the word  given
above, may act, 1st. Locally and primarily; 2d.
Remotely and  consecutively  ; and,  3d. Both local-
ly and remotely.   Thus the  substance applied
either to the  external surface, or inhaled into
the lungs, or taken into the stomach, may only
corrode  or inflame the part with which it comes
in contact, this effect being so intense as  to en-
danger or even to destroy life. It may produce
but little or no lesion or visible  change in the
part to which it is applied, and yet, through the
medium either of the nervous systems or of the
circulating  fluids  and vascular system, it may
destroy the individual.  And lastly, it may, after
having occasioned more or less remarkable lo-
cal changes, affect the nervous systems, or the
vascular system and fluids, or both the nervous
systems and  the vascular  system, with the
fluids, secretions, and excretions, thereby de-
 stroying life,  and  sometimes altering even the
 structure of several of the organs of the body
 before life is  extinguished.  Sufficient illustra-
 tion of these  modes of action will appear  in the
 sequel; but I must consider  them individually
 and more particularly, and  with reference  to
 the tissues which poisons seem especially to
 affect, and the channels  and media through
 which they act.
   12. i. Of the local and primary Action of
 Poisons.—Whether or no the injurious action
 of a substance be limited  to  the part to which
 it is applied,  or be extended  much farther and
 to distant parts of the frame, it is of moment
 that  we should have some  acquaintance, the
 more intimate and accurate the better, with the
 nature of the effect produced locally^ and with
 the changes  in the constituent tissues  of the
 part—(a)  Certain substances,  as  aconitine,
 prussic acid,  &c, even when applied to  an ex-
 ternal part, protected by its  cuticle, will occa-
 sion numbness or want of sensibility, without
 any other visible change, the local effect thus
 produced in the nerves not proceeding farther,
 unless the application be protracted or repeated,
 or the  activity of the poison be great,  or the
 cuticle  be removed.  This effect upon the sen-
 sibility  evinces not merely a special operation
 of the substance, but also  a disposition or pow-
 er possessed by it to affect more generally and
 sympathetically the whole nervous systems, al-
 though certain parts of this system may betray
 the effect in  a more remarkable degree.
   13. (b) Other substances produce a more se-
 vere  local effect, and yet this effect will con-
 tinue altogether,  or more  or  less, limited to the
 part, the injurious operation being caused rath-
 er by the intensity and extent of the irritation
 locally  excited than by any other more extend-
 ed impression or change  produced by it.  bub-
 stances occasioning a local injury or irritation,
 as mechanical irritants,  fragments  of  broken
 glass, &c, excite the organic and animal sen-
I sibility in the part with which they are brought
 into contact;  and soon afterward the vessels,
 the capillaries especially, and contractile parts
 are implicated, and even farther local changes
 of structure ensue, owing to  the effusion of
 lymph, serum, &c, and to the alterations there-
 by produced.
   14. (c) Certain substances, while  they be-
 numb the sensibility of the part to which  they
 are applied, also impair the irritability  of the
 fibrous or contractile tissues; and others, while
 they excite the sensibility, also increase for a
 time both the  susceptibility and  the power of
 contractile  or irritable parts, ultimately  ex-
 hausting these properties, according to the na-
 ture and quantity of the substance employed,
 and thereby showing the intimate connexion
 existing between  sensibility  and irritability,
 and demonstrating  that substances which ei-
 ther benumb or excite, or exhaust the one, sim-
 ilarly affect the  other.   The  more active of
 these agents may thus destroy life by their lo-
 cal effects, especially when they  act upon  vital
 organs or  parts.  Even mechanical agents or
 irritants, by their intense  action  locally, and
 the nature  or  functions of the organ, surface,
 or tissue with which they come in contact, may
 destroy life by their  local effects entirely  or
 chiefly.  The  changes produced by numerous
 substances  are of such a kind as admit of their
 usual procession  being observed.  First, the
 nerves of the part and the  sensibility are either
 benumbed or excited, or irritated, or  exhaust-
 ed,  and the contractile property  of fibrous tis-
 sues similarly affected.  Then the capillaries
 and the contained fluids are implicated, and all
 the phenomena,  either of congestion  or of in-
 flammation, with  the usual results, are  devel-
 oped, according to the nature of the agent em-
 ployed.
   15. (d) Other substances act so rapidly, and
 produce so  general an effect upon the constit-
 uent tissues of the part, involving them all in
 the effect produced, or inducing disorganization
 with so great  rapidity as to render it difficult,
 if not impossible, to  determine  the particular
 element or tissue primarily or principally af-
\ fected, or to trace the procession of  changes.
 Intense heat  and  cold,  numerous   chemical
 agents, and some septic poisons derived  from
 the animal and vegetable kingdoms, produce
 this more intense and disorganizing effect upon
 the part to which they are applied.  Some con-
 geal, constringe, desiccate, corrugate, carbon-
 ize, or  otherwise destroy the structure ;  and
 others dissolve, liquefy, or annihilate the vital
 and physical cohesion of the several  textures,
 which fall into a state  of dissolution or pulpy
 destruction with varying degrees of rapidity.
    16. ii. Of the  remote  or consecutive Ac-
 tion of Poisons.—The primary impression or
 action of poisons is seldom such as to destroy
 life of itself, or without producing remote or
 consecutive effects.  If,  owing either  to the
 intensity of the local action, or  to the exten-
 sive disorganization produced in the part, death
 should quickly follow the application  of an in-
 jurious or poisonous substance,  the effect may
 be imputed chiefly to the shock received by the
 vital power, unless the agent acts directly upon
 a vital organ, whose  circulation  and  functions
 it is capable of immediately arresting.  A cor-
 | rosive substance, as nitric or sulphuric  acidi 
350
POISONS—Their Channels  of Action.
&c, taken into  the stomach, owing either  to
its nature or the quantity employed, or to both,
causes death in a very short time ; but this re-
sult  is not owing merely to the local action,
but to the shock produced by a severe  injury
inflicted upon an organ supplied by nerves from
the organic or ganglial nervous system, and
intimately associated  in function and organic
nervous energy with the organs most necessa-
ry to the continuance of life.  The local injury
is  inflicted ;  the whole body instantly expe-
riences or feels it; the shock, or injurious im-
pression, is rapidly transmitted  throughout the
whole organic nervous system ; and if it be in-
tense, it annihilates not only the vital influence
of the organ  on which it primarily acts, but
also, and through the medium  of the organic
nervous system, the action of the heart, of the
diaphragm, of the lungs, of the brain, &c.  Thus
the more immediate of the remote effects are
produced, sometimes  with a  rapidity which
might lead to  the inference that the local im-
pression and the consecutive  result are but one
operation.  More frequently,  however, this re-
sult  takes place with much  less rapidity, the
primary injurious impression inducing a suc-
cession of pathological phenomena, which often
admit of due recognition, as they are  manifest-
ed in either the nervous or the vascular system,
or the blood, or the secretions, or the excre-
tions, or in several or  even in all these, as will
appear in the sequel.
  17. It is obvious that, while  some injurious
agents, from their nature or the quantity, may
act either locally or remotely, primarily or con-
secutively,  or  in either of these chiefly, there
are others which act in both modes, either one
predominating over the other, according to the
agent or agents employed.  The mineral acids,
in large quantity, or in  a concentrated  state,
act locally,  destroy the textures, occasion  a
general  shock of the  frame, and even termi-
nate life.   In  small quantity, or less concen-
trated, the  local action is  much less intense,
and remote effects are developed, and are such
as admit of being traced.  Various  vegetable
or narcotic poisons produce but  slight or no ap-
parent local change, yet affect  organs remote
from the seat of application in a very remark-
able manner ;  and many substances change not
only the  tissues, on which they primarily act,
but also the states of distant parts ;  these sub-
stances even deriving their chief appellations,
as acro-narcotics, &c, from their compound
properties.
  18. III. The Media or Channels  by which
Poisons act.—It is of great importance to trace
the channels through which substances act inju-
riously on the frame; for the knowledgeof these
enables  us on many occasions to prevent or to
arrest the effects  produced by  these  substan-
ces.   But in order that the media or channels
of remote or consecutive effects should be rec-
ognised, it is necessary, in  the first place, to as-
certain the local and primary operation of the
substance,  the more remote effects of which
we are  desirous  of tracing in  the successive
changes  produced by it.    It becomes, there-
fore, desirable to consider, 1st. The nature  of
the  local and primary impression produced by a
poison.  2d. The extent and amount of the sym-
pathetic effect, or of the operation by nervous com-
munication or  influence as  far  as this may  be
I known; and, 3d. The organic operation of a poi-
| son, or the circumstance of the imbibition and ab-
 sorption of the substance  injurious employed, and
 the probable extent or amount of the mischief
 produced which may be imputed to this  mode
 of operation.  As poisons thus act locally, sym-
 pathetically,  and organically, or in the ways now
 specified, and as it is obvious that the action
 of a particular poison is not limited to any one
 of these modes, although it  may operate in ei-
 ther way more  prominently than in the others,
 it may not be superfluous to consider the  mat-
 ter more in  detail.
   19.  i. The nature of the local and primary im-
 pression produced by a poison is not always read-
 ily ascertained ; for, owing either to the quan-
 tity or the intensity of action of the substance
 employed, the several constituent systems and
 tissues of a  part may be so instantly  and gen-
 erally impressed and altered by that substance
 as not to furnish distinct evidence of the tis-
 sue primarily affected, as I  have  above  con-
 tended ; but in other circumstances  the local
 changes, as  well  as the consecutive effects,
 often  admit  of analysis, although  sometimes
 imperfect, the results necessarily varying with
 the circumstances  of particular cases.
   20.  A. The nerves of the part, whether the
 organic, the sensory,  or the motory, are  evi-
 dently primarily affected according to the tex-
 ture to which the poison is applied, or are the
 first to manifest the effect, unless the substance
 be such as rapidly  to change the organization
 of the structure ;  and according as either of
 these  orders of nerves is implicated or  impress-
 ed, so will  the  secretions, the sensibility, or
 the movements  of the part be affected.
   21.  B. The irritability of contractile tissues
 is also altered by poisons, more especially by
 those  which  change the state or functions of
 the organic  nervous system.  If what I have
 contended for in the article Irritability, name-
 ly, the dependence  of this very prominent vital
 property upon the  organic  nervous influence,
 be admitted, it necessarily follows  that  this
 property will be co-ordinately affected  by what-
 ever changes the state of this influence ; and a
 close  investigation  of the operation  of many
 poisons- proves  that those substances, as  cer-
 tain animal poisons, which inordinately depress
 or altogether annihilate this influence, affect
 the irritability of the contractile tissues in a
 similar manner  and in a co-ordinate degree.
   22.  C. The capillaries and vessels of the part
 must  also be changed,  as  regards  their vital
 properties, whenever the organic nervous in-
 fluence  and  irritability are  affected ;  and the
 change  of these vessels must be  necessarily
 similar, as to kind and degree, with that prima-
 rily produced in the organic nerves and con-
 tractile tissues.  There is every reason, also, to
 believe  that  the change is not limited to the
 capillaries and  smaller vessels, but  extends
 more  or less manifestly to  the  contents of
 these  vessels, more especially to the red glob-
 ules and to the  fibrin of the blood which they
 contain ; the condition of the former constitu-
 ent of the blood in  these vessels, and the quan-
 tity or state of the latter,  being always very
 materially altered  by  the  morbid  impression
 made  upon the  organio nervous influence and
 irritability of the part, and upon the vital prop-
| erties of the capillaries, the physical and chem- 
Channels of Action.                      351
                         POISONS—Their i

ical characters of the blood in these vessels
being thereby thus rapidly changed.
  23.  D. The  alterations thus produced in the
organic  nervous influence, in the irritability,
in the state of the capillaries, and in the con-
tents of these capillaries—in the  blood—of a
part to which a poison has been applied, must
necessarily soon be followed by farther changes
in the whole of the tissues constituting the part
—in its whole structure—and these changes will
be rapid, extensive, and diversified in charac-
ter, according to the nature of the poison, and
as it  acts prominently upon either the nerves,
or the capillaries, or  the  fluids, or  the other
constituents of the part, or in any of the par-
ticular modes  which will  come under consid-
eration in the sequel.
  24. ii.  The sympathetic operation of poisons, or
the action  of  a  poison on parts remote from
that to which it is applied by means of the ner-
vous system, or by any of the  orders of this
system—the organic, the sensory, and the mo-
tory—evidently obtains to a very considerable
extent, especially as respects the action of some
poisonous substances; but, as this medium of op-
eration is not the only one, and as it is frequent-
ly associated with that about  to be considered,
namely,  the blood and vascular system, either
channel  being  more or less operative in pro-
ducing the remote effect, according to the na-
ture  of the  substance and  state  of  the system,
it is often difficult to determine  the precise ex-
tent  to which either contributes to the ultimate
result.   It will, however, be shown in the se-
quel, that certain substances, when taken into
the stomach, or injected  into the bowels, or
otherwise brought into contact with parts sup-
plied chiefly with the organic or ganglial nerves,
have not merely the sensibility of these nerves
excited, but also the involuntary  movements
of parts distant  from that to which  the sub-
stance was applied remarkably affected, owing
to the local irritation being transmitted through
the medium of this order of nerves, and the
connexion of these nerves with nerves of sen-
sation, and  with the roots  of the spinal nerves;
and,  farther, owing to  this connexion, the  ef-
fects are often extended to the spinal cord and
to the brain, and thence reflected  upon volun-
tary  muscles and the extremities of  the body,
the resulting phenomena varying with the na-
ture of the injurious agent and the temperament
and constitution of the person  poisoned by it.
It  is  unnecessary to illustrate this  topic at this
place, as it  is fully discussed in  the articles Ir-
ritation and  Irritability, and especially in
that on Sympathy or associated morbid states.
  25. iii. The  organic  operation of poisons, or
the imbibition and absorption of them, or the
action of them through the media of the circu-
lating fluids, as the lymph, the  chyle, and the
blood, is one of the most important ways in
which the effects of these substances are pro-
duced.   Still, this way is  not always the same,
the route varying with the  organ or part to
which the  poison is applied, and with the na-
ture  and action  of the particular poison em-
ployed.  The imbibition orendosmose of some
substances  through membranous tissues is often
much more rapid than that of others ; but much
depends upon the physical state of the poison,
and concentration of the  solution of it employ-
ed, and other circumstances.  The passage of
 some substances  into the blood, when either
 applied to a mucous surface, or to a surface
 denuded of its cuticle, or epithelium, or intro-
 duced into a wound, is often much more rapid
 than might be  supposed, if the fact had not
 been demonstrated by experiments.  Neverthe-
 less, the rapidity of the introduction of certain
 poisons into the circulation  has been, accord-
 ing  to a  few observations I have  made, over-
 rated by some writers, who have considered
 that the passage of a poison into the blood may
 take place in a very few seconds.   It will cer-
 tainly occur in much less than a minute in some
 cases;  but I doubt the extreme rapidity con-
 tended  for by some physiologists.  Great ra-
 pidity of absorption is observed chiefly as re-
 spects certain saline or virulent vegetable and
 animal  poisons, which are readily imbibed by
 the capillaries and carried into the blood.  Sub-
 stances which are  absorbed by lacteal or lym-
 phatic absorbents act much  more  slowly, and
 several of them require  a considerable period
 before they reach  the blood, especially if the
 vessels which have absorbed them pass through
 glands ; and when this is the case, the glands
 are often affected, and in some instances, when
 the poison is  not very virulent or  rapid in its
 operation, the glands either altogether arrest or
 delay, for a longer or shorter time, the progress
 of the mischief.
   [It is now generally conceded that poisons
 are not instantaneous in their action, but that
 sufficient time always elapses between the ap-
 plication of a poison and the first symptom of
«its action to admit of its contact with the tis-
 sue which  it affects.  Thus, hydrocyanic acid
 requires, according to  Professor Blake, of St.
 Louis, eleven seconds before  it will take effect,
 when applied in large quantity to  the tongue
 of a  dog ; and death does not occur under thir-
 ty seconds.  He found fifteen seconds elapsed
 after ten drops of conia had been injected into
 the femoral vein of a dog, before symptoms of
 the action of the poison appeared  ; and death
 did not occur until thirty seconds after the in-
 jection.  Dr. B. has also showed that the time
 required for a substance to be absorbed by the
 capillaries and diffused through the body, may
 not  exceed nine seconds.   The same experi-
 menter has proved that the celerity of action
 of any poison is  in a direct ratio with the rapidi-
 ty of the circulation : a fact of great  impor-
 tance as connected with the modus operandi of
 medicinal as well as poisonous agents.]
   26. The poison having been carried into the
 circulation either by the lacteal absorbents, or
 by the lymphatics, or  by  the  capillaries and
 veins, according to the seat or part to which it
 is applied, and the action which it exerts on
 the  constituent tissues, produces  ulterior ef-
 fects, which are about to be briefly considered,
 owing to its action, 1st, on  the blood itself, in
 which it  mixes, and which  it contaminates;
 2d, on the blood-vessels and  heart; 3d, on the
 nervous ganglia and plexuses ;  4th, on the spi-
 nal cord and the sensory and motory nerves ;
 and, 5th,  on the brain  and organs  of sense.
   27. iv.  Those poisons  which act  more or
 less chemically are most readily imbibed, are ab-
 sorbed  most directly and rapidly, and change
 not  only the physical characters,  but also the
 chemical  constitution  of the blood, as far as
 we are acquainted with that constitution. They 
352
POISONS—General Effects of.
change the colour, and there is reason to sup-
pose that they affect also the organization of
the red globules; they  alter or diminish the
fibrin,  and variously affect the saline and albu-
minous constituents of the  blood.  But there
are few of  those substances which  act  thus
chemically upon the blood, especially alkalies,
acids,  and numerous neutral salts, that  do not
also affect the vital condition of this fluid, and
change this condition and its chemical consti-
tution  both  in relation  to each other,  and in
connexion with the vessels and heart,  and with
the nervous centres,  more particularly  the
nervous system actuating the  circulating  ap-
paratus.
  28.   IV. General  Effects of Poisons.—i.
Some substances  or agents depress nervous influ-
ence and vascular action, and thereby lower vital
power  ; the depression being either relative or
absolute, and varied in its effects, according to
the agent  and the quantity, intensity,  or dura-
tion of its operation.  The application, for in-
stance, of cold, or, more correctly, the abstrac-
tion of vital caloric, when moderate or of short
duration, or acting upon a surface or part only
of the  body, depresses vital action in that part
during its continuance;  but reaction  takes
place when the depression is limited as to seat
and time, owing to the determination of the cir-
culation to more internal or to vital parts, or
when muscular action accelerates the flow of
blood in the vessels.   But when cold,  owing to
its  intensity or continuance  relatively to the
state of the system  while exposed to it, ren-
ders torpid the organic nervous influence, and
retards or interrupts  capillary and venous cir-
culation through a considerable extent of the
frame,  reaction may not take place, or may oc-
cur so  imperfectly or irregularly as not to re-
lieve internal congested organs; and if it occur,
it may be  attended with,  or develop inflamma-
tion in some predisposed organ.
  29.  There is, perhaps,  no other agent  which
tends  so completely  to depress hoth  the  ner-
vous and vascular functions, so as even to over-
whelm them altogether, as cold, when it  acts
either  intensely or for a long period relatively
to the  constitution and circumstances of those
subjected to its influence, or when it  exceeds
in grade that which has just been stated to ad-
mit only  of  imperfect reaction.   Like  other
agents, therefore, cold is  either a  tonic, a sed-
ative,  or destructive of  life, according to its
grade and the manner of its operation on the
living economy ; but there is scarcely another
physical agent whose sedative effects are so
equally manifested upon all the general systems I
and functions of the frame, and without  di-
rectly  producing some  other  operation, unless
the respiration of air, loaded with carbonic acid,
or with sulphureted hydrogen, or prussic acid
used in any form, be exceptions.  Aconite and
colchicum are sedatives to the sensory and or-
ganic  nerves especially,  but they also irritate
the surfaces to  which they are applied ;  and
digitalis and tobacco act chiefly on the heart
and vascular system, without  materially de-
pressing the nervous functions of animal life,
or the  functions of the brain and spinal cord.
When, however, these,  or  other substances,
which  produce a general sedative or depressing
effect,  as respects nervous influence and vas-
cular action, are exhibited in large or injurious
 quantities,  their  subordinate operations  are
 then so masked as to escape  notice, or are so
 inconsiderable as  not  to  deserve  attention.
 Certain poisons, which produce a narcotic effect
 upon the nervous system, when given in mod-
 erate doses, exert a sedative influence  upon
 the  vital actions generally, when taken in s'ill
 larger or poisonous quantities, as shown by
 opium,  belladonna, conium, hyoscyamus, &c,
 when so exhibited.
   30. The  sedative effect, when  it becomes
 injurious, is generally not limited  either to the
 part to which the agent  is applied,  or to a par-
 ticular system or organ.  Besides depressing
 nervous power in the surface or viscus to which
 a sedative poison is applied, and causing capil-
 lary and  venous congestion, the  morbid im-
 pression is propagated along the nerves to more
 distant parts, especially to the nervous centres,
 while the poison  itself  is partially absorbed,
 and, mixing with  the  blood, it  acts directly
 upon the nervous masses, and  more or  less,
 also, on various organs, according to its spe-
 cific influence.  This being the general effect
 —the result being  depressing, and ultimately
 destructive  of organic nervous power and vas-
 cular action, with varying degrees  of rapidity,
 according to the  nature  of the poison and the
 quantity employed—it may be  imputed, accord-
 ing,  also, to the nature and  quantity of the
 agent, to either of these channels or media
 principally, or to all of them, although in differ-
 ent  grades, the fatal  or injurious operation
 arising through these sources singly, or  con-
jointly, but in  varying proportions.
  31. ii.  Some poisons inordinately excite nervous
 influence and vascular action, or stimulate vital
 power for a time.  Heat and oxygen are  the
 most influential agents in producing this effect,
 and they perpetuate it perhaps longer than any
 other without exhausting vital  action,  espe-
 cially upon  withdrawing them.  Alcohol,  the
 ethers, ammonia, and  numerous other stimu-
 lants, may become poisons when exhibited in
 large quantities, or when long employed, owing
 partly to their effects locally, but especially to
 their influence, through  the media  of the  ner-
 vous and vascular  systems, and of the blood,
 upon the nervous masses or centres, and upon
 the liver and excreting organs.  It is seldom,
 however, that  stimulants destroy  life  before
 they have induced either exhaustion co-ordi-
 nate with the stimulating action, or effusion to
 an amount sufficient to interrupt the functions
 of a vital organ, or alterations of the circula-
 ting fluids incompatible  with the continuance
 of the nervous functions or of the heart's ac-
 tion, or even inflammatory or structural changes
 of some important viscus, or some two or more
 of these changes.
  32. iii.  Exhaustion of organic nervous power,
 and of sensory and motory influence, or of vital
 energy generally, is one of the most  manifest
 general effects of substances given in quanti-
 ties  sufficient to  destroy life in  a  short time.
 This exhaustion is especially remarkable when
 it  is caused by substances  which  injuriously
 impress the nervous systems,  or which act  so
 rapidly  as to render it  difficult to determine
 whether the impression of the agent be trans-
 mitted by means of the nerves to the heart and
 brain, or whether the substance is itself ab-
 sorbed into the circulation, where it directly 
POISONS—Special Effects  of.
353
acts upon these organs, or whether it acts in
both ways.  Poisons which may be said to kill
by exhausting the vital actions must necessa-
rily be considered as having first produced an
excessive stimulating effect, which has so rap-
idly passed  into exhaustion  as to  leave  the
primary operation  unobserved  or even unob-
servable,  for  exhaustion implies antecedent
stimulation.   Nevertheless, if the operation of
many of the substances which are generally
said to destroy life by exhausting vital power,
when given  in  large quantities, be considered
with reference to their effects upon  the living
economy in small doses, it will be found either
that the quantity which is stimulating is very
small, or that the stimulating operation of the
substance, even in  such quantity, is very equiv-
ocal ; and, if it may be  admitted to exist, it
rapidly lapses  into a distressing or peculiar
form  of exhaustion, as may be allowed in  re-
spect of tobacco and various narcotics.  From
this it will appear that the poisonous effect of
the same substance may be imputed  by one
person to the powerful  sedative  effect it had
produced  in  the quantity or dose in w-hich it
had been given, and by another to the extreme
exhaustion consequent upon a  great and rap-
idly evanescent stimulation, &c,  according to
the views each may entertain of the physiolo-
gical action of the substance in question.
   33.  iv.  The  general effects of poisons cannot
It viewed as  merely dynamic:  they also  alter or
change the states of nervous influence and of vas-
cular  action.    Those substances which prove
rapidly poisonous, owing to their nature or the
quantity taken, evince the dynamic  operation
more remarkably.   This may, however,  be
owing to  the circumstance that the dynamic
action is  much more recognisable  than  any
change in character or kind of action, during
the short period intervening between the im-
pression of the agent and a fatal result.  It is
chiefly such  poisons as act slowly, or some of
those which are more  virulent, but  which,
when taken in small quantities, are not rapidly
fatal, that produce more or less manifest alter-
ative effects.  Still, these effects  are not soli-
tary; they are generally associated  with one
or two of the general effects already noticed,
and also with certain others, which are  more
specific, or  which appertain  to the  poison in
question, and in some respects characterize its
operation when employed either medicinally or
otherwise.  The alterative effects of  poisons
being recognised with difficulty, in  connexion
with  other more general and remarkable  re-
sults, unless  the operation is slow, and as these
effects are more peculiar or specific, and, at the
same time, more complicated, I shall proceed
to consider them more in detail, and endeavour
to analyze them, or show  their more special
influences, although I cannot do so at this place
in so  full and satisfactory a  manner as  I  am
desirous of doing.
   34.  V.  The special Operation of Poisons.
—It is obvious to the  experienced observer of
the operation of the more active agents of na-
ture upon the living  economy, that very few
act in one unvarying  manner, or  that any one
of them produces a single effect, or acts solely
upon  a single  function  or part,  without also
affecting others more or less.  All that  such an
observer  of the more  special actions, either of
    III.              23
 medicines or of poisons—and most of the for-
 mer possess the latter property—can expect, is
 this, that, although any one of these substances
 produces certain general results,  and extends
 its influence more or less to different functions
 and even to remote organs, some  particular
 surface, function,  or viscus; some one of the
 chief factors of life, or of the constant actions
 and results which these factors produce ;  some
 of the manifestations of life in particular tis-
 sues, systems, organs, or parts, will  be  more
 prominently affected than others, or be chiefly,
 but not solely, changed by the aetion of that
 substance.  In the  analytical  survey  I  am
 about  briefly  to take, it must, therefore,  be
 considered,  that the special action of any sin-
 gle poison is not confined  to the production of
 one only of the several effects which I shall
 have to notice under the separate heads which
 the analysis furnishes; but  that it extends to
 more than one system or viscus, although some
 one manifests  it much more than another, and
 alters certain vital properties and functions, or
 a  particular property or function, more  than
 others.   When the  symptoms and  changes
 produced by individual poisons, and the modes
 of  obviating  and  removing  these changes,
 come  under consideration, then the associated
 and even complicated nature of these changes
 will be made more evident.
  35.  i.  Some  injurious agents abstract the ca-
loric, or depress the vital calorific process not only
in the  part  to which  they are applied, but also
throughout the  body.  This effect may  be pro-
duced by the application of cooling substances,
or by whatever lowers the organic nervous in-
fluence and vascular action, or by  both modes
 of action produced either simultaneously or in
 rapid  succession.   A  large quantity of  cold
 water or of  ice taken into the empty stomach,
 especially when the system is exhausted by fa-
 tigue, or when  the body is perspiring freely, may
 not only abstract the animal heat from  parts
 requiring a  certain  elevation of temperature
 for the performance of their functions, but also
 depress the organic nervous influence actua-
 ting these parts, so as to produce capillary and
 venous congestion, or an arrest of the circula-
 tion, and other consecutive  effects, until the
 action of the heart ultimately ceases.  Al-
 though cold fluids may destroy life very rapidly
 when taken largely in these circumstances, in
 the manner now stated, and owing to the in-
 fluence of cold upon  vital actions, as  noticed
 above (y 28, 29), yet there are hardly any sub-
 stances which are poisonous owing chiefly to
 this mode of action, although there are several
 which,  when  employed  in  large  or  frequent
 doses, produce a refrigerating and depressing
 effect  along with  other changes  of a  more
 prominently injurious  nature, more especially
 the hydrochlorate of ammonia, the nitrate of
 potash, and various other salts and  dilute acids,
 which not only depress the calorific process, but
 also chemically and physically affect the  blood
 and vascular system, and through this medium
 the nervous system also.
   36. ii. Certain poisons act  more  especially  in
 destroying the  sensibility, or the functions of the
 sensory and of the organic nerves, in benumbing,
 depressing, or suppressing sensibility, and the
 organic nervous influence.  Of these the most
 remarkable afe monk's-hood and its active prin- 
354
POISONS—Special Effects of.
ciple aconite, cold ;  ether and alcohol,  when
absorbed or injected  into the blood, or  when
their vapour  is inspired ;  belladonna, conium,
morphia, and most of those which have been
denominated  narcotics, sedatives, and  stupe-
facients.  But these produce also a paralyzing
effect, remarkably depress the organic nervous
influence, diminish irritability, impede secretion
and excretion, or even irritate the mucous sur-
face to  which they may be applied,  as colchi-
cum, tobacco, hyoscyamus, opium, &c.  [Chlo-
roform is another very active poison, which may
be ranked under this head, as it exerts a fli-
rectly depressing influence over the  heart and
cerebro-spinal system of nerves ; and if breath-
ed for a few minutes, would inevitably destroy
life]
  37. iii. Other poisons more prominently paralyze
the organs of voluntary motion, while they impair
the irritability of involuntary parts, diminish sen-
sibility,  and depress the organic nervous influence,
especially hemlock and its alkali, conia, hydro-
cyanic  acid,  and the cyanides, carbonic acid,
sulphureted hydrogen, &c.; stramonium, can-
nabis indica,  tobacco, digitalis, the preparations
of lead, &c.
  38. The substances which act energetically
upon the nervous system, in  impairing  either
the sensibility or the  irritability and  the volun-
tary movements of muscular parts supplied  by
nerves  respectively belonging to these systems,
have not their actions limited to one of these
functions only,  although  either may be more
prominently  affected  according to the  poison
employed.   Their effects may, moreover,  be
extended even to secreting and  excreting or-
gans, such poison acting  more or less on par-
ticular  functions than on the  others.  When
either of these  substances is  taken into  the
stomach in quantities which  are injurious, not
only are the nerves of the part affected, but ab-
sorption of the poison takes  place to a certain
extent, and the injurious impression made upon
the nerves by it is transmitted along the organic
and sensory  nerves to the ganglia,  brain, and
spinal cord, which are farther affected accord-
ing as the substance  is present in the circula-
tion.  Some of these poisons seem to affect one
order of the nervous system more than another;
certain  of them impress more especially the or-
ganic or ganglial nervous system, deranging the
several functions depending chiefly upon it; oth-
ers affect the brain, consciousness,  and  sensi-
bility,  and impair more or less the  voluntary
movements  and other allied functions ; and
these several results  are,  moreover,  varied not
only with the quantity of  the poison  taken, but
with the circumstances connected with  its ex-
hibition and  the constitution and temperament
of the person who is  its victim.
  39. iv. Certain poisons produce a septic action,
weakening and dissolving the vital cohesion of tis-
sues, or softening and even liquefying the struc-
tures.   These substances not  merely depress
the organic nervous  energy  of the  parts with
which they come in contact, but they also pro-
duce a  physical or chemical change  in the tis-
sues, contaminating  the  fluids, and favouring
the  imbibition and  absorption, not only  of the
poison  itself, but of the contaminated fluids of
the poisoned part.  Animal matters  act chiefly
 in  this way, more  particularly the poisons  of
 Berpents, offish, decomposing or putrid animal
substances, the animal poison generated in sau-
sages and preserved or dried meats,  the secre-
tions  and fluids in disease, or after death ; es-
pecially after  malignant  and infectious  mala-
dies, and still  more especially if any of these
be applied to a  punctured wound,  or to an
abraded surface.   In  most instances the local
action of these poisons is evinced by the part
being pained,  swollen, livid,  or otherwise dis-
coloured, soft or boggy, sometimes numbed, and
changed  in temperature, often rapidly passing
from a burning heat to coldness, or  being cold
from the commencement.   These changes pro-
ved from the extremities to the trunk, from
the •periphery to the centre,  and  extend more
or less rapidly, with remarkable sinking of vital
power, a very quick or irritable pulse, and man-
ifest indications of contamination of the fluids
and soft solids, moTe especially when  the poison
has been applied to an external surface, or to a
wound. When it has been taken into the stom-
ach, distressing nausea, vomiting, anxiety, and
feeling of sinking, evidently owing to depression
of the organic nervous energy, are then gener-
ally  observed, with other symptoms varying
with the particular poison which has been ta-
ken, as cutaneous blotches or eruptions, cold-
ness of the surface, suppression of urine, rapid,
weak pulse, watery stools, &c,  &c.
  40. The animal poisons which  act in the way
now described affect chiefly the  vital conditions
of the parts to which  they are applied ; de-
press organic nervous influence,  and  loosen the
vital cohesion of the tissues, while  they con-
taminate the fluids;  but  there are  other sub-
stances, which soften or liquefy  the  tissues, in
consequence rather of a chemical than  a vital
operation, although the vital conditions are also
to a certain extent affected.  These are the
alkalies, the sub-salts, or those saline substan-
ces in which the alkali is  the predominant ele-
ment, the biborate of soda, the iodide of potas-
sium, the alkaline sulphurets, the preparations
of antimony, of mercury, &c,  when used in
large quantity or long employed.  These sub-
stances act locally, more or less energetically,
as now stated, especially the pure alkalies ; but
they are also  rapidly absorbed, and  they then
alter the vital conditions of the nervous and vas-
cular systems, and the chemical constitution of
the blood, especially as regards the red globules
and fibrin, the proportions of which  they even
diminish, especially when they have been em-
ployed for a  considerable time.  When  thus
used, they also liquefy, and favour the absorp-
tion of morbid growths or tumours, while they
relax generally the soft solids.
  41. v. That various poisons excite the ganglial,
spinal, and sensory nerves, or either of these orders
of the nervous system, more than  the others, will
be admitted ; but this effect is generally varied
and associated, according to the nature of the
particular substance employed, with other chan-
ges manifested by secreting surfaces and or-
gans.  The stimulating operation is evidently
exerted primarily upon the nervous organization
of the part to which the substance is applied ;
and for a time it  tends to concentrate the ner-
vous  power, and even vascular  determination
and action, towards the surface or viscus thus
acted upon.  Subsequently, however,  the effects
become more or less diffused ; but the rapidity
of the diffusion of the stimulating influence over 
                              POISONS—Spe

the frame depends upon the nature and quan-
tity of the substance employed, ihe state of the
organs upon which it has acted, and the tem-
perament, constitution, and habits of the subject
acted on.   The principal question is, whether
or no the general or remote effects are produced
by nervous influence, or by the  rapid passage
of the substance into the circulating fluids, and
the consequent operation of it upon the several
organs and structures of the frame, or by both
these modes, either of them predominating ac-
cording to the circumstances just stated.
   42. A. As to the action of stimulants on  the
nervous system, on either the ganglial, the sen-
sory, or motory, or upon any two or all of these
divisions of the system, there can be no doubt
as respects that part of it supplying the organ
to which the  poison is applied ;  the question
being as to the extension of the stimulating
operation to distant parts by means of this  sys-
tem.  Formerly, the remote effect was imputed
altogether to this system, the other mode of
action just referred to being overlooked or dis-
carded.  From  1819 until  1826,  I made many
experiments with stimulating substances  and
tonics, vegetable and mineral, some  of which
were published in the journals of the day (es-
pecially in the London Medical and Physical
Journal, and London Medical Repository), with
the view of determining the modus operandi of
many active agents upon the frame ;  and I  de-
monstrated beyond dispute that this is  not  the
only mode of action, as regarded the great  ma-
jority of them, which, although  acting more or
less in this way, operate also, and even mainly,
through the medium of the circulating fluids.
   43. That the stimulating  impression made
upon the organic or sensory nerves of the viscus
to which the'substance is applied is transmitted,
more or less  remarkably,  by means of these
nerves to  remote  parts, which it thus  affects,
appears extremely probable;  for there are sev-
eral analogies, considerations, and even proofs,
both physical and pathological, of this being the
fact; and, moreover, these remote effects  are
often reflected upon other distant parts.  Thus
the stimulus existing in, or acting upon, an in-
ternal viscus, may be transmitted by the organic
nerves to the adjoining ganglion, or to the great
semilunar ganglion, or to the spinal cord, or to
the brain, becoming an object of either obscure
or distinct sensation or consciousness, and there
the effect  may  cease, or be  reflected thence
upon other parts, affecting the actions of invol-
untary organs, through the media of ganglial
nerves, or exciting the movements or sensibility
of voluntary parts through the medium of  the
spinal  cord.  The  remote effect  may  be  pro-
duced more or less by either order of nerves or
nervous masses, ganglial, cerebro-spinal, orsen-
sory and motory, according to the nature and
quantity of the substance employed,  and  the
mode of employing it.   Much of the miscon-
ception and confusion which have existed as to
the operation of agents on and through  the me-
dium of the nervous organization have arisen
chiefly from the following circumstances:  1st.
Experimenters  have considered the  organic
nerves as forming a part of those proceeding
from the cerebro-spinal axis; 2d. They have
viewed  the distinct orders or divisions of  the
nervous system as identical, and as performing
the same functions ; and, 3d.  They have over-
iial Effects of.                          355

 looked the fact that it is impossible to separate
 the vascular system from the nervous, so as to
 isolate each, and that it is  equally impossible
 to cut off the nervous communications existing
 in distant parts while the arterial communica-
 tions are allowed to continue, inasmuch, as all
 arteries are surrounded by a reticulum of gan-
 glial  nerves.   It is owing mainly to these  cir-
 cumstances, and their consequences, that so
 many ill-planned and ill-performed experiments
 on  living animals have been made ; experiments
 which  could  furnish  no correct  inferences,
 which, moreover,  were undertaken  to decide
 points not admitting of being thus decided,  and
 which could not prove the basis of even a loose
 hypothesis, far less of sound  doctrine.  Con-
 sidering, therefore, as will appear more fully in
 the sequel, that poisonous as well as medicinal
 agents produce an impression  upon the nerves
 of the  part to which  they are applied, that is
 not limited to such part, but which often affects
 sympathetically distant parts,  although in  va-
 rious degrees and modes, according to the  na-
 ture and state of the substance  employed, I pro-
 ceed to remark upon the operation of stimulants
 through the medium of the circulation.
  44. B. That numerous stimulating substances
 —vegetable, saline or mineral, and animal—are
 more or less rapidly imbibed  by the tissues,  and
 absorbed into,  and are afterward  eliminated
 from, the circulation, are  among the best  es-
 tablished facts in physiological science. The
 effects which these substances produce, when
 taken either medicinally or in hurtful doses, are
 chiefly  owing to this mode of  action,  although
 the impression primarily made by them on  the
 several divisions of the nervous system is also
 more or less influential in producing these ef-
 fects ; but the exact  extent of that influence
 can hardly be determined.   That the majority
 of stimulating substances are actually absorbed
 into the circulation, to an extent varying with
 the substance employed, and  the slate and mode
 of  its employment, has been fully established,
 inasmuch as  they have been  detected in  the
 blood  itself,  and in  the several secretions  and
 excretions.   The  special operation  of many
 stimulants thus depend not only upon their  pri-
 mary impressions upon the nervous system,  but
 also upon their presence in the blood, and their
 action on the nervous masses arid centres, and
 more specifically upon the functions of certain
 orgaps and  surfaces, particularly upon those
 organs by which they are eliminated from  the
 blood.  The alcoholic, the ethereal, the balsam-
 ic, the camphoraceous, and several other classes.
 of stimulants, both vegetable and mineral,, act
 in the way now stated.*

  *During 1819. 1820, and 1821, I  made a number of ex-
 periments upon the operation of several active substances ;
 and the results c( those which I made  with the terebinthi-
 nates were puWished in the London Medical and Physical
 Journal for July, 1821.  At that time it was generally be-
 lieved that medicinal as well as poisonous substances acted
 upon the nervous system directly and entirely, the results
 depending altogether upon this system, without reference
 to the blood and vascular system, and without distinction
 between the organic, the sensitive, and the motory divis-
 ions of the nervous system.  I believe myself to have been,
 if not the first, at least among the first, to determine by ex-
 periments the action of these substances through the  me-
 dium of the blood, and to show that  many of these substan-
 ces act differently upon the different orders of the nervous
 system ;  upon the organic nerves either chiefly, distinctly,
 or differently from their action on the cerebro-spinal.  (Seo
 Lond. Med. and Phys. Journ., July, 1821, p. 112, et seq ,
 and August, 1821, p. 185, et seq.) 
356
POISONS—Special Effects of.
  45. vi  That many poisonous substances are
capable of astringing the tissues and of increasing
the tone or vital cohesion of certain structures, when
employed in small quantities, cannot be doubted;
but this effect more rarely follows their employ-
ment as poisons, unless in the case of mineral
poisons ; and then the operation of these, espe-
cially when used in large or injurious quantities,
is more chemical than vital; several of them,
as the mineral  acids and  salts, combining to a
certain extent with the tissues and the liquid el-
ements of the tissues, altering the constitution
of the capillaries and of the capillary contents,
and thereby affecting the state of vital function
and action.  Many of the substances which act
as stimulants, by the greater permanency  of
their effects, and by their action, in the manner
now stated, upon the tissues, have an  astrin-
ging operation.   Substances acting thus on the
economy have not their effects always  limited
to the parts to which they are applied ;  for I
have ascertained that they are absorbed, espe-
cially when much diluted, or when dissolved,
into  the circulation, and  are afterward carried
out of it chiefly by the kidneys and skin.  The
metallic salts and  the mineral acids severally
act in this way more or less rapidly, energeti-
cally, and manifestly; and produce their effects
on parts of the frame the most remote  from
those to which they were applied.   The metal-
lic sulphates  and nitrates, the superacetate of
lead,  the balsams  and resins, the phosphoric,
the mineral, and many of the vegetable acids,
although acting in the way now stated, sever-
ally  produce  other effects, when employed in
hurtful quantities.   Some of them excite cer-
tain of the organs concerned in excreting them
from the circulation ;  others of them depress or
exhaust the organic  nervous influence and the
irritability  of the  heart  and other contractile
parts; and many of them alter the constitution
of the blood, especially of the red globules and
fibrin, so as to render this fluid  unsuitable to
the perpetuation of the nervous and vital func-
tions.
  46. vii. Numerous substances  act  especially
upon the irritability of contractile parts, and either
impair or increase this vital property, according
to the nature of the  substance.   These modes
of action evidently result from the impression
produced either  primarily  upon  the  organic
nerves of the part, or consecutively upon the
ganglia, the poison having been carried into the
circulation, or from both these modes of opera-
tion.   Prussic acid and the prussiates, monk's-
hood, tobacco, aconite, digitalis, arsenious acid,
colchicum, antimonials, borax, and boracic acid,
ergot of rye, nitre, and several other substan-
ces, when employed in large doses, depress the
organic nervous power,  and the irritability of
involuntary organs,  especially  of the heart,
without directly impairing the functions of the
brain and spinal cord, and of voluntary parts,
although affecting them through the media of
the ganglial and vascular systems.  Other sub-
stances affect the irritability by increasing it at
first and exhausting  it afterward, the effect va-
rying with the  substance and the quantity em-
ployed.  This operation probably obtains in re-
spect even of some of the articles just enumer-
ated, as arsenic and antimony.  Other substan-
ces excite the irritability of both  voluntary and
involuntary organs more or less remarkably, as
 nux vomica and strychnia, brucia. St. Ignatius's
 bean, snake-wood,  [the different  species  of
 rhus], &.c.
   47. viii. Numerous articles act more especially
 in augmenting certain secretions and excretions;
 and they produce these effects either by their
 direct action  on the organs to which they are
 applied,  or  by  their  consecutive  operation,
 through  the  medium of the circulation, upon
 the organs and surfaces which they specifically
 influence. Thus, emetics and purgatives taken
 into the stomach excite or irritate  the organic
 nerves supplying the villous surface of the ali-
 mentary  canal, and thereby increase the  secre-
 tions and involuntary movements of the tube,
 each substance possessing either an emetic or
 a purgative property acting in a manner more
 or less peculiar  to itself, and producing,  more-
 over, in some cases, additional effects.   Other
 substances, as many of those which act upon
 the  kidneys,  as  the terebinthinates, several
 salts, particularly the nitrate of potash, the ni-
 trate of soda, the acetate of potash, canthari-
 des  or its active principle, and various  other
 articles,  are absorbed into the circulation, and
 excite especially the kidneys, so as  to increase
 their secretion,  or even  to  over-excite  or in-
 flame them.   Other  substances, through  the
 medium  of the circulation,  affect the exhala-
 tions and secretions from the bronchi; and oth-
 ers, again, those from the skin.  But this sub-
 ject need not be  farther pursued at  this place.
   48.  ix.  That some articles  irritate particular
 organs or parts in a way more or less peculiar to
 these articles,  either  when directly  applied, or
 absorbed  and carried in the blood to the  organ
 affected by them, may  be admitted.  But al-
 though this operation, and those just noticed,
 constitute the chief modes in  which substances
 are  expected to act medicinally—their  princi-
 pal therapeutical effects—yet they  are merely
 subordinate to the  more  energetic or violent
 results produced upon the nervous influences
 and vital  actions, when the same substances are
 employed in hurtful quantities.
   49. x.  In connexion with this irritating opera-
 tion,  varying with the substance employed and the
 mode of its employment, an alterative action  is also
 produced; the  vital functions, the  secretions, the
 sensible qualities  and conditions, and the nutrition,
 of particular organs and parts being changed in
 kind  or character, as well as dynamically or in de-
 gree.  These  effects are  manifested  chiefly
 when poisonous  substances  are given repeat-
 edly  in small doses, are employed medicinally,
 or with the view of producing deleterious ef-
 fects slowly and  latently.  Numerous medicines
 have acted injuriously in this way, as well as
 in the two preceding modes, in consequence of
 having been  employed injudiciously; inappro-
 priately as respects the nature of the disorder,
 and either during too long a period,  or  in too
 large or too frequent doses, the effects thereby
 produced having been mistaken for the progress
 of the  disease.  When  substances  have thus
 produced an  alterative effect or change  of ac-
 tion in any one or more organ or part, they have
 generally been absorbed to a greater or less ex-
 tent  into the circulation, and  have  operated,
 through  the medium  of the  blood,  on the tis-
 sues, or  on the  organs eliminating them from
 the system.
|  50. xi. Substances which irritate or excite inor- 
POISONS—Circumstances which modify the Effects of.              357
iinately the parts or tissues to which they are ap-
plied, determine or solicit increased circulation and
vital action to these parts, and proportionately di-
minish vascular action in distant parts, or in the
viscera less intimately connected or  associated in
function with those on which  these substances act
directly.  Many articles are employed medici-
nally with the intention of producing these ef-
fects, as revulsives, derivatives, or revellents ; and
many  of the phenomena observed as consequen-
ces of poisoning depend  upon this revulsive or
derivative operation.  This effect arises chiefly
from the influence of the organic nerves, which,
when  irritated, influence the circulation  in the
associated  capillaries and  arteries, increase
the vRal expansion  and  action of these ves-
sels, and augment the exhalations and  secre-
tions  from them ;  the results varying, in kind
and in grade, with the irritant or substance thus
affecting the organic  nerves of the part to which
the increased action  is thus  determined.
   51.  VI. The Circumstances which  modify
the Effects of Poisons require to be briefly
noticed.—(a) The quantity used materially  af-
fects  the action of a poison, so much so that
the most virulent poison  is  medicinal, or even
salutary, when taken in minute doses.  Thus
prussic acid  in a very small dose is soothing
and antispasmodic, in a large  dose it  annihi-
lates the vital action.  Several poisons, in small
quantities, slightly irritate or inflame the digest-
ive canal, but in larger doses they produce con-
vulsions, coma, and death.
   52. (b) The aggregation and degree of dilution
very materially modify the operation of a poison.
The more  minutely  a deleterious  substance is
divided, and the more completely it is dissolved
in oil  or in water, the more energetically and
the more rapidly it will act, especially when ta-
ken into the stomach.  This necessarily follows
from the preparation thus made for  the  action
of the poison over a large surface, and for the
imbibition  of it by the tissues and  absorption
by the vessels.   Certain substances, which are
extremely  active when thus prepared, remain
for some time inactive when they have been ta-
ken in a concrete or  aggregated  state.  The
dissolving influence  of the juices of the stom-
ach, and of the secretions poured  into the duo-
denum, is  not  without influence upon certain
poisons, when  taken in  an  undissolved state ;
for the carbonate of barytes  and arsenite of
copper are more soluble in these than in water.
The operation of poisons is farther changed by
aggregation and by  degree  of dilution.  Cam-
phor,  in weak dilution, is cooling, sedative, and
soothing ; in stronger dilution in oil, or minute-
ly divided in mucilage," it is exciting ;  and, in
still larger  quantity,  productive  of delirium,
coma, or convulsions ; and in fragments it may
occasion inflammation, or even ulceration of
the part to which it is applied.  Certain poisons
in a state of vapour, or even substances which
cannot, in their usual states, be viewed as poi-
sons,  when employed in a state of vapour may
become poisonous, if they be applied to exten-
sive surfaces of the frame.  Thus the inhala-
tion of the vapour procured from numerous as-
certained poisons, narcotics, and others ; or of
the vapour of ether,  of alcohol, [of chloroform],
and of certain volatile oils, when continued even
for a  short time, rapidly affects the frame, ow-
ing to the remarkably great extent of living
surface to which substances in a state of vapour
are thus directly applied, to  the extent of the
impression produced by them on the organic
nerves, and to their rapid absorption into the
circulation.
  53. (c)  Chemical conditions or combinations,
and  the states in which  chemical  substances
are  employed, modify  the  effects  produced.
Some chemical substances, when employed in
a concentrated state, act locally merely, as the
mineral acids; but when  taken internally in a
state of weak dilution, they are carried into the
circulation, and act  upon  and through the me-
dium of the  blood.  Morphia, being insoluble,
is comparatively inert, unless very minutely  di-
vided, but when dissolved in a fixed oil, or in
alcohol, or combined with an acid,  it becomes
very active;  and numerous substances which,
in an uncombined state, are most deleterious,
become innocuous when  chemically combined
with their opposites, as alkalies with acids, and
vice versd.  But this topic is so trite that I need
not pursue it farther.
  54. (d) Admixture  of various substances, ali-
mentary or others, either before or after inges-
tion, varies the effects ; generally by diminish-
ing the activity of the  poison, owing to  slow
absorption and imperfect or intercepted contact
with the villous  surface  of  the stomach.   If,
however, the poison be taken in a state of com-
plete solution, and if the substances taken with
it, or those  already present in the  stomach,
serve to dissolve or minutely divide  it,  they
may not impede, but, on  the contrary,  ensure
its action.  If it be swallowed in a state of im-
perfect division or in fragments, the alimentary
or other substances given with it  may so  in-
volve these particles, or the mucus  of the sur-
face may so protect  the organ, as either to  di-
minish its effects, or to occasion vomiting, by
which it may be altogether or partly thrown off.
Dr. Booth has recorded  an instance of an ounce
of corrosive sublimate having been swallowed
after a full meal, without  any  remarkably bad
effects having been produced, full vomiting hav-
ing been speedily induced ; and other cases are
referred to by Dr. Christison (see above, y  3).
  55. (c) The organ  or tissue to which a poison
is applied has been already stated materially to
influence its  action on the economy, both local-
ly and  generally (y 3-10).  It has also  been
stated  that the cuticle  protects the skin more
or less from  the action  of  poisons, even the
most corrosive and  subtile;  and it is not until
it be removed or destroyed that the poison acts,
or if it act, the effect is  much more slowly pro-
duced.  The mucous surfaces are  much more
readily acted upon :  still the  mucus and epithe-
lium covering them protect  them to some ex-
tent, and render them less susceptible of the poi-
sonous impression, and  less prone to imbibition
and absorption, than serous  surfaces, or denu-
ded or  incised parts.   These latter parts, or
wounds of any description, may, however,  es-
cape, if they bleed so freely as to wash away
the poison.   The rapidity of action varies much
with the tissue to which the poison is applied ;
and is  manifestly attributable to the celerity
with which absorption proceeds in such tissue,
and the extent of surface presented to the poi-
son.  Thus it is  very rapid when a  fluid poison
is injected into the bronchi.
   56. It is worthy of mention, as remarked, but 
358
POISONS—Circumstances suggesting Suspicions of.
not explained, by Dr. Christison, that the poi-
sons which  seem  to operate energetically on
the sentient extremities of the  nerves, and in-
directly through the brain and spinal cord, act
not at all upon the divided surfaces of the brain
and large nerves, or upon the course of the lat-
ter ; as proved in  respect of prussic acid, opi-
um,  strychnia, and  several  narcotics.  This
circumstance may be partly owing to the mode
of operation of poisons above  contended for,
viz., upon the organic nerves,  or the  organic
and sensory nerves chiefly ;  the application of
them to a cut portion of the fibrous structure
of the  brain, or of a nerve, not being likely to
produce any farther effect than what may arise
from the division of certain fibres of these
structures.   The effects of poisons on differ-
ent parts depend much upon the  vascularity and
the disposition to imbibition and absorption pos-
sessed by the texture to which the poison is di-
rectly applied.  The connexion  also subsisting
between the texture and the more vital organs,
especially the dependence of the part upon the
organic nervous system; the state of the ves-
sels, the amount of haemorrhage from them, and
a variety of circumstances, also modify the re-
sults.
  57. Mineral  and vegetable poisons are much
less controlled or influenced in  their action by
the organ or tissue to which they are applied
than animal poisons are.  The  digestive canal
and its secretions change the usual operation
of mineral  poisons but  little ; some vegetable
poisons are somewhat more modified by the
digestive organs in certain cases ; but several
animal poisons, which, if applied to a denuded
surface, or  to a wound, would be rapidly fatal,
may be so altered by these organs as to be pro-
ductive of but little disorder when taken inter-
nally.
  58. (/) The operation of various  poisons,
especially of narcotic and sedative substances,
is modified,  also, by  habitual use of them, and
by idiosyncrasy.  While use diminishes the poi-
sonous effect, idiosyncrasy more commonly in-
creases it.  A person who has become addicted
to opium, or even to some other narcotics,  may
take as much at once, with advantage, as would
destroy the life of a person not accustomed to
the substance ;  and a person may be almost
poisoned by a substance, or  an  article of diet,
as a particular kind of fish, that would not dis-
order others.  The influence of habit, or  use,
is shown chiefly by  the  organic poisons,  par-
ticularly those already mentioned.  Inorganic
or mineral substances have not  their injurious
operation so remarkably impaired by use.  Dr.
Christison supposes that this "effect of habit
is nothing more than an increased power ac-
quired  by the stomach of decomposing the  poi-
son, just as  it gradually acquires an increased
facility in digesting some alimentary substances
which  are at first indigestible" (p. 29).   This
may be the case  in part;  but something is
probably, also, owing to a gradually diminishing
susceptibility of the impression  produced by
narcotics in the  organic nerves,  and of the
nervous system generally, owing to their fre-
quent exhibition.
  59- (g) The moral and physical states of the
system  also modify ihe  operation of poisons,
especially of organic poisons, narcotics espe-
cially.   Great  mental excitement, anger,  pas-
 sion, &c, delay, or, to a certain extent, coun-
 teract the  operation of narcotic and sedative
 substances, while the depressing passions has-
 ten and ensure their effects.  Several diseases,
 especially those of the nervous systems, as te-
 tanus, rabies, mania, hysteria, &c, admit of
 large doses of opium, or of other narcotics, be-
 ing given without injurious effects.  Other sub-
 stances, however, which are more sedative than
 narcotic, as  tobacco, colchicum, prussic acid,
 &c, and which act more  upon the heart, are
 not  tolerated so manifestly  during these dis-
 eases.   Febrile diseases, especially during the
 stage of excitement and increased vascular ac-
 tion, delay or counteract in  some degree  the
 action of some poisons ; while the samS mal-
 adies, and  more especially pestilential fevers
 and pestilential cholera, particularly during the
 stage  of exhaustion, show that the  frame is
 more or less insusceptible of the impression
 usually made by poisons.  This want of sus-
 ceptibility  is owing to the low or exhausted
 state of vital function throughout the body, and
 to the absence of those vital conditions, or the
 commencing departure of these conditions, by
 means of which agents act upon living bodies.
   60.  Other  diseases, or  a  predisposition to
 them, as  to  apoplexy,  palsy,  or congestive
 states of the brain, diseases  of the heart, in-
 flammatory states of the stomach or intestines,
 congestions  of  the liver,  &c,  may severally
 favour the operation  of certain  poisons, while
 these latter may excite or determine an attack
 of  these maladies.  Where  there is an apo-
 plectic or paralytic tendency, a small dose of a
 narcotic may occasion a serious effect, or even
 produce  a  seizure ; and, when  there is seri-
 ous organic change in the  heart, a large dose
 of a sedative, as of hydrocyanic acid, colchi-
 cum, or even a moderate dose, may terminate
 life.  The  irritant poison, which  may  be  in-
 nocuous in some  instances, may be fatal in
 others, where disease of the stomach or bowels,
 or a  tendency to  it, already exists ;  but this
 subject requires  no  farther  illustration    It
 should also be kept in recollection that blood-
 letting, either soon  after or before a poison has
 been taken, accelerates the action  of such poi-
 son, if it remain in the part, by promoting its
 absorption.
  61. VII.  Circumstances  which should sug-
 gest  Suspicions of being  poisoned.—(a) The
 sudden appearance of severe symptoms  while the
patient is in health.  It is  comparatively rare
 that a substance can  be taken in  an injurious
 quantity without almost immediately producing
 serious ailment.    Without  denying  the oc-
 casional  production of slow  poisoning by the
 practiced poisoners of the Middle .Ages, and of
 the succeeding two or three  centuries, it may
 be admitted that this mode of poisoning was
 not so frequently attempted or accomplished as
 is  generally supposed.  At the  same time, it
 should not  be overlooked that poisons may be
 administered,  as  they sometimes  have been,
 during the illness or the intoxication of the poi-
 soned person, in order that  the act  may appear
 as the result of these states.  The poison may
 even  be added to  the patient's medicine, or
 substituted for it, as has been shown on several
 occasions.  Generally, the symptoms of being
 poisoned appear either immediately, or within
 an hour after the poison has been  taken ; and 
POISONS—When Suspicions of are  excited.
359
it very rarely occurs that they are deferred be-
yond two hours, or three hours at the farthest.
There  are occasions, however,  in which slow
poisoning may occur unintentionally, and the
symptoms be gradually and very slowly devel-
oped.   I have met with several  instances, in a
somewhat long course of practice, of active and
cumulative medicines having been given in large
or frequent doses for so long a time as to pro-
duce dangerous, and even fatal effects; these
effects having been mistaken, owing to the ig-
norance of the practitioner, for the progress and
issue of the  natural disease.  Colchicum, digi-
talis, tobacco injections, opiate injections, tar-
tar emetic, the preparations of iodine, and sev-
eral other substances, have thus produced ef-
fects for which they  did not receive the credit.
  62.  (b) The appearance of severe symptoms af-
ter a meal, or after taking any substance, fluid or
consistent, into the stomach, or after any substance
has otherwise been exhibited or applied, should also
be a source of strong  suspicion.    What I have
said above (y 2-11), as to the several modes of
poisoning, is sufficient to show that poisoning
may be produced in  various ways, besides the
usual way of mixing the poison in the food or
drink of the poisoned person.  When, therefore,
violent or fatal symptoms occur suddenly, or
proceed rapidly, diligent inquiry should be made
as to the time, nature, and kind of the patient's
last meal, as to the  circumstances and occur-
rences to which he has been exposed, as to the
persons with  whom he  last had communica-
tions, and as to his habits and morbid ten-
dencies.  It should be kept in recollection that
disease may exist, even for a long time, with-
out occasioning suffering so great as to prevent
his usual avocations ; and  that the stomach it-
self even may be the seat of disease, and yet a
full meal may be taken, after which the  most
violent symptoms may supervene suddenly and
carry off the patient.   This is not an  infrequent
occurrence in cases of perforation of the stom-
ach met with  in practice,  especially in  young
women (see  Stomach, Diseases of).   A fatal re-
sult, presenting the symptoms of poisoning, may
also follow the ingurgitation of a large meal, or
of indigestible substances,  after long fasting, or
of cold fluids when exhausted.
  63.  When several persons have partaken of
the same meal, or of the same substances, as
the individual who has been attacked with se-
vere illness, the circumstance of the greater or
less disorder of all,  according  as a particular
article was partaken of, or  the escape of any or
of all, with reference to  the meal generally, or
to any  particular article which  it comprised,
Bhould  receive due  consideration ;  for, when
all, or several of those who have partaken of
the same meal, suffer  more or  less,  the sus-
picion of poison amounts almost to proof, while
the illness of one merely,  others who had par-
taken of the same article not being affected, is
a presumptive indication of the disorder being
owing to other causes.   In estimating, how-
ever, matters of this kind,  the liquors and fluids
drank, and the congruous  nature of these, the
one with the other,  and with the several arti-
cles of diet also  partaken of, should be  taken
into the account.  Although it may be inferred
that all who partake of the same poisoned dish
will suffer  according to the quantity partaken
of, yet such is not  always the case;  for the
poison may be unequally mixed in the food;
and,  as  respects certain  poisons, especially
those most frequently employed in this manner,
as arsenic, a larger quantity of the  poison may
prove more innocuous than  the  smaller quan-
tity ;  for the former may be vomited, while the
latter may be retained and act most violently.
  64. It  ought to be recollected that various
articles of diet may produce symptoms which
may be more or less severe in  all who have
partaken of either of these articles, and these
symptoms may depend upon the  nature of the
article itself, and not upon the  admixture  of
any poison.   Nevertheless, the  article  of diet
is poisonous ; but there is generally in this case
no criminal  poisoning; for  the state and proba-
ble effects of the article are generally unknown,
and not suspected by any one until the effects
appear.   Rancid bacon; unclean or improperly-
fed  fresh  pork;  dried or ill-cured meats and
sausages ; various kinds of fish, whether dis-
eased or imperfectly cured, or kept too long;
[cheese]  ; the flesh of diseased or  over-driven
animals ; several kinds of shell-fish, [as oysters
and muscles], especially when out  of season ;
tainted or fly-blown meats, &c, are often pro-
ductive  of irritating  and depressing, or acro-
sedative  effects,  and have  suggested the  ar-
rangement of these articles in the class of poi-
sons which act in this manner.
  65. (c)  The state of the patient's  spirits or feel-
ings previously to his seizure, and other  matters
which circumstances may suggest, should receive
attention.  Acute  observation and inquiry, exer-
cised with due discretion and proper feeling by
the  physician,  will often  throw considerable
light upon the origin and the agent of  poison-
ing ; will indicate either the accidental, the sui-
cidal, or  criminal nature of the act.  The acu-
men required in such circumstances as present
themselves  in connexion with poisoning can-
not be aided by what I can  say on the topic; it
will  generally be sufficiently exercis.ed by the
well-educated practitioner of the present day •
but the following should be more  particularly
observed, in  all their relations,  as upon them
depend not only the recognition of the  poison-
ous substance, but the treatment  and Hfe of the
poisoned person,  and the discovery and punish-
ment of  the guilty.*
  66. Matters  requiring the Attention  of
the  Physician  when Suspicions of Poisoning
are  excited.—When severe illness occurs  in
the  circumstances just noticed,  endeavours
should be used to ascertain every particular as
to circumstances and manner of its appearance.
The vessel, utensil, or bottle, or paper which
contained the injurious  or suspected article;
the remains of such article, whatever it may  be,
and  of the food or drink which  had more  re-
cently been taken ; the matters thrown off the
stomach, and the substances on which the sus-
  [* During the prevalence of malignant cholera in 1832,
we mistook a case of poisoning by arsenic for an attack of
this disease.   A lady took more than a drachm of  the
arseniate of potash, as we afterward ascertained, with  the
intention of destroying her life ; which  was followed by
severe retching, vomiting, cramps, lividity of skin, cold und
clammy state of the surface, and the other symptoms which
usually attended a severe attack of cholera. During  the
prevalence of  this disease much greater caution  will be
necessary ou the part of the practitioner, or he will be liable
to err in diagnosis.  The symptoms which attend a violent
attack of cholera scarcely differ from those caused by  tho
irritant class of poisons.] 
360                         POISONS—Symptoms caused by.
pected article has been spilt or rejected, should
be carefully examined, in order to ascertain the
nature of the poison ; and, in cases of criminal
poisoning,  they  ought  to be  preserved  and
chemically  investigated, as fully  set forth in
works on Medical Jurisprudence.   If death take
place, the examination of the body as to posi-
tion and external appearances  should  be  mi-
nute; and the contents of the alimentary canal,
and of the  urinary bladder, as well as  the di-
gestive organs, and, in some instances, other
organs also, should be  carefully investigated,
both anatomically and chemically, in order to
ascertain the actual presence of  the poison  and
the amount of structural change  produced by it.
Numerous other matters connected  with  the
poisoned person, and with the appearances of
the various objects around him, both before  and
after death, ought  to be noted ; but,  as these
have especial reference to judicial  proceedings,
I must refer the reader  to medico-legal  works,
especially to what has been stated by Mr. Tay-
lor in his " Medical Jurisprudence."
  67. VIII.  The Symptoms caused by Poisons
cannot be duly considered until I  treat of the
operation of individual  poisons.   I may, how-
ever, remark, that the  symptoms usually as-
signed to many poisons have not been observed
with accuracy nor described with due precision ;
and that they do not in many cases admit of
either accuracy or precision, as  they vary with
the dose of the  poison, and with the circum-
stances shown above (y 51, et seq.) to  modify
them more  or less.  It will be  seen from  the
arrangement I have adopted in  discussing  the
action  of particular poisons,  that I have  at-
tempted  to  take  a  more intimate  view of the
effects produced by them than has  usually been
taken, and to base upon these effects a classifi-
cation which may aid not only the recognition
of the injurious agent, but also the adoption of
appropriate  means for the removal of these ef-
fects.  It must have been manifest to all who
have observed the operation  of poisons, that
many acrid  or irritant poisons do  not produce
nearly the same nor similar symptoms ; that
several substances which have  been arranged
as  acro-narcotic poisons  produce no narcotic
effects,  unless  contingently;  that vitally  de-
pressing agents  have been  classed with pure
narcotics,  the  effects  resembling narcotism
sometimes observed being merely  those of de-
parting cerebral functions, and that the  effects
which  have  been imputed  to local irritation
only have been quite as much owing to change
of function  throughout the economy, or to  ex-
treme  vital depression.   M. Orfila, who  has
devoted himself so ably and remarkably to  the
subject  now before me, and has performed so
many experiments  with poisons on the  lower
animals,  has certainly reduced the classes of
poisons to a too limited  number,  and has erred
in considering many of the symptoms, as well
as  of the lesions  after  death,  to have been
caused by the poisons experimented with, in-
stead of viewing them as partly  tho results of
the injury inflicted on the animals the subject
of experiment.   Other experimenters no less
deserve  the same  imputation.  When  he as
well as  they  inform  us that certain poisons
were given  to  dogs, that, in order to prevent
their rejection by vomiting, the oesophagus was
tied, and that,  in addition to various lesions
  thereby produced, the lungs were found con-
  gested or inflamed, can we be warranted in as-
  signing the  pulmonary  lesion to  the poison
  only.   Is not some part of these or of other
  lesions observed owing  to the injury  inflicted
  by the operation or by the ligature on the nerves
  in the vicinity, or on those actuating the oesoph-
  agus or adjoining parts 1
    68.  i. The more  intimately and accurately
  the  symptoms  of poisons  are observed,  the
  more easily will they  be distinguished from
  natural diseases; and it is of the utmost im-
  portance that the former should not be mistaken
  for the latter.  The distinctions will be noticed
  in the sequel;  but I may here state,  that the
  features of gastritis, enteritis, gastro-enteritis,
  peritonitis, bilious and malignant cholera, the sev-
  eral forms of colic, malignant or adynamic dys-
  entery, internal  strangulation of the intestines,
  strangulated hernia, and perforations of the stom-
  ach or intestinal canal may be very closely sim-
  ulated by poisoning with most of the substances
  classed under the heads  of acrid and corrosive,
  acro-sedative, acro-alteralive, and septic poisons
  (§ 106); the particular features of the assumed
  disease varying with the particular poison, the
  quantity taken, and the various circumstances
  already shown  to modify  its operation ; and
  that apoplexy, epilepsy and convulsions, diseases
  of the  brain  or  spinal marrow, diseases of the
  heart, rupture of internal  viscera or of large ves-
  sels, and  spontaneous congestion of the  lungs
  may likewise be simulated by the operation of
  many of the poisons ranked under the classes
  depressing and paralyzing, exciting and  exhaust-
  ing, narcotic  or  stupefying, and narcotico-acrid,
  the particular or special effect varying accord-
  ing to the circumstances just alluded to.
   69. From this it will readily appear that the
  difficulty of inferring, with any degree of ac-
  curacy, the  particular poison  which has been
  taken, from its effects only, is extremely great;
  and hence the necessity of  obtaining farther
  information as to its nature from what  may re-
  main of the vehicle in which it has been taken
  or otherwise employed, from the matters vom-
  ited or evacuated by the bowels, and from other
  sources or circumstances.  In examining the
I  symptoms caused by poisons, care should be
[  taken to estimate as accurately as possible the
j  remaining vital and nervous energy of the pa-
|  tient, to ascertain by the hand and  by  the ear,
'■  or stethoscope, the impulse and energy of the
  contractions  of the heart, to  observe the man-
  ner in which position affects the state and feel-
  ings of the  patient, as well as the pulse, and
i  to distinguish between effects which are truly
  narcotic  and those which are still  more seri-
  ous, viz , those proceeding from extremely de-
  pressed or departing vital manifestation of the
  brain.   Equal care should be exerted not to
I  mistake increased irritability for excitement or
  augmented power, and not to confound a very
  rapid or a very open and  compressible pulse
  with consecutive inflammation, although in-
  flammation may be actually induced, but it is
  of an asthenic or spreading kind when it thus
j  appears ;  for these  states of the  pulse may
I  arise merely from some  degree of remaining
  irritation, from the alterations produced in the
  blood, or even from a portion of the poison still
  irritating the organic nerves and vascular sys-
  tem.  In fine, care should be taken not to mis- 
POISONS—General Diagnosis  of  Poisoning.
361
 take the constitutional commotion consequent
 upon vital shock and exhaustion for sthenic or
 increased vascular action ; and not thus be in-
 duced to deplete and lower the system, when
 we should calm its agitations and support its
 powers.
   70.  ii. The Duration of Poisoning necessa-
 rily varies with  the virulence of the poison,
 with the quantity taken, and the repetition and
 frequency  of the dose, and  with the circum-
 stances stated above as modifying the opera-
 tion of poisons (y 51, et seq.).  Owing to these
 and a  variety of  other causes, appertaining
 either to the nature of the poison or to the
 state of the poisoned person, and to the effects
 more immediately resulting from a combination
 of these, poisoning may be, 1st, acute or rapid;
 2d, chronic or slow.
   71.  A. Acuteness or rapidity of action is usu-
 ally the result of the virulence and quantity
 of the poison ; but, owing to the greatness of
 the quantity, the poison may be rejected by the
 stomach, and the expected result may either
 fail, or be more  slowly produced.  The state
 of the stomach, especially as respects the con-
 tents of the  viscus, may also cause a similar
 issue,  by  absorbing much of the  poison,  and
 protecting  the stomach from  it.
   72.  B. Chronic or slow poisoning may result,
 1st. From  the lesion caused by a large dose of '
 an active or virulent  poison, which,  although
 insufficient of itself to produce immediate or
 rapid death, owing to the above or other causes,
 is still sufficient to occasion changes leading,
 more or less directly and manifestly, to a fatal
 issue,  acute thus subsiding into chronic poison-
 ing ; 2d. From the nature and  quantity of the
 substance, which had been given in such a dose
 at first as  to produce  a slow but fatal effect;
 3d. From the repeated ingestion of small quan-
 tities,  which have gradually developed structu-
 ral changes, or which, by their cumulative and
 latent  influence,  have ultimately burst  forth
 into active operation.  Illustrations of these
 several manifestations of the effects of poisons
 will appear in the sequel.  Of the writers who
 have discussed the  action, the effects, and  the
 treatment of poisons, none has so judiciously
 marked  the  distinction between  acute  and
 chronic poisoning  as Dr. Pereira, in  his very
 distinguished work on the Materia Medica.
   73. IX. The General Diagnosis of Poison-
 ing.—The diagnosis of poisoning in the living
 and dead body is general and special.   The for-
 mer I shall briefly advert to ;  the special diag-
 nosis of poisons, or of poisoning, requires a re-
 course to the most precise analysis, to chem-
 ical manipulations and chemical tests, and falls
 not within the scope of  my undertaking.—i.
 The general diagnosis  of poisoning during  life
 has been partly considered in the preceding
 sections (Y 28-72), and it is more fully exhibited
 in the description of the several poisons about
 to be noticed ; but  farther  evidence is to be
 obtained from the presence of poison  in, or the
 absence of it from, the articles or fluids par-
 taken of by the patient, and from the matters
 vomited by him.  When poison is found in the
 matters vomited in the presence of a medical
 or scientific  man, the  proof  of poisoning is
 much stronger than  when it is found  in  the
remnants of food partaken of;  inasmuch as it
is evident from this that the  poison has  actu-
 ally been taken ;  whereas, in the latter case, it
 may have been put into the food  with some
 sinister  purpose, and not have  been swallow-
 ed at all.   Mr. Taylor justly remarks, that
 it should be recollected, while investigating a
 case of poisoning in the living subject, that this
 act is sometimes feigned, and at others imputed.
 It is very easy for an evil-intentioned person to
 put  poison  in  food and  to accuse  another of
 having administered it, and to introduce poison
 into the  matters,  either vomited or  discharged
 from the bowels.  The detection of poison  in
 the  matters thrown off the stomach affords no
 decisive  proof that it has been swallowed, ex-
 cept under two circumstances : 1st. When the
 accuser actually labours under the usual symp-
 toms of  poisoning ; in which case there can be
 no feigning.  2d.  When the matters  are un-
 doubtedly vomited into  a clean vessel, in the
 presence of the medical  man, or of some per-
 son  on whose  testimony perfect reliance may
 be placed ; these  matters never having passed
 from his view, from the moment of their re-
jection from the stomach until their analysis,
 examination,  or  due custody,  under  proper
 seals.
   74. A.  The time at which  death occurs after
 the first symptoms  of poisoning is of importance,
 inasmuch as death from  natural causes rarely
 occurs in so short a time as from  poisoning.
 Having ascertained all the circumstances con-
 nected with the attack, and all the  symptoms
 manifested from the moment of attack until
death, the exact time which has elapsed from
the  former  period until  the  latter  should be
correctly estimated, as one of the elements for
the formation of an accurate opinion as to the
existence or non-existence  of poisoning, and
even as to the particular cause or agent of it.
When a poison has been given in large quantity,
the result may be supposed most likely to occur
in the shortest time in which it is usually found
to act. But the circumstances pointed out above
(v 52, et seq.) may delay its action or its ultimate
effects.  Poisons not  only differ  from  each
other in the period they take  to produce a fatal
result, but the same poison differs remarkably
in this respect in different persons, although
the several circumstances, as far as they may
be known, appear to be nearly the same.  Hence
it  is  difficult to determine the shortest period
in which  a  given poison  will destroy  human
life,  when swallowed in large quantity;  and
little reliance can be placed  upon the circum-
stance of an imputed death from a certain poi-
son having occurred too rapidly or too slowly,
as a  proof of its not having been  taken;  for an
empty state of the stomach, the retention of
the poison, and an exhausted state of the poi-
soned person will accelerate, and a full stomach
and  free  vomiting will delay,  the fatal result.
On this subject Mr. Taylor states, that a large
dose of strong prussic acid, i. e., from half an
ounce to  an ounce, will destroy life in from ten
to twenty minutes.  In one case of this kind of
poisoning, the  particulars of  which  I had oc-
casion to investigate, death must have taken
place in about five or six minutes.   If the per-
son  who is  poisoned by  this  acid survive an
hour, or  even less, there are  hopes of his re-
covery.   Oxalic acid may prove fatal, in the
dose of from half  an  ounce to one or two oun-
ces, in a  period varying from ten minutes to an 
362                   POISONS—General  Diagnosis of Poisoning.
 hour ;  and if the poison be not dissolved when
 swallowed, the period may be very much lon-
 ger.  The strong mineral acids  destroy life, in
 large doses, in from twelve or sixteen hours to
 twenty-four hours.  Arsenious  acid usually is
 fatal, in periods varying  from twelve hours to
 two or three days ; but it may cause death in
 much shorter periods—in one, two, three, or
 four hours—an hour being about the  shortest
 time.  Mr.  Taylor,  however,  remarks,  that
 there is  nothing  to  prevent  arsenic from  de-
 stroying life in one hour; and  that, in a case
 which was most probably one of poisoning by
 arsenic, death took place in half an hour.  The
 shortest  time  in which opium has been said to
 destroy life is  three hours ; but the period usu-
 ally varies from six to twelve hours ; but with
 it,  as with  all other poisons, the fatal issue
 may be protracted long beyond the limits men-
 tioned of the more common period.
   75. While  the  rapidity with which death
 from poison may take place is duly recognised
 by both  professional and  other persons,  the
 fact that the  same or other poisonous sub-
 stances may occasion death slowly as well as
 suddenly, and  even  as  slowly as the most
 chronic diseases, has not been  sufficiently re-
 garded,   and the  evidences  connected  with
 these effects have not been  sufficiently, even
 if at all,  investigated.  There can be no doubt
 —and several  instances of the fact have come
 under my own observation  in  the course of
 practice—of powerful medicines—of poisonous
 substances—having been too  frequently or too
 long prescribed, in what  was then considered
 full medicinal  doses, now more justly estima-
 ted  as dangerous quantities, and  the  conse-
 quences have  been attributed to the  progress
 of disease, to  idiosyncrasy, or to other  causes
 than the  real.   To those  slow or chronic oper-
 ations of poisons  I shall advert when treating
 of individual poisons.  It should not, however,
 be  overlooked  that disease of  the heart  and
 apoplexy may produce death  as suddenly as a
 most virulent  poison ; and  sometimes even
 more suddenly than any poison, with the ex-
 ception of hydrocyanic acid.  Death may occur
 almost instantly from organic  disease of the
 heart, and but  rarely within an hour from apo-
 plexy, this acid being, perhaps, the only sub-
 stance, unless in the very rare instances above
 noticed, which occasions  death in so short a
 time; but, unless it  be  employed to  commit
murder, some traces of this poison are usually
found at hand.
  76. B.  It may so happen that the duration of
the symptoms  is the  only or the chief medical
 diagnosis of poisoning. In this case there must
be both difficulty and uncertainty ; and an opin-
ion should not be  formed without farther aids,
although  a careful review of all the known  cir-
cumstances of the  case, and of all the appear-
ances about the person poisoned, may lead to
very probable, and even correct inferences.   In
acute poisoning, or when life is rapidly destroy-
ed, the diagnosis  is generally more easy than
in the chronic,  or when death  is occasioned by
the consecutive effects of poison. But in many,
even of the chronic cases, the cause of death is
more or less manifest; as when a person who
has swallowed a mineral acid, only partially
recovers, and continues for many months after-
ward to complain of stricture of the cesophagus,
  of which he ultimately dies.  More frequently,
  however, it is most difficult to assign, with le-
  gal strictness, the ultimate result to the prima-
  ry agent ;  to connect the fatal issue with the
  changes-first produced by the poison, in cases
  of chronic poisoning ; for numerous fortuitous
  influences  or contingent agents may have in-
  tervened to re-enforce,  modify,  aggravate, or
  otherwise  affect the earlier alterations, and
  thereby to subvert the  regular succession of
  morbid phenomena from the first impression
  of the efficient cause until the fatal issue.
    77. It is chiefly in a medical and strictly prac-
  tical point  of view that the slow effects of poi-
  sons—that chronic and slow poisoning—becoines
  interesting, and  even most important: a form
  of poisoning altogether neglected by medical
  jurists, because rarely admitting of proof which
  may not be impugned.   Corrosive sublimate,
  iodine, the arsenical solution, strychnine, digi-
  talis,  colchicum, and many other substances
  may severally be given in doses so large, or
  for so  long a time, either with a  beneficial or
  with a criminal  intention, as to destroy life
  after a more or less prolonged period.  In these
  cases the slow operation of the poison may oc-
  casion symptoms which  may not be recognised
  as the  effects of the medicine ; or little or no
  effect may appear for a considerable period, un-
  til it suddenly breaks forth with such violence
  as to threaten, or even suddenly to destroy, the
  life of the person to whom the substance has
  been thus  administered.  But the effects may
  be both marked  and  characteristic of the poi-
  sonous substance prescribed, and yet be viewed
  as a part of  the disease, and even  identified
  with  the disease  which it was employed to re-
 move.  I hope, however, to direct a more es-
 pecial  attention  to this  matter in the sequel
 than  it has  hitherto received.
   78.  ii. The diagnosis of poisoning furnished
  by post-mortem appearances has been very ably
  considered  by the recent writers on medical
  jurisprudence.   Mr. Taylor,  whose  accuracy
  is generally commendable, remarks, that  " in
  relation to external appearances there are  none
  indicative of poisoning upon which we can safe-
  ly rely.  It was formerly  supposed that the
  bodies  of persons who were poisoned putrefied
 more rapidly than those of others who had died
 of natural disease ; and evidence  for or against
 poisoning was at one time drawn from the ex-
 ternal  appearance of the body.   This is now
 known to be  an  error;  the bodies of persons
 poisoned are not  more  rapidly decomposed,
 caterisparibus, than those who have died a sud-
 den or violent death from any other cause what-
 ever."   (P. 42.)   To the above too general and
 positive inference the following exceptions may
 be made:  1st. That external marks  or chan-
 ges may be left  on parts of the external sur-
 face, as the mouth, face, neck, hands, and  near
 the outlets of the natural canals, which  not
 only may indicate poisoning, but even the par-
 ticular substance employed, as several of the
 corrosive and irritant poisons.  2d. I have had
 proofs furnished to more  than one of the senses
 —namely, to sight, smell, taste,  and touch—
 that certain poisons, which I have classed un-
 der the head septic and disorganizing, actually
 produce a more rapid solution of the  vital  and
  physical cohesion of the tissues, or a  more
( rapid  progress of those post-mortem changes 
POISONS—General Diagnosis of Poisoning.
363
 either preceding  or  constituting putrefaction,
 than is usually met with, all the circumstances
 being otherwise the  same.  3d. These  senses
 have  furnished me with  evidence that certain
 poisons will sometimes delay these changes, at
 least  in some parts, and even about the outlets
 of mucous canals.
  79. A.  The several internal, and  especially
 the digestive viscera,  however, are the quarters
 in which the physician should endeavour to as-
 certain the fact of poisoning, in defect or in
 aid of other evidence.   The  mouth, throat,
 (esophagus, stomach, and intestinal canal often
 furnish proofs of it, especially when acrid, cor-
 rosive, or irritant poisons have been employed ;
 and although these proofs consist of the most
 severe lesions, and  even of almost complete
 disorganization, they are  often insufficient of
 themselves to show the particular poison which
 has been swallowed,  or even  the action of any
 poison at all, without proof of its actual pres-
 ence, or  other additional evidence, so com-
 pletely do these lesions  assume, in  many in-
 stances, the appearances consequent upon  cer-
 tain  natural diseases.  Much of the difficulty
 of distinguishing the  effects of poison from the
 consequences  of  disease  is owing to the pe-
 riod which has elapsed from the time of death
 until  that of making  the examination ; for du-
 ring that period  various post-mortem  altera-
 tions  supervene, which obscure certain  of the
 more intimate changes existing at the moment
 of, or just previously to dissolution.  Much of
 the softening, of the corrosion, or of the disso-
 lution of tissues, found  twenty, twenty-four,
 or thirty-six hours after death, has taken place
 during that period ; and even the changes ob-
 served in the  colour of the  blood and of the
 several membranes and tissues,  have chiefly
 occurred subsequently to death.  In cases where
 the poison is of a virulent, septic, or of a chem-
 ical nature, as the strong mineral acids, or the
 alkalies, and when these have not been entire-
 ly thrown off during the short period of life fol-
 lowing their ingestion, it may reasonably be
 supposed that the portion remaining in contact
 with the tissues will  produce some change of
 the structures, even after death — will affect
 the dead  textures as we perceive such sub-
 stances to act in some of the  operations of do-
 mestic economy, and either hasten or delay the
 solution of vital or physical cohesion, or other-
 wise  change the  appearance and condition of
 the textures by combining more or  less inti-
 mately with them.  In cases  proving thus  rap-
 idly fatal, many of the poisons, especially the
 corrosive, the mineral, or  saline, will be found
 either in the contents of the stomach or bow-
 els, or in contact  with the villous membrane
 of these viscera, or may even  be detected by
 chemical analysis in  the coats of the stomach,
 or even in the liver or in the blood.
  80. Death,  however, may take place sud-
 denly, and various morbid changes may be de-
 tected  in  the  digestive canal,  resembling, or
 even identical with, those produced by certain
 poisons;  but unless the poison be detected in
 the matters vomited  during life, or in the con-
 tents  of the stomach, or of other parts of the
 canal, or in the blood, or  in the substance of
 the  viscera, the  evidence furnished by these
changes alone is  altogether inconclusive;  for
similar changes may occur about the time of
' dissolution in cases of sudden death, or previ-
 ously, or even subsequently to death, in various
 diseases not  necessarily causing the confine-
 ment of the patient until shortly before, or even
 not until a few hours before death.   To these
 alterations I now more particularly advert.
   81.  a. Redness of the villous membrane  of
 the stomach and intestines is generally caused
 by acrid, corrosive, or irritant substances ; but
 it is not of itself a sign of poisoning upon which
 much  dependence can be placed, for it may be
 inconsiderable where corrosion and disorgani-
 zation, caused by the  most corrosive poisons,
 are the greatest; it usually characterizes all in-
 flammatory diseases of the digestive canal, and
 it may be very remarkable in  cases  of sudden
 death  from accident, external injury, or other
 causes producing fatal shock, and independent-
 ly of any existing disease, or of the ingestion
 of any  irritating  agent, as shown by Dr. Yel-
 loly, and subsequently confirmed by numerous
 observers.   -It has been shown, 1st.  That vas-
 cular congestion of the  villous surface of the
 stomach, with a florid or dark-red hue, is not a
 proof of disease, and is not inconsistent with a
 state of health  at the time of dissolution  or
 shortly before it.  2d.  That this state  of red-
 ness and congestion, found in some cases  after
 death, is not even proof of gastritis.   3d. That
 it is not alone an indication of the ingestion of
 a poison, or even of any  irritant.   4th. That
 the vascularity of the villous membrane is  an
 injection of the venous  capillaries and veins,
 the redness depending, in the instances observ-
 ed  the  soonest after death, upon the arterial
 character of the blood congesting the venous
 capillaries;  and in those observed the latest af-
 ter dissolution, upon the transudation of the col-
 ouring matter, or to  the post-mortem changes.
  82. b. It is obvious  that redness,  as well  as
 congestion of the villous membrane of the stom-
 ach, is liable to various changes during the time
 elapsing from death until examination.  The3e
 changes are not  only such as take place in or-
 dinary circumstances during this time, both in
 the  blood itself  and  in  the tissues,  but those
 also which are more especially caused by the
 morbid impression of the poison by the treat-
 ment resorted to, and by the action,  previously
 and subsequent to dissolution, of the  poison
 upon the textures and upon  the blood itself.
 When the redness is caused by poisons which
 not  only irritate, but arrest more  or less  the
 putrefactive process, then it may be inferred to
 continue the longest after death.  Mr. Taylor
 found  it continue in the  stomach and  duode-
 num of the exhumed body of a man poisoned
 by arsenic, twenty-eight days after he had been
 interred.
  83. c.  Ulceration of the internal surface of the
 stomach is seldom observed in cases  of poison-
 ing, and never unless in those which have been
 manifested by well-marked symptoms previous-
 ly to death.  Ulceration is more frequently cau-
 sed  by arsenic than  by any other  poison, and
 this poison  may  even  be found lodged in  the
 edges of the ulcers, which present more gener-
 ally the appearance of small circular abrasions
 of the villous membrane, which is more or less
 generally inflamed, or inflamed in the intervals
 between the ulcers, the  inflammation  some-
 times  extending to  the duodenum  and intes-
 tines.   Ulceration from disease is  not unusual 
3G4
POISONS—General Diagnosis of Poisoning.
(see Stomach, Diseases of);  but in these cases
the inflammation  surrounds the ulcer, which
often has tumefied or thickened margins, while
the ulcers produced by poisons present differ-
ent appearances.  The history of the case be-
fore  death will generally enable the physician
to determine to what  cause the  ulceration
should be imputed.  But ulceration should not
be confounded with corrosion.   Ulceration, al-
though  a morbid,  is also a  vital process, in
which the secretions, the nutrition, and the ab-
sorption  of  the part  are disordered, consecu-
tively of inflammation.   Corrosion is a disor-
ganization of the intimate structure by a chem-
ical action, which destroys the vital properties,
and dissolves the vital cohesion of the textures;
the corroding substance combining more or less
with the tissues upon which  it acts.  Ulcera-
tion  requires time to  produce it;  corrosion
takes place instantaneously or almost immedi-
ately (see more fully on this subject,  Digestive
Canal, y 36, et seq.).
  84.  d. Softening of the inner surface of the
digestive canal is a frequent effect of poisons,
and is  often  found associated with  corrosion,
but is more  diffused.   Softening may be often
viewed as merely  a lesser grade of  corrosion,
especially when it extends to the several coats.
It is generally most remarkable in  the stom-
ach,  but, when it  is limited to this organ,  it
cannot be considered as a consequence of poi-
sons unless  the inference be supported by far-
ther  evidence, inasmuch as it  is,  when  thus
limited, most commonly the result of disease.
When it is  caused by poisons, corrosions of
some parts often accompany it;  and the  soft-
ening is  frequently extended  from  the  fauces
down the oesophagus, into the  stomach and du-
odenum.   This change should, however, never
be considered as a result of poison, unless the
poison be detected in  matters which have  been
vomited, or in the contents of the digestive ca-
nal, or in the coats of this canal;  for it is,  even
when thus extended, a very frequent result of
disease, more especially in infants and children.
  [In this connexion, it should be borne in mind
that softening of the gastro-intestinal mucous
membrane, especially that portion lining the
stomach, is very frequently met with in intem-
perate subjects ; indeed, it is the most common
pathological change met with in such cases.]
  85.  e. Perforation of  the  digestive canal is
sometimes found,  upon  dissections, after the
ingestion of poison, but it is also not  unfre-
qdently a consequence of disease.  When cau-
sed by poison, it is commonly merely the ex-
tension  of corrosion through  all the  coats of
the viscus, and is most frequently found in the
stomach, but it occurs in rare instances, also, in
the duodenum and  oesophagus.  Perforation,
like all other alterations of the digestive canal,
although preceded by symptoms of poisoning,
is not  a proof of this  act, unless  the  other
proofs just noticed be also present.   When it
is a consequence of disease, it is produced by
ulceration, which  rarely or never  occurs  in
cases of sudden or rapid poisoning,  ulceration
being the result of a morbid process requiring
some time for its  production ;  but  this  topic
will be noticed in  the sequel  (v 114), and it is
fully discussed in the article Digestive Canal.
  86. /. The villous coat of the  stomach may
present other lesions which may furnish stron-
 ger evidence of poisonmg than any of those al-
 ready noticed.   These  are  corrugation, partial
i detachment, dark discoloration,  resembling  char-
 ring, of the villous membrane ; ccchymosis, or
 small extravasations of dark, coagulated blood, un-
 derneath this membrane, which is raised into
 small elevations, and a dark-red or livid engorge-
 ment of the capillaries and veins.  These chan-
 ges are most frequently found in the stomach ;
 but they are sometimes seen, although in a less
 marked degree, in the duodenum, and even in
 other parts of the intestinal canal.*   Some de-
 gree of induration of the villous membrane of
 the stomach has  been found in some cases af-
 ter poisoning with sulphuric acid.
   87. g. A post-mortem change, which has  been
 variously denominated, and especially as spon-
 taneous  softening, pulpy degeneration, and spon-
 taneous perforation of the coats of the stomach,
 is met with  upon  dissection, in rare instances.
 When this alteration is found in a patient who
 evinced no indications of gastric disease during
 life, and when  it  is unattended by any inflam-
 matory appearances, the coats being gelatinous
 or pulpy,  it may then be viewed  as a conse-
 quence of the action of the gastric juices  after
 death, as first stated by John Hunter, and ren-
 dered probable by the more recent researches
 of Carswell,  Burns,  Sharpey,  and others.
 But a nearly similar change may be the result
I either of poisons  or of disease.  In the former
 case, which will  be more particularly noticed
 hereafter, evidence of poison will generally be
 found either in  the organ itself, in its contents,
 or in the matters vomited ;  and, in the latter,
 gastric disorder will have been manifested pre-
 viously to dissolution, and the pulpy softening
 or perforation will be accompanied with some
 indications of inflammatory irritation, although
 in the aphthous, mesenteric gastric, and gastro-
 enteric  diseases of children,  and  more espe-
 cially of infants, about  the period of teething,
 weaning, and, when improperly fed, softening,
 and even perforation of the stomach will occa-
j sionally he  found, inflammatory appearances
 either not existing, or,  if they have  existed,
 having altogether disappeared soon after death
[ (see Digestive  Canal, <j 35, 42).
   88. iii. The other means of diagnosis, so fre-
 quently adverted to above, namely, the detection
j of the poison by chemical analysis and tests, and
 the support  which moral circumstances may af-
 ford the evidence, belong more especially to the
i medical jurist.—A. The moral circumstances and
 appearances, falling under the  observation of
 the physician,  should always be carefully re-
 marked  by him, not only as they may suggest
 to him the existence of poisoning, and thereby
 direct his attention to every  point and aspect
 of the case, but also  as they  may be required
 from him in the judicial investigation, in which
 he will appear as a principal evidence.  In ev-
 ery instance admitting of the least suspicion of
 poisoning, it is  the duty of the  medical man  to
 ascertain  as fully as  in  his power the whole
 range of symptoms or morbid phenomena ;  to
 observe assiduously the progress of the symp-
 toms, from  the moment they  came  under his
 notice until  their termination in recovery or in
 death; to obtain  information  from those  best

   [* All these appearances  result from the habitual use of
 distilled liquors, and when met with, the habits of the in-
 dividual should be closely investigated.] 
POISONS—Diagnosis of
Poisoning during Disease.                 365
able to furnish it, as to the circumstances con-
nected with the origin and progress of the sei-
zure ; to trace their  origin in obvious or impu-
ted causes ; to connect them, as far as may be
done,  with such causes as usually produce sim-
ilar effects, and to determine, as far as possible,
the presence of such causes in the case in ques-
tion ;  and, if death take place, to note carefully
all the changes observed in the dead body.
  89.  The importance of care and circumspec-
tion in these matters is shown  by the fact that,
although instances often occur in which the
diagnosis of poisoning cannot be established,
unless the poison  be actually  detected, to the
satisfaction of the tribunals, still it may be suf-
ficiently  so  to warrant  the  physician  in the
adoption of such measures as the symptoms
will suggest for the recovery  of  the  patient.
And it should  be recollected  that, even in the
event of death, there are many poisons which,
owing to their nature, cannot  be detected  by
any analysis or test,  while  there are others
quite  susceptible of  analysis, which may be so
changed  or mixed  with substances, alimentary
 and others, as to escape  detection by chemical
 agents, either in the  vomited matters, or in the
contents of the viscera, or in  the blood.  In
 many such  cases, there may  be  satisfactory
proof of the persons having been poisoned, and,
 in  some,  conviction has actually followed,  al-
 though the poison has not been detected in the
 dead body;  the symptoms, the  appearances  af-
 ter death, and the moral circumstances  being
 sufficient to establish the fact.   Moreover, due
 attention to every circumstance connected with
 the history and progress  of the case, as insist-
 ed on above (y 61-72), will enable the physi-
 cian to ascertain,  even  during the life of the
patient, the particular poison employed, or, in
default of this, the class  of poisons to which it
belongs,  and to adopt a plan of treatment,
which, if not successful, may nevertheless  be
appropriate to the  symptoms and circumstan-
ces of the case.  In the event of death, also,
he will be more surely directed in his  search
for the substance which  caused it, and his an-
alysis and tests will be  chiefly suggested and
guided by the changes which  the post-mortem
examination will disclose.
   90.  B. As soon  as suspicions of poisoning
are excited, or indications  of it evinced, the
portions of the substance which has produced the
symptoms should be sought for on the persons
of the poisoned and of the suspected individu-
al; and if the substance cannot be found in the
pure state, or in  that of mixture  with  other
substances, a chemical analysis should be  in-
stituted of the several articles, fluid and consist-
ent, of which the patient  last partook; and this
inquiry should be full and satisfactory ; for one
portion of a  dish may be  poisoned, and not the
other; the gravy, and not the meat; the sauce,
and not the fish ; the  pie-crust, and not the fruit,
&c., &c.   The salt  may contain arsenic, and
nothing else at table may contain this poison;
and so on as respects various articles, and as
regards several poisons.   The  matters  vomited,
and those evacuated  from the bowels,  the for-
mer especially, should be chemically examin-
ed,  or tested, as soon  as possible,  and during
the life of the patient, whenever there is doubt
as to the nature of the poison, in order that the
treatment may be  as appropriate as possible;
but as tests, and a chemical laboratory, cannot
be carried about with the physician, the physi-
cal appearances and characters  of the matters
thrown up should be carefully observed, in con-
nexion with the history of the case, and the ex-
isting  symptoms, and the treatment  directed
accordingly.   The vomited and evacuated mat-
ters ought, however, to be carefully preserved
for chemical analysis, and those thrown off the
stomach  should be compared with the  matters
found  in the stomach and intestines after death.
These matters, with the digestive canal itself,
and often with the collatitious and other visce-
ra, should then  be made the objects of chemi-
cal research,  in  order to  satisfy the ends  of
justice.  But  this subject does  not fall within
the scope of this work.
  91.- X. Diagnosis  of Poisoning  during Dis-
ease.^—This is a topic which has been slightly
adverted to  above (y 59, 60) as one which has
received  but little attention from medical wri-
ters, and  which  hardly admits of satisfactory
elucidation.—(a) Poisoning, either criminal, ac-
cidental, or suicidal, while the poisoned person is
the subject of disease, or under medical treatment,
has occurred oftener than has been commonly
suspected.  Poisoning in  these  circumstances
has certainly been attempted, and even accom.
plished, much  more frequently than it has been
detected,  owing, 1st. To the difficulty of de-
termining the  symptoms  during life, and the
changes after  death, which belong respectively
to disease and to poison ;  2d. To the  facility
with which a poisonous substance may be add-
ed to, or substituted for, the patient's medicine,
without suspicion being excited;  3d. To the
symptoms caused by the poison being mistaken
for the severity and progress of the disease;
the previous duration of illness  and  other cir-
cumstances  preventing any inquiry as to the
cause of death ; and, 4th. To the circumstance
of the poison which has been employed not ad-
mitting of chemical  detection,  either from ita
nature, or from the state of admixture or com-
bination in which it has been taken.   The dif-
ficulties in forming a correct diagnosis when a
person is poisoned, in the course of disease, is
heightened by the acuteness and severity of the
malady;  and when a poison has been adminis-
tered whose operation  is such as closely to re-
semble, or as to appear, an aggravation of the
symptoms of which the patient had complained,
then the diagnosis  can hardly  be  established,
unless by the  detection of poison in the mat-
ters  vomited or  in  the evacuations from the
bowels or kidneys, or in the body after death.
  92. (b) When a patient is suffering from dis-
eases of  debility, or is  labouring under exhaus-
tion, anamia, the effects of losses of blood, and
chronic discharges, poisoning is more readily ef-
fected, especially by depressing, paralyzing, and
acro-sedative substances, than in other circum-
stances ;  and  the effects, especially  when the
poison has  been administered  in  successive
doses,  or  at intervals,  are not readily recogni-
sed or distinguished from  the progress of the
malady.   In these states, also, of the patient's
health, more especially when haemorrhage  or
vascular depletions have preceded the ingestion
of poison, absorption of it  into the circulation
more readily and more injuriously takes place,
and the patient furnishes much less of vital re-
sistance to its fatal operation. 
366
POISONS—General Principles of Treatment.
  93. (c) I have had several reasons to believe,
from the history of cases, &c, that poisoning
has been both attempted  and accomplished in
the puerperal states, especially during the first
two  or three weeks after delivery; the opera-
tion of the poison having been mistaken for one
or other of the diseases incidental to that state ;
and having been such as not  to be distinguish-
ed from such disease unless  by the discovery
of the poison, aided by various moral consider-
ations.
  94. (d) Acute diseases of the digestive canal
and associated organs may have existed for a
longer or shorter time,  and irritant, acro-seda-
tive, or  corrosive substances may be adminis-
tered accidentally,  criminally, or from  igno-
rance, which may so aggravate the attack as to
render it dangerous or fatal.  The heroic prac-
tice of medicine, so general and so much laud-
ed, even within the range of my own  obser-
vation and recollection, by those who concealed
their ignorance by the swaggering boast of be-
ing " practical men," and that the literature and
science of medicine were beneath their notice,
as they were certainly beyond their reach, has
furnished me with several proofs of actual poi-
soning having been committed  by  those self-
sufficient and illiberal medicasters in the  treat-
ment of the diseases just mentioned.  I have
often seen, and had still  more frequent  occa-
sion to remark, in medical writings, the recom-
mendation of the most irritant  purgatives,  in
excessive doses, in cases of enteritis, or in dys-
entery, with the intention of removing obstruc-
tions, or of expelling matters  which had no ex-
istence, the substances prescribed either cau-
sing inflammation,  or  increasing  that  which
already  existed, and urging it on to  a fatal is-
sue.  Irritant, corrosive, acro-sedative, or acro-
narcotic substances, given either in  poisonous
quantities, or in so frequent doses as to become
poisonous, in the course of these maladies, could
not  readily  be recognised by their  effects  in
these circumstances,  nor even by chemical re-
search,  if the employment of them were con-
cealed, and  the mischievous  tendency of their
operation were not  known.
  95. (e) Even in chronic diseases of the aliment-
ary canal, especially  chronic  dysentery, or the
chronic diarrhoea of warm climates, the exhibi-
tion of repeated doses  of acrid purgatives,  or
of other medicines,  with erroneous views of
the nature of the case, and of the operation of
the substance prescribed, has  converted a com-
plaint by no means serious into one which has
become rapidly fatal.  I have  seen this practice
in various places, and I could  adduce numerous
cases in which it has  been  recorded in  pub-
lished works, or in the case-books of hospitals,
furnishing useful, although fatal, beacons in nav-
igating the shoals of medical practice.
  96. (/) Persons  already the subjects of dis-
eases of the heart or of the lungs may be cut off
by a criminal, or  an incautious use of various
sedative, acro-sedative,  or acro-narcotic sub-
stances, especially when taken in too frequent
doses, or continued for  too long a time.   Digi-
talis, tartar-emetic, colchicum, aconite,  &c,
may be given in  these diseases so  as to pro-
duce a fatal result, without the symptoms being
suspected as being caused by poison, or the re-
sult being viewed otherwise than as the natural
termination of the disease; and the examination
of the body after death, and chemical research,
will fail of discovering the cause.  From 1810
until 1830—a period  abounding with medical
cant, heroic and empirical practice, and disgust-
ing dogmatism—certain substances came into
very general use, from the abuse of which much
mischief accrued, even within the sphere of
my own observation ; calomel,  tartar-emetic,
colchicum, digitalis, and, more recently, iodine,
were  often given  in such excessive doses, or
continued in smaller  quantities  for so long a
time,  as to induce more serious diseases than
those for the cure of which they were resorted
to.  The natural maladies had the efforts of na-
ture to aid them, if these efforts had  been de-
veloped or duly directed ;  but the substances
which were employed  subverted vital energy,
suppressed the natural effbris, produced morbid
actions and organic  lesions, which were mis-
taken  for the course or turn of the primary
malady; and, when they failed of causing death,
occasioned a new or different  form of disease.
A patient had disease of the valves of the heart
and dropsical effusion ; large doses of infusion
of digitalis were prescribed to act as a diuretic,
and this effect was sometimes produced, and a
certain amount of ease resulted ; but quite as
frequently the disease was arrested in a differ-
ent way ;  the action of the heart was so much
weakened by this treatment as  to become in-
sufficient to overcome the obstacle to the cir-
culation, and death was the consequence  Early
in the  present century, colchicum and tartar-
emetic were lauded as antiphlogistic remedies,
as they certainly are, and were  often brought
in aid of the copious blood-lettings and various
other empirical means unduly lauded by the ig-
norant pretenders and writers of the day.  More
than one writer of great but ephemeral popular-
ity extolled these substances, and prescribed
them  in excessive doses for the inflammatory
and other diseases of the lungs  and  bronchi,
both of children and adults ; and I am confident
that, in the former class of patients more espe-
cially,  they were employed in  such quantities.
and for so long a time, as to prove fatal to more
than they cured.  The vital resistance, which
so successfully opposes the progress of disease
in most instances where there ie no constitu-
tional vice, was completely overthrown by these
and similar means; and while vitality was ei-
ther suppressed, impaired,  or altogether de-
stroyed by them, no opposition  could  be fur-
nished to the unfavourable progress and conse-
quences of the disease.
  97.  This subject might be pursued with ref-
erence to the diseases of other organs, and to
various constitutional and febrile maladies ; but
I have, perhaps,  stated what may be more than
sufficient  to rouse the attention of those who
are not sufficiently aware  of the importance
which  ought  to  be attached to it;  well-educa-
ted, closely observing, and, in  virtue of  these,
the only experienced  practitioners, hardly re-
quire  to be reminded of the several  maitera
which these suggestions will undoubtedly recall
to their recollection.   Any further notice which
this subject may require, will be taken of it in
the discussion of the effects and treatment of
individual poisons.
  98.  XI. The General Principles of Treat-
ment.—What I  have  advanced will show the
importance which should  be attached to the 
POISONS—General Principles  of Treatment.
367
operation of poisons, as forming the basis of
rational measures of prevention and cure.  Be-
fore I proceed to notice the injurious operation
of particular poisons, and the treatment which
each appears to require, I shall first offer a few
remarks upon certain intentions and principles
of treatment, which are more or less generally
applicable, according to the mode of poisoning
which has been resorted to.  These brief re-
marks will refer to  the prevention,  to the coun-
teraction,  and to  the removal of the effects of
poisons.
  99. A.  Prevention of the action of poisons may
be attempted in  certain circumstances, and may
succeed either partially or completely.   A poi-
son may be swallowed, and, if the means be im-
mediately resorted to, it may be removed before
it has acted, or acted to a very injurious extent.
—(a) The means of removal are emetics and the
stomach-pump.   Of the former, but little may be
said more than that they often fail to act, owing
to the paralysis, or want of power  of contract-
ing,  experienced by the parts  concerned in the
act of vomiting from the action of the  poison
which  has been swallowed.  It is, therefore,
requisite to give powerful and warm emetics,
as the sulphate of  zinc, with capsicum, mus-
tard, &c, according to the  nature of the  poison
which has been taken ; the intention being to
excite the organic nervous infloence at the same
time that the discharge of the  poison  is pro-
cured, when this latter is of a sedative or nar-
cotic kind.
  100. (b) The removal of the contents  of the
 stomach by means of an apparatus, such as that
 now m general  use under the name of stomach-
 pump,  although suggested by several  persons
 long before the practicability of such   means
 was actuaVly put to the test, was first demon-
 strated, as being efficacious in cases of poison-
 ing, by Messrs. Jukes and  Scott in 1822, then
 medical practitioners in Westminster;  and, in
 many instances, it is the most efficient and cer-
 tain mode of removing  the poison ; but it is
 liable to  certain objections.   The perforations
 in the end of the tube may be obstructed, or
 the  canal of the tube choked by the alimentary
 substances present in the stomach, and the
 withdrawal of  the contents and of the  poison
 will be thus delayed or even prevented, if fluids
 be not injected into the stomach by this tube,
 in order to remove the obstruction and dilute
 the contents of the viscus.   In cases, therefore,
 in which imperfectly dissolved poisons have
 been taken, or where a greater activity may be
imparted to the poison by dilution or solution,
the recourse to  injections may be injurious, and
the  use of this apparatus may be less effica-
cious,  in these circumstances,  than an active
emetic, which often empties not only the stom-
ach, hut the duodenum also, and increases the
secretions of the villous surface and of the liver,
thereby washing off the adhering portions of the
poison, or preventing the imbibition and absorp-
tion of them.   When, however, a judiciously-
prescribed emetic fails  to act,  or in  cases in
which an emetic may be  inferred to be inac-
tive, or  in other doubtful circumstances, re-
course to the stomach-pump should not  be  a
moment  delaved.
  101. The removal of the poison  is an indica-
tion which is  not confined to cases in which
the substance has been swallowed.  It is equally
important in instances of external poisoning, the
object  being the  prevention of the imbibition
and absorption of the poison.  There are two
modes by which this intention may be accom-
plished : 1st. The application of a ligature above
the part  which has  been inoculated with the
poison, or between it and the trunk,  so  as to
arrest its absorption and contaminating  influ-
ence,  and the  diffusion  of its  impression by
means of the nerves.  This mode of prevention
has been in  use from the earliest ages, and  is
practiced by most savage tribes.  It is obvious,
however, that this practice would  be ineffica-
cious  if nothing farther  were attempted, and
that the poison would act as  soon as the liga-
ture was removed.  The great advantage of the
ligature is to delay the operation of the poison
until it can  be  either generally or partially re-
moved by suction, or counteracted by local ap-
plications  and internal remedies.  Many sub-
stances are poisonous when applied  to the skin
denuded of  its cuticle, or when inserted in a
wound ; and may yet come in contact with the
mucous surface of the lips and mouth without
risk, if there be no abrasion of the epithelium :
and hence suction of a poisoned wound with the
mouth, after the application of a ligature, where
this can be applied,  or suction without this an-
tecedent  in  other circumstances, has been re-
sorted  to  from the  earliest ages, and is still
practiced in  all uncivilized countries.  The lig-
ature, by arresting  the return of blood,  while
arterial action increases the capillary injection,
and even augments the  discharge from the
wounded surface, thereby favours the removal
of the poison by suction, or by any other  mode
of exhausting the air over the part which may
be adopted.
  102.  The  intention of removing the poison
introduced into a wound  by exhausting the air
over the  wounded part  was strenuously con-
tended for by the late Sir D. Barry ;  and for
this purpose he advised the application of the
cupping-glasses; and in situations where  a lig-
ature cannot be applied, cupping-glasses are the
best means  of sucking out the poison, or the
blood  and serum  contaminated by the poison,
from the  part.  But not only is absorption thus
prevented, and the  poison withdrawn,  but the
injurious impression made by the substance on
the nerves of the part is prevented from ex-
tending, owing to the pressure produced by the
margins of the glasses.  We have certainly not
improved  in modern times upon the treatment
of poisoned wounds recommended  by the an-
cient  Greeks, Romans,  and .Arabians, as Mr.
Adams has  fully  shown.  Nicander, Celsus,
Dioscorides, Galen, and nearly all the A\rabi-
ans, advise  the application of a ligature, and
then the extraction of the poison  by sucking,
by cupping instruments with scarifications, cau-
teries, escharotics, &c.   They likewise pre-
scribed remedies with the view of  altering or
counteracting the effects of the poison.   If the
poison was  of a  depressing kind or produced
cold,  they resorted  to stimulating and heating
medicines ;  if it was of an opposite nature, they
gave refrigerants; but they most frequently had
recourse to articles  of a heating nature, as they
believed  that the greatest part of poisons de-
stroyed life  by producing cold.
   103. B. The counteraction of the operation of the
poison is the next indication ; and it often sue- 
368
POISONS—Classification of.
ceeds in respect of some, especially if attempted '
soon after the poison has  been swallowed or >
applied ;  and the substances which  thus coun-
teract the poison have been called the antidote,
or counter-poison.  The antidotes of some poi-
sons,  especially  of some mineral poisons, are
well ascertained ; and it is chiefly to chemical
science that we are indebted for this knowledge ; ;
but we know but little of the means  of counter- j
acting many other poisons, especially those of
the vegetable and  animal kingdoms.   Those |
antidotes whose actions have been ascertained j
are, 1st, those which form chemical combina-
tions with the poison that are not injurious, as
alkalies with acids,  &c.; and, 2d,  those  sub-
stances which deprive acrid and corrosive poi- j
sons of their properties, or which form  insolu- I
ble compounds with the poison.  Certain  anti- \
dotes are complete and  efficient, if administer-
ed sufficiently early, or  before  organic or  vital
changes of a dangerous nature have been pro-
duced ; others are only partially efficacious, as
ammonia in cases of poisoning with prussic  acid.
   104. Means which enable the system to resist
the action  of a  poison may be ranked  in this
category.  Those which prevent the absorption
of the poison, as several of those which  have
been already noticed, or such as counteract the
depressing influence of certain poisons, as the I
spices, cayenne pepper, aromatics, spirituous li- J
quors, &c , in cases of animal  or fish poisons, i
are often more or less efficacious.  When poi- ]
sons are taken in large quantities, the economy, j
especially the nervous system, sustains more i
or less of shock ; and, if appropriate means be !
immediately used to aid it in rallying, a greater j
degree of vital resistance will be opposed to the
progressive advance of the effects.  From these j
remarks, it may be inferred, that in our endeav-
ours to counteract the operation of a poison, j
we should attend to the following cautions: 1st. j
To avoid all means which may render the poi- J
son more soluble, or which may dissolve it, or ,
add otherwise to its activity; thus we  should
not give wine or vinegar soon after a large quan-
tity of opium has been taken.   2d. To avoid j
such measures as may promote the absorption j
of the poison into the circulation, as hlood-let- J
ting.  3d. In cases of poisoning by  depressing i
agents and  narcotics, or such as destroy  ner- J
vous power and  irritability, medicines, emetics
or others,  which act in a somewhat  similar
manner,  as tartar emetic, ipecacuanha, &c,
should not be exhibited.  4th.  That the shock
sustained by the ingestion  of virulent poisons
should be counteracted by energetic means of
a stimulating and restorative kind, administered j
according to the peculiarities of the  case ;  and
that vomitings, however frequent, should  not
prevent the exhibition of these, in cases of nar-
cotic, depressing, and animal poisons, or even
in others, unless the vomitings proceed from
the action of corrosive and very acrid poisons.
   105. C. The removal of the progressive effects
of the poison, and opposing the tendency  to death,
remain to be put in  practice  either when  the
first and second  intentions  cannot be attempt-
ed, owing to the time which has elapsed from
the exhibition of the poison,  or  after one or
both have failed.  To  be successful in these
circumstances, the physician should  be well ac-
quainted with the physiological action of  poi-
sons,  and with the phenomena by which  this
 action, in its progressive phases, are indicated ;
 with  the symptoms and progress of the mis-
 chief; and  with the pathological states produ-
 ced by individual poisons, and  more immedi-
 ately inducing death ;  he should be acquainted
 with the operation of active substances on the
 economy, both in medicinal and in poisonous
 doses, in order that he may duly recognise the
 nature and  effects of the latter doses, and may
 apply the former to the removal of these ef-
 fects, according to rational indications.  That a
 knowledge  of the physiological and pathologi-
 cal actions  conjoined,  consequent upon the ex-
 hibition  of  a poison, and of the ultimate chan-
 ges of which death is the result, is of the ut-
 most importance to the physician, is evinced by
 the fact  that it is this very knowledge  which,
 in  extreme cases, and after other  indications
 and means have failed, enables him to devise
 farther measures which may still be successful.
 Thus, if it  be ascertained that the poison, in
 the advanced course of its effects, has produ-
 ced paralysis of the muscles of respiration, or
 spasm or closure of the glottis, means directed
 to  the continuance of respiration, or the pro-
 duction  of  artificial respiration, may yet save
 the patient. This fact has been demonstrated
 on several occasions, and other analogous illus-
 trations  of  the principle will appear in the se-
 quel.  It is obvious that nothing farther can be
 advanced with due precision under this head,
 until the effects  of the individual poisons  are
 considered.
   106. XII. Classification of Poisons.—The
 effects, and the ultimate results of poisons being
 so  diversified and complex—many producing
 nearly similar or variously modified effects, and
 the same substance evincing very different phe-
 nomena in different persons and circumstances,
 the effects of a single poison being thus neither
 constant, nor always  distinctly developed—it
 follows that a satisfactory classification of them
 can hardly  be expected. Indeed, all attempts
 at  classification must  be conventional;  for if
 we endeavour  to arrange them conformably
 with  their physiological aclion, or according to
 the systems or tissues on which each appears
 especially to act, we shall find, as must he man-
 ifest  from what I  have already advanced, that
 many of them act upon, or through the media
 of, two or more systems, and upon several func-
 tions ; and that the substance which affects one
 person, or one system, in a more or less defi-
 nite manner, operates differently in others, the
 effects varying with the circumstances shown
 to modify the operation  of poisons (y 51, el seq.).
 •\lthough we should have regard to the succes-
 sion of changes consequent upon the ingestion
 of a poison  until  the ultimate results appear,
still we have here comparatively little concern
 with those which  follow the employment of the
same substance in small or medicinal doses.  It
is the deleterious action which should  be ob-
served, and the best means of counteracting
 that operation, and of averting or removing its
 usual effects.  The question is not whether or
no  opium, morphia, or hydrocyanic  acid, &c,
 be stimulants, sedatives, or narcotics, or  enti-
tled to other appellations which have been giv-
 en them ; but it is practically, to which of these
 properties, or to what  other property, are the
 injurious effects chiefly  owing, and by what suc-
 cessive changes are these ultimate effects pro- 
POISONS—Symptoms and Diagnosis of  Corrosive  Poisoning.
369
luced 1  It is principally the progressing and ad-
vanced alterations of vital function or of struc-
tural lesion that are to be arrested and remedied,
and it becomes most requisite that we should not
only know the  nature  of these changes, their
whole extent, and their probable issue, but also
that we should arrange those substances which
operate in similar or nearly similar modes, and
induce similar results, in order that the treat-
ment which may be found  successful  against
one poison belonging to this category  may be
advantageously extended to the others.  That
an arrangement of poisons should be adopted
according to this  principle, with  reference to
the operation and  effects of these agents, and
that the classification may thus be made prac-
tically useful in a therapeutical point of view,
is shown by the extension by the author of the
affusion of cold water  on the head and  neck to
cases of poisoning by various narcotic and  sed-
ative poisons.   The cold affusion had been em-
ployed for ages for intoxication and insensibil-
ity  caused by inebriating liquors ; and  the au-
thor, having repeatedly seen it thus employed
with success, had recourse to it  in 1821,  in a
case of poisoning  by opium,  published  in 1822
in the London Medical  Repository (vol. xviii., p.
29), and in 1825 he recommended, in the work
now named (vol.  xxv., p. 40), this practice in
cases of poisoning  with prussic acid, and with
other poisons belonging to the  same classes as
those just named ; and this treatment has been
found most efficacious  in states of vital  depres-
sion and insensibility produced by narcotics and
sedatives generally.  The propriety, therefore,
of adopting a classification based upon the most
(prominent operation and effects of individual
poisons, as  being  the  most practically useful,
must be apparent.   In venturing to recommend
an  arrangement different from that  which has
been suggested by Dr.  Paris, and  from that ad-
vised  by Fodere, and adopted,  with  certain
modifications, by Orfila, and still further mod-
ified by Christison, Devekgie, Beck, Taylor,
and several  other recent writers,* I have been
influenced chiefly by the firm conviction, enter-
tained without  any doubt from the  first enun-
ciation of these classifications, that they were
inadequate  and inaccurate ; inasmuch  as the
principal operation and effects produced by sev-
eral virulent poisons had no place given them,
or did not fall within the scope of the arrange-
ment, and as various substances  were  classed
under heads to which  they could  not with due
accuracy be assigned,  and were hence viewed
 * The arrangement proposed by Professor Fodere was
as fol Iowa :                          , .
 i. Septic  poisons, ii. Narcotic  or stupefying poisons.
iii. Narcotico-acrid. iv. Acrid or  rubefacient,  v. Corro-
sive or escharotic.  vi.  Astringent  poisons.
 Or.KiLA at first adopted, with slight modifications, the
above arrangement, but afterward reduced the classes to the

VTmtants.  ii.  Narcotics,  iii.  Narcotico-acrids; and,
iv.  Septic poisons.                    ,    .  ,.
 Christison. Beck,  and Taylor have adopted this ar-
rangement of M. Orkila, discarding most undeservedly

*\1?c\^aC^ggestcd by Dr-Parts is based  upon
the presumed mode in which individual poisons act.
 i.PPo sons which act through the nieoi.im of the nerve.




Sy on the mucuous membrane of the stomach, excHmg
a high degree of inflammation,

    III             24
as productive of effects of which they were al-
together innocent, while those which they did
actually produce were not at all, or not  suffi-
ciently recognised.  Thus prussic acid and the
prussiales were arranged in the class narcotics,
and numerous substances were classed as irri-
tants, whose operation in this respect was the
least considerable of the several effects produ-
ced by them. From the observations made above
as to the general and special operation of poisons
on the animal economy (§28, 34, et seq.), the fol-
lowing  classification is suggested as corolla-
ries :  i.  Acrid and corrosive poisons,  ii. Depress-
ing and  paralyzing, or sedative poisons, iii. Ex-
citing and astringing. iv. Exciting and exhaust-
ing poisons,   v. Irritating and depressing or par-
alyzing—acro-sedative poisons, vi. Irritating and
alterative—acro-alterativepoisons,  vii. Narcotiz-
ing or stupefying poisons,  viii. Narcotizing and
irritating—narcotico-acrid poisons,  ix. Septic or
disorganizing  poisons—dissolving the vital cohe-
sion of tissues.
  107. As to these classes, I may remark, that
the operation of the substances arranged under
the first is more or less strictly local, when the
quantity of either is large, or when  the poison
is concentrated ; but that when certain of these
substances are employed  in  small doses, or in
weak solutions, they will then act in  such a
manner as may warrant the arrangement of
them  under  different  heads.  The third and
fourth classes might have been comprised in
one and divided into two orders, but I consider-
ed it better to have too many classes than to
subdivide them.  I may offer the same remark
as to the fifth and sixth classes, but  for practi-
cal purposes  I preferred the arrangement as it
stands.
  108.  XIII.  Of the special  Effects  and
Treatment of Poisons—Class  I.  Acrid and
Corrosive Poisons.—The irritant poisons of sev-
eral recent authors.   The numerous substances
arranged by recent  writers  as  irritants,  com-
prise many which I have here denominated and
expressed  more  strictly in accordance  with
their  real operation.   It surely cannot be ad-
mitted,  moreover, that the substances which  I
am about to  consider  under  this class destroy
life by  merely irritating the surface to which
they are applied.  Is there no local lesion pro-
duced beyond irritation 1  That the local action
amounts to something far beyond irritation will
be admitted by every one who is in the habit of
observing closely, or of attaching precise mean-
ings to  words.  The want of precision is here
chiefly owing to the circumstance of these wri-
ters having classed  under the same kind those
substances which are most acrid and corrosive,
and most limited in their sphere of action, with
others which are really but slightly irritant, and
which are destructive of life  by producing other
and very different effects from irritation.   This
will become  more apparent in the sequel.
   109.  i  Of the Symptoms  and Diagnosis of
poisoning by acrid and corrosive Substances.
—The symptoms vary with the degree of solu-
bility, the concentration of the solution, and
with the nature and admixture of the substance.
When the poison  is very soluble or is fluid, and
very corrosive, the  mouth and tongue evince
most severe symptoms ; there are burning and
pricking or darting pain, redness, swelling with
exudation of lymph, or corrosion and destruc- 
370                  POISONS—Diagnosis o

tion of the mucuous membrane or epithelium,
and an acrid and burning sensation in the mouth
and fauces.  These sensations and alterations
extend more or less to the pharynx, and along
the oesophagus ;  and the patient is incapable of
swallowing, or, if he attempt to swallow, the
matters are spasmodically rejected.  When the
poison is fluid, as a mineral acid or an alkali,
the burning pain and change of structure rapid-
ly produced in the mouth, throat, and oesopha-
gus, and all the symptoms referable to  those
parts, precede disorder of the stomach ; and in
some  instances the poison is not conveyed far-
ther than the oesophagus, owing to its violent
action on the pharynx, and the spastic contrac-
tion of this part and of the upper part of the gul-
let. When, however, owing to the peculiarities
of the case, or to the less solubility or state of
admixture  of the poison, the mouth and throat
are but little or slightly affected, the stomach
then evinces the chief disturbance.  Pain, sick-
ness,  or nausea, burning  heat, and vomiting,
are rapidly produced.   In some instances the
burning pain'  and  acrid  constriction  extend
from  the mouth or pharynx, along the oesopha-
gus to the stomach.  The pain and vomiting
follow immediately upon the passage of the poi-
son into this viscus.  The rejected matters con-
sist at first of the contents of the stomach, with
more  or less of the poison, and subsequently
of mucus and serum, often streaked with blood
and mixed with bile, but frequently also altered
by a portion of the poison being conjoined with
them.  Owing to the rapid rejection of its con-
tents, and  of the greater portion of the poison,
the stomach may be chiefly or almost alone af-
fected.  This is the case,  however, in compar-
atively  rare occasions, for  some of the poison
most  commonly passes into the duodenum, and
often  also  into the  small intestines, especially
when the poison, as arsenic, is not very soluble,
or is taken in  an undissolved state ; and in
these circumstances some time may elapse be-
tween the ingestion of it and  the  occurrence
of vomiting.  But when this or any other poi-
son is  taken in such quantity and state  as to
produce a corrosive effect, the action on the
stomach is manifested  very soon  after its in-
gestion ; and is attended by more or less ten-
derness, tension, and soreness in the upper re-
gions of the abdomen, and by a terrified  or an
anxious expression of countenance.
   110.  When  an  acrid or  corrosive poison
reaches the intestines—which may not  occur
when the poison is very active, and the lesion
of parts above the  pylorus is  intense, and  the
shock to  the  vital endowment  consequently
great—most acute  burning or lacerating  pains
more or less constant, but aggravated at  inter-
vals, are felt around the umbilicus or over the
whole abdomen, and  are attended by a sensa-
 tion of twisting, sometimes by a feeling as if
 the intestines  were drawn against the spine,
 and often  by a  distressing aching in the loins
 extending to the epigastrum.  The abdomen is
 always tense and tender, but at first there is no
 swelling, but rather a retraction of the  parie-
 tes ;  but distention from flatus generally super-
 venes.  Purging is frequently present with te
 nesmus, and sometimes with excoriation  of the
 anus.  After  feculent matters are passed the
 stools  are mucous, watery, or serous, streaked
 with blood, or contain a considerable quantity of
f Corrosive  Poisoning.

blood. The affection of the bowels may be the
prominent effect, the  stomach being compara-
tively but little disturbed; but more frequently
the whole alimentary canal is affected, and vom-
iting and purging, with distressing pain and vital
depression, are present at the same time.
   111. As the operation of the poison proceeds
painful and scanty micturition occurs;  hiccough
sooner or later appears, and becomes distress-
ing ;  the pulse is rapid, small, and weak ;  the
strength and spirits are prostrated, the features
sunk, the surface is covered with clammy cold
sweats, the extremities  are  cold  and shrunk,
and the voice fails.   In cases where the poison
excoriates the fauces, pharynx, or upper por-
tion of the gullet during deglutition, the irrita-
tion often extends more or less to the epiglottis
and glottis, producing wheezing or difficult res-
 piration, hoarseness,  or  spasm  of the glottis,
and, in rarer instances, even death  by asphyxia.
 It will appear from this that this class of poi-
sons produce effects which may readily be mis-
 taken for  several of  the diseases mentioned
 above (y 68);  and to the diagnosis between
 these effects and those  diseases  I shall next
 briefly advert.
   112.  A. Certain Lesions of the  Stomach
 are attended by symptoms, especially near a fa-
 tal termination, very closely resembling those
 produced  by corrosive substances.—(a) Rup-
 ture and partial laceration of the stomach may fol-
 low sooner or later after a full meal, and owing
 to the circumstance, as well as to the attendant
 phenomena,  occasion  suspicions of poisoning,
 which,  however, an examination  of  the body
 after death readily  disproves.  Instances have
 occurred of persons who have eaten too large-
 ly, either after long abstinence, or after having
 suffered from dyspeptic disorder, and who have
 been seized with violent but ineffectual attempts
to vomit, pain in  the stomach, sudden collapse,
 and death in a short time, preceded by abdom-
 inal tumefaction and  tenderness.   On dissec-
 tion, laceration of the coats of the viscus and
the passage of the alimentary matters into the
 peritoneal cavity have been found.  In the case
 described by M. Lallemand, which occurred af-
 ter long privation and dyspeptic symptoms, the
 patient exclaimed  that she  felt her stomach
 tearing itself open.  The laceration was  five
 inches long ;  the coats were not diseased, but
 the pylorus was indurated.  Dr. Christison re-
 fers to two  cases in which the laceration ap-
 peared  to have been  caused by the accumula-
 tion of gases arising from depraved digestion.
 In these, as  well as in cases where the distend-
 ing matters have been more consistent, the la-
 ceration has been owing as much  to weakened
 vital cohesion of the coats of the stomach as
 to the amount of the distending matters.   In-
 stances of rupture  of the stomach have been
 recorded by  Dr. Roberts  and Mr. Weeks ; and
 upon dissection  no sufficient cause of the oc-
 currence was detected.   It may be, therefore,
 inferred that flatulent distention of the stomach
 having occurred, as it usually does, when the
 vital tone and cohesion of the organ  are most
 impaired, spasmodic reaction or  contraction of
 the parieties had taken place, during which la-
 ceration had been the result.  The rupture may
 be only partial;  as in the case  related by Mr.
 Chevalier,  where  the symptoms  of conosive
 poisoning occurred after a very fall meal, at- 
POISONS—Diagnosis of Corrosive  Poisoning.
371
tended by vomitings of blood towards its close.
Upon examination  after death, the inner coat
of the stomach was torn in several places, and
that of the duodenum was also extensively la-
cerated.
   113. (b)  Rupture of the coats of the stomach
at the bottom of a chronic ulcer, or perforation of
the stomach, may be  attended by similar phe-
nomena to those caused by corrosive poisons.
1st. The ulceration may have existed and been
attended by paroxysms of pain, or of retchings,
and when it had proceeded as far as the perito-
neal  coat,  or  partially through the  muscular
coats, the distention of a full meal, or of flatus,
in connexion with efforts at vomiting, has pro-
duced rupture of the tissue forming the  bottom of
the ulcer, and the escape of the contents of the
viscus into the peritoneal cavity.   2d. The ul-
ceration may have gone on to perforation with-
out any evidence  of rupture  or  laceration.
 Perforation may, however, take place without
the escape  of the contents of the stomach into
the peritoneal cavity; the  peritoneal surface
around the perforation having become aggluti-
nated to an adjoining viscus, as in twTo cases
which occurred in my practice.
   114. Perforations of the stomach  are  descri-
bed in the articles Digestive Canal (y 36-43)
and Stomach ;  it is, therefore,  only necessary
to state at this place, that the symptoms attend-
ing them in their course, and towards their fatal
termination, should be carefully distinguished
from poisoning; for the diagnosis is not always
easy.  Perforation  occurs  most frequently in
females between 16 or 17 years, and  25 years
of  age, especially in  the scrofulous diathesis,
in the sedentary, and in connexion with disor-
dered catamenia, and in delicate or  weak con-
stitutions.  The severe symptoms, especially
sudden and acute pains, retchings, or  vomit-
ings, anxiety,  vital depression, &c, generally
occur after eating or  drinking, and especially
after a full  meal; and, if perforation has actu-
ally taken place, there is always vital shock or
collapse, accompanied by the extension of pain
and tenderness, with more or less tumefaction
or tension, over the whole abdomen.   In these
cases, the advanced symptoms and death  are
results of the peritonitis caused by the matters
which have escaped into the peritone'al cavity ;
and the  vomiting is often slight,  consisting
chiefly or altogether of articles recently taken.
There is seldom purging, which frequently ac-
companies  poisoning, although constipation is
not so generally observed  as stated  by some
writers.  The appearances  found after death,
and a careful examination  of the articles par-
taken of, and of the  matters thrown up, are the
chief means of diagnosis.
  115. B. Lesions  of the  Intestines and of
allied Parts  may  be attended by symptoms
resembling the action of corrosive poisons.—(a)
The duodenum, as well as the stomach, may be
ruptured, independently of  external  violence,
without any other  apparent  cause  than over-
distention,  and retchings  while in  this state.
Dr. Christison refers to an instance of a man
who was seized after dinner, when  mentally
excited, with violent pain in the stomach, vom-
iting, and failing pulse, soon followed by death.
The mucous surface  of the duodenum  was
much inflamed; and, four inches and a half from
the pylorus, a laceration extending through a
 third of the circumference of the bowel was ob-
 served.
   116. (b) The passage of gall-stones, and  the
.violent pain, vomitings, and vital  depression
 accompanying this affection, may suggest sus-
 picions of poison ;  but the slowness of  the
 pulse, or the absence of febrile symptoms, the
 tolerance of pressure in the region of the stom-
 ach, or the presence of jaundice, will, in  some
 instances, indicate the nature of the case.  Still
 these symptoms cannot be relied upon, and
 they may not be present; other circumstances
 duly investigated furnishing the chief sources
 of  diagnosis.   Besides, gall-stones  may pro-
 duce severe irritation,  with abdominal or epi-
 gastric tenderness and tension, as well as pain
 and vomiting ; and when these occur soon af-
 ter the ingestion of food or drink, they furnish
 sufficient reasons for careful  observation and
 examination on  the part of the physician.  An
 elderly lady, after slight jaundice, was sudden-
 ly seized with violent pain in the stomach, vom-
 itings recurring in frequent fits, followed, after
 some hours, by most excruciating pains, inces-
 sant retchings, coldness of the skin, and failure
 of the pulse.  In  seven hours from the  fresh
 accession of suffering she expired.  The hepat-
 ic duct was found torn across, a gall-stone at
 the opening of the cystic duct, and three pounds
 of blood and bile in the peritoneal cavity, which
 was inflamed  in  different parts.  (Journal des
 Prog, des Sc. Med., t. xiv., p 245).
  117. (c)  The sudden flow of acrid bile into the
 duodenum, especially during  warm seasons, af-
 ter this secretion had accumulated in  the gall-
 bladder and ducts, is not infrequently the cause
 of symptoms which have been  mistaken for the
 ingestion of acrid poisons.   This is most like-
 ly to occur where a  person  who is subject to
 this biliary accumulation takes some article
 which disagrees with him, or some chologogue
 purgative.  I have met with two or three in-
 stances of persons  who complained of  the
 symptoms  I have described as diagnostic of
 biliary accumulation  or obstruction (see Gall-
 bladder, § 18, et seq., and Liver, § 48, et seq.,
 and y 78, et seq.), and for whom a moderate pur-
 gative  dose was  ordered.   But the medicine
 having removed the obstruction, the passage
 of  acrid bile  into the  duodenum  occasioned
 symptoms of so violent a nature—retching and
 vomitings, diarrhcea, pains in the stomach and
 throughout the abdomen, &c—as to suggest
 suspicions of an acrid or corrosive poison hav-
 ing been given,  instead of  the medicine  pre-
 scribed.  The bile which passed into the duode-
 num in these instances possessed sufficient ac-
 ridity to occasion many of the symptoms of poi-
 soning.
  118.  (d) Bilious cholera may likewise be mis-
 taken for the effects  of acrid or corrosive poi-
 sons ; indeed, it  is most difficult in many cases
 to distinguish between them, and still more dif-
 ficult to point out any means of diagnosis which
 can be depended upon.   Much will depend upon
 the acumen of the physician, and the  view he
 takes of the history of the case, and all the cir-
 cumstances attending it.  The nature of the
 ingesta, and the state of the matters  ejected,
should  be carefully inquired into ; and  if heat,
acridity, or darting pains be felt in the mouth,
pharynx, or oesophagus,  their occurrence before
or after the vomiting ought to  be ascertained, 
372
POISONS—Diagnosis of Corrosive Poisoning.
 and the mouth and pharynx should be examin-
 ed.  These symptoms seldom even attend, and
 never precede bilious cholera ;  while they very
 frequently,  indeed most commonly, precede
 poisoning with acrid or corrosive substances.
 Blood is never seen in the matters thrown from
 the stomach in cholera, whereas it is frequent-
 ly seen in these matters when the vomiting has
 been caused by these poisons.  Bilious cholera,
 or  any state of cholera observed sporadically
 in this country, even when excited by indigest-
 ible articles of  diet, rarely terminates fatally
 within 48 hours, and, indeed, very seldom thus
 terminates  even  in  a much  longer  period,
 whereas the  effects of corrosive poisons are
 much more rapidly fatal.
   119. (e) Pestilential cholera is also liable to be
 mistaken for poisoning with acrid substances ;
 but the same circumstances as have been just
 noticed serve  to  distinguish  between  them,
 with the exception of the rapid termination of
 the former, which is frequently equally rapid
 with the latter.   But  the prevalence and  in-
 fectious nature of this pestilence, the general
 symptoms, the state of the surface and of the
 extremities, and the appearances and odour of
 the fluids thrown off during the progress of the
 malady, will readily distinguish it from poison-
 ing, especially if the physician have seen cases
 of it on any former occasion.
   120. (/)  Inflammation of the stomach, or  of
 the intestines, or of the peritoneum, may be con-
 founded with poisoning with corrosive substan-
 ces, the first of these more especially.  Acute
 gastritis, uncomplicated with inflammation  of
 an adjoining viscus, seldom occurs primarily in
 temperate climates, and not very frequently in
 warm countries, unless as a consequence of the
 excessive use of spirituous liquors  or other
 stimulants ; but it does occur more frequently
 both in England and Scotland than Dr. Chris-
 tison has inferred from the statements of M.
 Louis.  Acute gastritis sometimes is produced
 primarily—and formerly it was produced more
 frequently—by drinking excessively of spiritu-
 ous liquors, and the severity of the symptoms
 were occasionally such as to equal the violence
 of those occasioned by  acrid poisons  ; but the
 history of the case, the symptoms of intoxica-
 tion, the odour and appearances of the matters
 rejected, &c, will  sufficiently point out the na-
 ture of the affection.  It must be admitted that
 the possibility of acute gastritis being produ-
 ced by natural causes is a question of great in-
 terest  and  importance  to the practical physi-
 cian.   Dr. Christison remarks, that the possi-
 ble occurrence of this  disease, independently
 of poison, is the only obstacle in the way of a
 decision in favour of poisoning  when, in cases
 characterized by signs of violent irritation du-
 ring life and early death, bright redness, ulcers,
 and  black  granular, warty extravasation are
 found in the internal surface of the stomach ;
 and in regard to their effects he adds, that they
 can  very rarely indeed all arise from natural
 causes, or,  indeed, from any other cause than
 poison.  Admitting the truth of this,  I may
$tate,  that  violent gastritic symptoms, death
 after some hours,  with vascular injection, red-
 ness of the inner  surface of the stomach, and
 numerous ecchymoses, have occurred,  with-
 out sufficient evidence of poisoning, unless, in
 some instances, the excessive use of spirituous
 liquors be considered as such, and to which it
 is strictly entitled.  When ulcers, excoriations,
 abrasions, or corrosions of the inner surface of
 the viscus are found, in cases which have ter-
 minated rapidly, and in connexion with bright
 redness, ecchymosis,  &c, there can be little
 doubt of the ingestion of an  acrid or corrosive
 poison, although it may have  escaped detection.
 .\n important sign in cases of gastritis, as well
 as of cholera, is the absence of excessive heat
 or burning in  the  throat, or of painful and dif-
 ficult deglutition ; which very frequently pre-
 cede  the vomiting in cases of poisoning by ac-
 rid substances, and which seldom attend and
 never precede the vomiting from spontaneous
 gastritis or enteritis.
   121. (g) Acute enteritis, gastro-enteritis, or per-
 itonitis, may,  in some  instances, give rise to
 suspicions of poisoning; and the physician will
 consequently  be induced to  inquire, as in the
 diseases already noticed, 1st. .\s to the time at
 which vomiting appeared after a meal, or after
 the ingestion of any article whatever.  2d. As
 to whether the disease was ushered in by chills
 or rigours, or is attended by  febrile reaction or
 commotion.   3d. As to the state of the bowels,
 of the evacuations, and of the matters thrown
 off the stomach.  4th.  As  to  the  symptoms
 referable to the mouth, throat, and oesophagus.
 5th. As to the presence or absence of diarrhcea,
 and of excoriations at the anus;  and, 6th, into
 all the circumstances connected with the histo-
 ry and existing state of the case.  The causes
 assigned for the attack; the relations subsist-
 ing between these causes, and the supervention
 of chills or rigours, of vomitings, and of consec-
 utive  febrile reaction ;  the existence of con-
 stipation,  and  the absence of lancinating pains
 or burning sensations in the mouth, throat, and
 oesophagus at  the commencement, and of pain-
 ful and violent purging and excoriations of the
 anus  at an advanced period, with other partic-
 ulars  connected with the history of the case,
 will distinguish  most instances of spontaneous
 inflammation  of the  digestive organs  and of
 the peritoneum from poisoning with acrid or
 corrosive substances.
   122. (h) Perforation of the  intestines, as well
 as perforation of the stomach,  always termi-
 nates fatally;  and when it is attended by symp-
 toms  simulating those  which are caused by ac-
 rid poisons, an  examination after death will
 show  the  nature of the case.  (See Digestivk
 L anal, y 40, et seq., and Intestines, $ 80, 81.)*
   123. (i)  Colic, iliac passion, and strangulated
hernia may severally be mistaken for poisoning
 with  corrosive  substances,  especially  when
they are attended  by. violent retchings or vom-
iting ;  or poisoning by these substances may be
mistaken for these.  Internal strangulation, in-
tussusception of a portion of intestine, and the
existence   of  intestinal  concretions, or other
causes of  obstruction, may likewise occasion
symptoms  closely resembling poisoning, espe-
cially  the  vomitings,  pain, anxiety,  and vital
exhaustion attending  them.  But the history
of the case, the  obstinate constipation, the ap-
pearances and odour of the matters thrown off
the stomach ;  the  sensations  of the patient as
to the seat of obstruction  and pain ; and the
lesions found  after death, with the other cir-

  [* This statement is too broad : perforation of the intes-
tines, though generallyi is not always fatal.] 
POISONS—Corrosive—Acetic Acid—Mineral Acids.
373
cumstances already adverted to, will serve to
distinguish these maladies from the effects of
poisons.
  124. Having taken  a view of the features
distinguishing certain  natural  diseases  from
the effects of corrosive or  acrid poisons, I
should now proceed to describe the structural
lesions produced by  these latter; but as these
lesions differ very remarkably from each other,
according to the particular substance causing
them, I shall briefly notice them in connexion
with the especial  consideration of the  several
substances acting chiefly by their corrosive or
acrid  properties, or by the local changes produ-
ced in the viscera, with which they are brought
in contact; and for facility of reference, I shall
treat  of them in alphabetical order.
   125. i. Acids.—A. Acetic a\cid, in its con-
centrated state, acts chiefly as a corrosive agent.
Although, in its various forms, it is in daily use,
it is rarely the cause of death, even when swal-
lowed by mistake in considerable quantity.   Its
injurious effects have been  described by Orfi-
 la, Barruel, Schubarth, and Hebreart.
   126. a. According to the last-named  experi-
menter, a small quantity of acetic acid dropped
into the windpipe occasions difficult and hissing
respiration, croupy cough, and death in two or
 three days, the surface of the larynx and tra-
chea being covered with a false membrane sim-
 ilar to that found after croup.
   127. b. The concentrated acid, applied 'exter-
nally, acts  as a corrosive agent on the tissues.
 In this state it operates  chiefly locally, dissolv-
 ing the albumen, fibrin, and gelatin ; and is but
 slightly absorbed.   It  coagulates, and renders
 dark the blood in the capillaries.
   128. c. If injected into the veins in a strong or
 concentrated state,  or if the  quantity be con-
 siderable, it  changes the physical appearances
 of the blood,  and  alters the  colour and condi-
 tion of the  red globules.  According  to Dr.
 Pommer, when it is dilute, or about the strength
 of the distilled vinegar in common  use,  several
 ounces of it  may be  injected into the blood
 without material  mischief; but the more re-
 cent experiments  of Orfila throw much doubt
 upon this inference.
   129. d. Acetic acid taken into the stomach in
 large quantity,  but  more especially in a very
 concentrated state, and if the stomach be emp-
 ty, produces agonizing pain, and a sensation of
 burning in the stomach, with anxiety at the ep-
 igastrium, and convulsions,  and death after a
 few hours.   In  this concentrated  state it acts
 chiefly locally, and is not absorbed  in an appre-
 ciable degree.  It affects violently the nerves
 of the organ, the affection being propagated to
 the large visceral ganglia; and it coagulates the
 blood in the capillary vessels of the organ, and
 arrests the circulation through them, occasion-
 ing also a  vital  shock.  In dilute states and in
 frequent doses, this acid acts  chiefly  through
 the medium of the blood, lowering nervous en-
ergy and vascular action, as will be shown here-
after.   (See next Class.)
   130.  e. The appearances after  death by  the
concentrated acetic acid are, lividity of the in-
teguments of depending parts of the  body; a
brownish and leathery appearance of the mouth,
fauces, and pharynx ; and a similar change ex-
tending down the oesophagus to the stomach or
to parts of this viscus.   The inner surface of
the oesophagus presents large patches of a dark-
brown hue, with reticulations of injected cap-
illary vessels.  The stomach, in some places,
has a grayish tint, interspersed with dark-red-
dish  spots,  with numerous ecchymoses, and
several large, black elevations, consisting chief-
ly of coagulated blood in the sub-villous cellular
tissue.  A livid or  black hue of the fundus or
near the pylorus;  a thick, dark, pulpy matter
adhering to parts of the internal surface of the
organ ; and the presence of more or less of the
acid in this viscus or in the intestines, have also
been observed.   The intestines are not materi-
ally altered.
  131. /. Treatment.—Draughts containing cal-
cined magnesia, or the alkaline or magnesian
carbonates; the cautious use  of the stomach-
pump, as the villous surface of the oesophagus
and stomach is readily injured by mechanical
agents after  corrosive poisons; the injection
of magnesian or alkaline solutions, and the re-
moval of the contents of the viscus soon  after-
ward  by this  apparatus, are the measures more
immediately required.  Subsequently, albumin-
ous or demulcent fluids, mild broths, arrow-
root, sago, and various mucilaginous and fari-
naceous articles of  diet, may be given in small
quantities, and frequently.
  132. B.  The Hydrochloric,  the  Nitric,
and the Sulphuric—As these  acids,  usually
denominated the mineral acids,  when  used in
poisonous states and quantities, produce simi-
lar phenomena, and  require  the same means for
the counteraction and removal of their effects,
I shall consider them under  the  same  head,
and,  in some respects, in connexion.  Hydro-
chloric acid—muriatic acid—spirit of salt—is not
infrequently employed as a poison  ; but the ni-
tric acid—aquafortis ; and the sulphuric acid—
vitriolic acid—vitriol—oil of vitriol, are not in-
frequently resorted  to, for  purposes of murder
or suicide, or of external injury short  of mur-
der.   Either of these acids may be swallowed
by mistake, or be employed in various criminal
ways.  Tartra  adduces an instance  of a fe-
male  who, having  been  intoxicated, was poi-
soned by nitric  acid, which was  mixed  with
wine  and poured down her throat.  A woman
was  convicted of murdering  her  husband  by
pouring sulphuric acid down  his throat  while
he lay asleep with his mouth open ; and several
instances have occurred  of the same acid hav-
ing been given in poisonous doses, in place of
the medicines which had  been prescribed.  The
mineral  acids, especially the sulphuric, have
likewise been employed, by abandoned persons,
to poison their own  infants  ; but they are much
more frequently resorted to as a means of sui-
cide.   They  have  also  been employed, from
motives  of revenge or of  dislike, to disfigure
the countenance or person ; the concentrated
acid  being  squirted  or  thrown over exposed
parts of the body.   Mr. Taylor states  that the
external application of nitric acid has been a
criminal cause of  death on many occasions.
In one instance this  acid was poured into the
ear of a person while sleeping, and it led  to the
slow  destruction of life.
   133. a. The symptoms occasioned by the min-
eral  acids, when swallowed in a concentrated form,
are of the most violent description, but the al-
terations  produced  by them on the  organization
are chiefly local and structural.  Dr. Christi- 
374
POISOaXS—Corrosive—Mineral Acids.
 son justly remarks, that they afford the purest
 examples of true corrosive poisons, their poi-
 sonous effects depending entirely on the organ-
 ic injury they occasion in the textures to which
 they are applied;  and that it is of use to set
 out, in the investigation of the effects of poi-
 sons, by determining the phenomena presented
 under such  circumstances.   I shall have more
 immediately to describe the  violent symptoms
 and the severe structural change produced  by
 these substances  before a  fatal result  ensues;
 and in the sequel  to  show the much less vio-
 lent phenomena, and the very slight local signs
 which other poisons hitherto classed with these
 leave of their operation, and yet  prove more
 rapidly and certainly fatal than they ; and few
 will fail of being struck by discovering the great
 extent of lesion the animal  frame  will some-
 times endure  from the former—the most vio-
 lent of all corrosive substances—and  yet  re-
 cover; and  the very  slight alterations locally
 produced by these other poisons, whose opera-
 tion is so'rapidly fatal.   These circumstances
 will of themselves prove sufficient to warrant
 an  arrangement in which substances differing
 so very materially in  their local and constitu-
 tional effects as those alluded to should not  be
classed, as they hitherto have been, under the
 same head, but should be arranged under differ-
 ent classes,  according to their most prominent
 mode of operation and effects.
  134.  b. The mineral acids  may produce fatal
 effects when applied  externally, when  injected
into the veins or into mucous  canals, when inhaled
in  the  form  of fumes,  and  when  swallowed.
 When applied externally in a concentrated form,
 or even in a state of strong dilution, they irri-
tate, corrode, or inflame the skin.   The nitric,
 or rather the strong nitrous or fuming nitrous
 acid, produces these effects most severely ; but
the sulphuric  and  hydrochloric act almost  as
 violently as it.  In the stronger states these
 acids chiefly act locally and disorganize the tis-
sues, the coagulation  of the blood in the capil-
laries and the destruction  of the organization
 on which  they act  generally preventing their
imbibition and absorption.
  135.  c. When injected into the veins, even in a
 state of considerable dilution,  they coagulate
the blood, and thus destroy life; but when the
dilution is still greater, or  such as to allow of
 the circulation and presence of either of/these
 acids in the vessels of the heart, ganglia,  or
 brain, before coagulation even partially takes
place, it may  reasonably be  inferred  that the
 vital manifestations  of these  organs will  be
 thereby rapidly subverted.
  136.  d.  If the fumes of either of these acids,  or
 any of the gaseous forms which they assume,
 either singly or in states of admixture with oth-
 er  gases or vapours,  be inhaled, the most se-
 vere effects on the respiratory passages and
 lungs are produced.   When either nitric oxide
 gas, or nitrous acid vapour,  hydrochloric acid
 gas, chlorine,  or sulphurous  acid,  in more  or
 less strong states, is  attempted to be  inspired,
 spasm  of the  glottis is produced by it,  and its
 entrance into the  respiratory organs is thereby
 prevented.   In a weaker form, either of these
 acid vapours may pass into the lungs, but it  ir-
 ritates and inflames the mucous surface of the
 larynx and trachea, the inflammation extending
 along the bronchi to the air-cells and lungs, pro-
ducing dangerous or even fatal laryngitis, bron-
chitis, or  pneumonia,  or a  complication  of
these.  Several instances are  on  record  of
persons having  been destroyed  by the violent
and extensive inflammation of the respiratory
surfaces produced by these fumes, and  by the
nitric oxide gas converted into nitrous acid va-
pour by mixing with the atmosphere.
   137. e.  The injection  of either of these acids
into mucous canals with a criminal intention has
been rarely recorded.   But an instance is pub-
lished in the Medical Gazette (vol. xvii., p 623),
abridged from  a French  journal,  of sulphuric
acid having been given in an enema by mistake
for oil.  As soon as the enema was injected, the
patient uttered distressing screams, passed the
night in the utmost agony,  and  died in the
course of the following  day.   Numerous in-
stances have been published of the murder of
children with sulphuric or nitric  acid, chiefly
the former, which has  generally been poured
into the mouth or throat.  When  poisoning is
effected in this way, the acid may not  reach
the stomach ; it may not even get farther than
the pharynx or upper portion of the oesophagus.
Being poured into the mouth or throat of the
child when asleep, or when crying or struggling,
a portion of it irritates  the epiglottis, or even
escapes into the glottis, occasioning strangula-
ting cough, and asphyxia by closure of the glot-
tis, with violent inflammation or disorganization
of the pharynx and adjoining parts, as  observed
in some cases when acid has been swallowed
accidentally.
   138. /.  When  either of these acids, or an ad-
mixture' of these acids, has been  swallowed, the
effects vary conformably with the  circumstan-
ces mentioned above (6 51, et seq).  These ef-
fects have been most ably  investigated by Tar-
tra,  with reference  more especially  to  nitric
acid, which, as well as the sulphuric and hydro-
chloric, may be employed for  the  purposes of
suicide, or of murder,  or may  be swallowed
accidentally. However ta'ken, with whatever
motive, or in whatever quantity or degree of
concentration,  the  acid  may not, especially
when taken accidentally, reach farther than the
pharynx or oesophagus, its acridity, the violence
of its  effects, or the discovery of a mistake ar-
resting  deglutition  before any  portion  of it
could  have  reached  the stomach.  Neverthe-
less, fatal results may rapidly ensue owing ei-
ther  to the extensive  disorganization of tex-
tures  in, and adjoining to, the pharynx, or to
the inflammation or corrosion of the larynx,
the tumefaction of these parts closing the glot-
tis, and either causing or threatening asphyxia.
In these cases, although the acid may not  reach
farther than the upper part of the  oesophagus,
the effect upon the larynx may be so violent as
rapidly to  ,produce suffocation, if tracheotomy
be not performed.  M. Tartra considers that
the mineral acids produce  effects which may be
arranged as follows : 1.  Speedy death from vi-
olent  corrosion  and  inflammation.   2.  Slow
death from  a peculiar organic change of the
stomach and intestines.  3. Imperfect recov-
ery, the person  remaining liable ever after to
irritability of the stomach.  4.  The recovery of
perfect health ;  but the operation, by means of
asphyxia, caused in the way now  stated, should
be ranked as a fifth mode or variety.
   139. g.  The most common symptoms are those 
POISONS—Corrosive—Mineral Acids.
375
of the first of these varieties, namely,  burning
pain, and acrid acid taste in the mouth, extend-
ing to the throat; extreme  heat and pain be-
tween the sternum and spine, extending to the
epigastrium and stomach, where it is most ex-
cruciating, and attended by extreme anxiety
by most  painful or impossible deglutition ; and
M increase of these on attempts to swallow, on
pressure, and on  coughing.  Eructations often
take place from the stomach, and aggravate the
sufferings of the  patient, especially in  the sit-
uations just named.  The lips are  commonly
shrivelled, and are, at first, whitish, and after-
ward yellowish, if nitric acid have been taken ;
and  brownish, if sulphuric acid.   Excoriations
or corrosions, but rarely blisters, are sometimes
observed on or about the lips, or on parts of the
skin with which  the acid may have come in
contact, as the cheeks, neck, breast, or fingers ;
and  these marks  undergo the same  change of
colour as observed in the lips and mouth.   The
inside of the mouth and of the cheeks is  also
more or  less shrivelled, white, or  corroded ;
and the teeth often in a very few hours become
loose, brown, or yellowish-brown. The colour
of the tongue varies with the acid, and the time
which has elapsed from the  application of the
acid; but it is  often yellowish, or  yellowish-
brown.  Deglutition is so difficult, that attempts
to take fluids are followed by the forcible re-
jection of them by the nose, the pharynx being
spastically contracted.   The matters vomited
are generally brownish or black; and  if they
fall on marble or limestone, they produce ef-
fervescence.  Afterward they are mixed with
altered blood,  and with membranous shreds,
which resemble portions of the villous coat of
the stomach, and  sometimes actually  consist
of these,  but most generally of coagulated  mu-
cus.  The bowels are obstinately constipated,
and  the  urine is  scanty or suppressed.   The
abdomen, especially its upper regions, is tender
and swollen.  The pulse is very weak, and, to-
ward the close, very small, imperceptible, or in-
termitting.  It is seldom very frequent, and it
may even continue hut little or not at all ac-
celerated throughout. The countenance, at first
expressive of anxiety, pain, and distress, soon
becomes  collapsed, pale, and the extremities
cold or clammy.   The breathing is laborious, is
often attended by singultus, and the movements
of the diaphragm increase the pain of the stom-
ach and epigastrium.  In many cases the  irri-
tation and swelling in the pharynx and epiglot-
tis, or even in the larynx, cause fits  of suffoca-
tive cough, with croupy respiration, and, where
the larynx has been more particularly injured,
suffocation may not merely be threatened, but
actually produced.
  140. In some instances, especially when the
quantity  of acid  which  has passed into  the
stomach  has been large, the  symptoms may be
less excruciating, but more rapid ; while in oth-
ers there may be a deceitful tranquillity, and life
may be somewhat longer sustained.  Thus, in
the case  adduced by Tartra, of a woman  who
had been intoxicated, and was poisoned by aqua-
fortis mixed in wine, although there were  both
pain  and vomiting at first, yet  none of these
symptoms were afterward complained of, death
taking place within twenty hours;  but the in-
toxication  probably  obscured  the  sensibility,
while the admixture with much wine modified
 the operation of the poison. The intellectual fac-
 ulties generally remain unimpaired to the last.
 Should  the patient survive the first effects of
 the poison, the mucous membrane of the fauces,
 pharynx,  or oesophagus may be detached  and
 discharged in irregular shreds, or in portions of
 considerable size, or even in a perfect cylinder.
   141. h.  The duration of this variety of corro-
 sive poisoning may vary from two or four hours,
 as in the cases recorded by Remer and Sinclair,
 to two or three days ;  but life may be prolonged
 to ten or  fifteen days.  The  usual pericd is
 from twelve to forty-eight hours.  Death may
 be caused altogether by asphyxia, owing to the
 closure of the larynx, [the acid not reaching the
 stomach]; and if tracheotomy be resorted to,
 life may be thereby prolonged, as in the case
 recorded by Mr. Arnott ;  but death more  fre-
 quently results ; the structural change, the vio-
 lent impression made upon the nerves, the vital
 shock, the coagulation of the blood in ihe ves-
 sels  of the parts with which the acid came in
 contact, and the local arrest of the circulation
 and of the associated vital functions, combining
 to produce the fatal issue.  [In these cases death
 generally results very speedily, often within  a
 few minutes.]
  142. i. The quantity of a mineral acid capable
 of producing fatal effects cannot be stated with
 any precision, as the  result  depends upon the
 several  circumstances stated  above  (y 51, et
 seq).  Dr.  Christison remarks that the smallest
 fatal dose  of sulphuric acid which he has found
 recorded,  was one drachm,  which was taken
with sugar by mistake for stomachic drops by a
stout young man, and  produced death in seven
days. A man has recovered  after taking six
drachms.   In a case of poisoning with hydro-
chloric acid, an ounce and a half proved fatal in
 about twenty-four hours ; and in another case,
 alluded to by Taylor, a man walked about three
quarters of a mile after taking nearly an ounce.
 Mr. Orr and Dr. Craigie refer to two cases of
 recovery, although two ounces of the concentra-
 ted sulphuric acid had been swallowed in each.
  143. k. The symptoms of the second of these va-
 rieties, according to Tartra, are  at first those
 already described,  but  they soon abate in vio-
 lence.  The patient then becomes affected with
 general fever, dry skin, difficult breathing, ten-
 sion of the abdomen, spasms, and pains of the
 limbs, salivation, and occasional vomiting, par-
 ticularly of food and drink.  The salivation is
 attended by fetor, and membranous flakes, re-
 sembling the villous coat of the stomach,  are
 vomited.  These flakes are most probably mem-
 branous exudations of lymph, resembling those
 of croup, thrown out on the excoriated and in-
 flamed surface of the organ.  Worms are some-
 times discharged dead and excoriated by the
 acid.  The functions of digestion and assimila-
 tion are arrested, or remarkably impaired, and
 the frame  becomes extremely debilitated and
 emaciated.  Death usually takes place in pe-
 riods varying from a fortnight to several months.
 Tartra adduces an instance in which death did
 not  take  place  until  after eight months,  the
 vomiting of membranous flakes continuing until
 the last.
   144. /. The third and fourth varieties described
 by M. Tartra are characterized, as respects the
 former of these, chiefly by the greater mildness
 of the symptoms from the commencement, and 
376                      POISONS—Corrosive—Mineral Acids.
by the patient continuing through life  liable to
attacks of pain in the stomach, vomiting of food,
and general disorder of the digestive functions.
The latter consists of cases of perfect recovery
Of 55 cases  of poisoning by the mineral acids
recorded by Tartra, 26 died; 19 of the  primary,
and 7 of the secondary effects.  Twenty-nine
recovered, and of these 21 perfectly.   Suicidal
cases, for obvious reasons, were more frequent-
ly fatal than the  accidental.
  145.  m. The strong mineral acids, as  above
mentioned (y 137, 138), may not reach the stom-
ach, especially when the poisoning is accidental
or attempted criminally.  The effects produced
by them, under these circumstances, upon the
pharynx, oesophagus, and larynx, being often so
violent  as to occasion  death in a few days.
Several instances of this kind have been record-
ed ; and even when a person has discovered his
mistake, and taken only a small portion, which
could have reached no  farther than the phar-
ynx or upper part of the gullet, partial recovery
may take place, with stricture of the upper por-
tion of  the oesophagus;  or fatal inflammation
of the pharynx and larynx, with or without as-
phyxia,  may be the immediate result.   That a
large  proportion of the children  poisoned,  by
the abandoned classes, with the mineral acids,
die from the effects of the poison on these parts,
without reaching the stomach, is proved in some
cases by the appearances observed after death,
and is rendered  probable in others by the cir-
cumstances under which the act is perpetrated.
In the case recorded by Mr. Arnott, the injury
was confined chiefly to the larynx and gullet,
the stomach being distended with food  and very
little affected. The symptoms were general de-
pression, with croupy respiration and threaten-
ed suffocation, for which tracheotomy  was per-
formed,  with relief to the  breathing; hut the
patient died, with symptoms of general exhaus-
tion, in thirty-six hours, without presenting any
marked signs of the operation of the acid on the
stomach.
   146. In the circumstances and in the concen-
trated form, in which the stronger mineral acids
are poisonous, whether taken accidentally, or
with a suicidal intention, or given with acriminal
object, danger or death arises chiefly  from the
local or structural change ;  comparatively little
of the acid, as stated above (§ 134), being carried
into the circulation.   But these acids may be
taken in such states  of dilution as will admit
of  their absorption,  and action on the frame
through the medium of the  blood;  and thus
they may produce noxious effects, especially
when given frequently, or in too large  quantity,
or a form of slow poisoning; but as they do not
act by producing a corrosive effect, when given
in  states of dilution which admit of  their ab-
sorption, they will be considered, in this form
of exhibition, under the class to which the dif-
ferent effects they then produce more  appro-
priately belong.*
   147.  n. Appearances after death from the con-
 centrated mineral acids may be confined  chiefly to
 the fauces,  pharynx, larynx, and oesophagus,
 and may be comparatively slight in the stom-
 ach.   The whole of the alimentary canal, from
 the mouth  to the anus, should be examined,
 and the lesions  of the upper portions should  be
   [* In these  cases they may readily be detected in the
 urine.—Lond. Med. Gazette, May 37, 1842.]
carefully observed; as these portions, especially
those particularized, suffer  most in cases of
poisoning with these substances.  Spots on the
skin, about the mouth and lips, are often pres-
ent, and should be examined.  If the case have
proved fatal within the usual period, and if the
concentrated sulphuric acid have been swallowed,
the inner surface  of the mouth is generally
white, softened, and corroded, the mucous coat
is readily detached, and the tissues underneath
are of a dark red.  The same change is  ob-
served in the fauces, pharynx, and oesophagus,
the colour of the mucous surface of these parts
sometimes being brownish  or ash-gray.  The
mucous membrane is often more or less corro-
ded,  partially detached,  and, in the oesophagus,
assumes longitudinal plicae,  owing to  the con-
traction of the canal and its partial detachment.
The  stomach is usually contracted, corroded,
and sometimes perforated.  When opened, its
contents are commonly of a dark brown or black
hue, of a tarry consistence, and consistingchiefly
of altered  blood and mucus.   The existence of
acidity depends upon the treatment and the pe-
riod which had elapsed from  the ingestion of
the acid.   The villous surface of the  stomach
is traversed by black striae, is more or less cor-
rugated, or is generally of a brownish or black
colour, which is not removed by washing.  Be-
tween the rugae and underneath the blackened
membrane, the issues are of a deep or dark  red
hue ;  but this redness and the blackness of the
villous membrane are sometimes partial, or in
patches of various extent.   The small intes-
tines, especially when  much of  the acid has
passed into the stomach, are more  or less in-
flamed, their contents much resembling those of
that viscus. When perforation of the  stomach
has taken  place, all the  coats are  much soften-
ed, especially in the vicinity of the perforation,
the margins of which are black, irregular, and
very soft.   The contents of the viscus may not
have escaped through the aperture ;  but if they
have passed through, the adjoining  organs  are
generally altered by the acid.   Mr Taylor re-
fers  to  a  case in which the spleen, the liver,
and the coats of the aorta were found  corroded
and  blackened by the acid which had escaped
through the perforation.
   148. When the acid has been taken in a di-
luted state, or at least  in a less  concentrated
form, and if the  patient live some  days or
weeks,  the oesophagus  is more  or less con-
stricted, and its mucous surface inflamed or
otherwise changed.  Inflammatory  lesions are
commonly found in the stomach, and the cor-
rosion or charring of the villous membrane is
not so great as described above.  The blood in
the  vessels is always very dark; that in  the
vessels of the  stomach and spleen is almost
black and coagulated.   In the more prolonged
cases the  villous coat  of both the oesophagus
and  stomach is either more  or less abraded, ul-
cerated, or almost entirely destroyed.   The
pylorus is generally constricted.  In these  ca-
ses the patient sinks from the irritability of the
stomach,  from  the almost total arrest of  the
functions   of digestion  and  assimilation, and
from the action of the acid upon the blood and
nervous systems.   In some, at least,  of these
cases, and especially when  the acid has been
much diluted, a partial absorption of it into the
circulation takes place, and changes the colour 
                           PRISONS—Corro

and state of the blood, and acts otherwise in-
juriously on the frame, as will be noticed more
fully in the sequel.*
  149. o. The appearances produced by the nitric
and nitrous  acids are  not materially different
from those caused by sulphuric acid.  The ex-
ternal surface of the lips  often present yellow-
ish or yellowish brown spots, the cuticle being
easily detached.   Yellowish  spots are some-
times found about  the neck, or on the  hands.
A yellow frothy liquid escapes from the mouth
and nose.  The  abdomen is  often  distended
with flatus.  The inner surface of the mouth
and cheeks  is  of a whitish or yellowish col-
our.   The pharynx, larynx, and  oesophagus
are softened, tumefied, of a yellowish or brown
colour, and their mucous membrane  is easily
detached, or it is already detached in  long
shreds or folds.  The stomach is similarly al-
tered.  It is rarely perforated, and is often dis-
tended with gas.  The villous membrane pre-
sents extensive patches of a yellowish, brown,
green, or black hue, and  the coats of this vis-
cus are remarkably softened throughout.  The
duodenum is often changed in a similar man-
ner,  although not so  extensively; the  other
intestines are seldom much altered.  The non-
perforation of  the stomach is most  probably
owing, as Mr.  Taylor suggests, to  the cir-
cumstance of the acid having been swallowed,
in most instances, while the stomach contained
much alimentary matters.  When  death takes
place rapidly, the contents of this  viscus gen-
erally yield more or less  of the acid.   When
the larynx is implicated by swallowing this or
any of the other strong mineral acids, more es-
pecially if suffocation have been thus produced,
the lungs and mucous membrane of the trachea
and bronchi  are congested with black blood.
In more  chronic cases, especially if the patient
has  lived several weeks, softening,  redness,
and ulceration in various  stages of the mucous
membrane of the oesophagus  and stomach are
found.  The  oesophagus  is often constricted,
and constriction is sometimes, also, met with in
the pylorus and duodenum.
  150. p. The hydrochloric acid  produces simi-
lar symptoms and  appearances after death to
those which have been now described.  Cases
of poisoning by this acid are  much more rare
than  by  the  other strong mineral  acids;  but
those which have been observed with due at-
tention present the same phenomena and le-
sions as  are produced  by  nitric acid.
  151. q. Instances of poisoning by an admix-
ture of mineral acids—by the nitric and muriatic
acids—aqua  regia, which  is often  used in the
arts for dissolving gold and platina—and by the
nitric  and sulphuric acids—aqua regina, which is
employed for dissolving silver,  may occur, but
they have been very rarely met with-  Qrfila
ive—Mineral Acids.                      377

 has given one instance of poisoning by the lat-
 ter of these combinations.  The symptoms and
 post-mortem appearances were much the same
 as those already stated, but approached the
 nearest to those caused by the nitric acid, which
 predominated  in the mixture.  The  nitro-mu-
 riatic acids most probably produce symptoms
 and changes very closely resembling those de-
 scribed  above, especially those in connexion
 with nitric acid  ($ 139-149) ;* but they  have
 not hitherto been recorded.
   152. r. Treatment.—The difficulty of swallow-
 ing, in almost every instance of  poisoning by
 these acids, is the  great  obstacle to the treat-
 ment of their effects.   The means  and  the in-
 tentions which should guide the employment
 of them are obvious ;  but  when  the  constric-
 tion of the pharynx and Ihe spasmodic action
 of the pharyngeal muscles are such that all ar-
 ticles are forcibly rejected upon every attempt
 to swallow them, the most influential antidotes
 and remedies are altogether prevented from ex-
 erting their  effects.   If,  however,  the patient
 be still able to swallow,  calcined  magnesia, or
 the carbonate of magnesia, should be  instantly
 given in milk, or in any mucilaginous fluid ;
 but  if these  are  not immediately to be procu-
 red, finely-powdered chalk, whiting,  common
 soap or soda should be substituted, and taken
 in milk,  or in water, or in oleaginous  or muci-
 laginous fluids, according as either may be in
 instant readiness.   The  success  of treatment
 entirely depends  upon the rapidity  with which
 the  antidote is administered.  Oleaginous and
 mucilaginous fluids should be  freely  adminis-
 tered.   Linseed  or olive  oil, linseed tea, gruel,
 milk, [flour  and  water], are severally  of use
 when they can be swallowed, either alone or
 as the vehicles of the antidotes just named.
   153. If swallowing be impossible, owing both
 to the constriction and to the tumefaction and
 irritability of the pharynx and oesophagus, the
 propriety of introducing the remedies now  men-
 tioned by  the tube of the stomach-pump into
 the stomach  should be considered.  The tume-
 faction of the coats of these passages, the cor-
 rosion and softening  they have  experienced,
 and their partial detachment, and the frequent
 recurrence of severe singultus, are often  such
 as almost to preclude  the  introduction of the
 tube, and to risk perforation of the canal in the
 attempt.   Orfila, in 1817, recommended  a re-
 course to  the stomach-pump, which, however,
 was first proposed  by Boerhaave, and strongly
 advised  by Renault and Dupuytren  shortly
 before the recommendation of Orfila.  But,
 although thus approved  of, this apparatus ap-
 pears never to have been brought into use until
  * The plan of my work and  my limits  prevent me from
 entering upon the chemical analysis and tests of the several
 poisons.  If  these several topics cannot he fully discussed
 with reference  to the states, combinations, &c, in  which
 poisons should be investigated by the medical jurist,  and to
 the various objections which may be urged against certain
 methods of analysis and tests, in ever varying circumstan-
 ces, they should be entirely relinquished ; and it is prefer-
 able that the reader should consult either of the able pro-
 ductions of Beck, Christison, Orfila, Devergie, Tay-
 lor, aud Guy, as to these matters, than that I should give
 an insufficient account of them ; and to such an account
 my limits  must necessarily have confined me.
  [The American reader will have little cause to regret the
 omission of this part  of toxicology, inasmuch as the  works
 of Taylor, Beck, and Guy are in almost every medical
 library.  The editor would particularly recommend the re-
 cent work of Taylor on Poisons, as containing everything
 needed or  known on this important branch of medicine.]
  [J The following case is reported by Dr. Toothaker,
in the Boston Med. and Surg. Journal, vol. xv., p. 270.
An ounce of the officinal muriatic acid was swallowed by
mistake, and immediately succeeded by violent burning of
the mouth and fauces, a sense of suffocation, and spasms.
Olive oil was given, followed by milk and water, thickened
with calcined magnesia.  Copious vomiting succeeded.  An
emetic was  next administered, and  this  again followed by
magnesia.  The strength was greatly reduced, and the ex-
tremities so cold as to require the application of sinapisms.
The next day there was pain and costiveness, hut these
were  relieved l.v a dose of castor oil.  After this, the pa-
tient rraduully recovered, although not without subsequent
symptoms consequent upon the action of the corrosive sub-
stanc x Lien he had taken.] 
378
POISONS—Corrosive—Oxalic Acid.
 1822, when its utility  was demonstrated  by
 the practitioners mentioned above (y 100 )  It
 is obvious that the prospect of having recourse
 to it with advantage, in the circumstances now
 under consideration, must depend upon the pe-
 culiarities of the case, and the acumen and dex-
 terity of the surgeon.
   154. When  the larynx is affected, causing
 lifficulty of breathing approaching to  suffoca-
 tion, tracheotomy  should be performed ;  nor
 should this operation  be then delayed,  as pro-
 longed difficulty of breathing causes more or
 less congestion of the lungs a"nd bronchial mem-
 brane, which always accelerates a fatal issue,
 which  issue the  lesions of the stomach and
 oesophagus might  not otherwise have produced.
   155. Having neutralized the acid, our chief
 endeavours should be* .next directed to  the re-
 moval of the effects which may be inferred to
 have been produced by it.  Mucilaginous fluids,
 almond or spermaceti emulsions, gruel, decoc-
 tion of marsh-mallows, gum-water, sugared wa-
 ter, thin broths, especially veal  broths and jel-
 lies,  may be severally given, and warm baths
 may be  allowed.  If the patient complain  of
 colicky pains, ofdysuria.or of tenesmus, starch,
 or other demulcent and oleaginous enemata,
 especially those with olive oil, with gruel or
 with veal or mutton broths, &c, should be ad-
 ministered  from time to time ;  for, under any
 circumstance of the case, these enemata will
 be of service.
   156.  The  symptoms  of  pharyngitis, or  of
 oesophagitis, or  of gastritis, or of the association
 of these  affections, which frequently continue
 until either a  fatal  issue or recovery results,
 should be treated  conformably with the princi-
 ples advised for these maladies.  But generally
 the amount of vascular depletions required for
 the idiopathic sthenic inflammations of the ali-
 mentary canal is  not  required  after poisoning
by these strong acids. The frame has received
both a severe injury of its violent organs and a
 violent shock; and  the  former generally pre-
vents the reaction usually consequent upon the
latter.   Hence venesection may not  be re
 nuired, or it may even be dangerous ; the habit
 jf body, strength, age, and circumstances of
 the case, in connexion with the degree and
 character of existing vascular action, being the
 guides to the adoption either of this practice or
of moderate local depletions, or merely of emol-
lients, of demulcent broths, of mucilaginous di-
luents, of gelatinous and farinaceous articles,
and of external derivatives.
   157.  The irritability of the stomach, and the
spasms and pains  of the  voluntary muscles and
extremities which often  continue for  several
days, both in cases which recover and in those
which end fatally—these  pains and  spasms
being caused by the injury and irritation sus-
tained by the  visceral or ganglial nerves, the
morbid conditions of  these nerves being ex-
 tended to the  sensory  nerves, and reflected
 upon the  voluntary muscles by the  motory
nerves—are among the most distressing symp-
 toms which are afterward experienced, and are
 alleviated with the greatest difficulty.  In these
circumstances, emollient and tonic substances
 may  be  given  in small and frequent doses,
 vith opium or the tinctura camphorae composi-
 a ; or the simple infusion of roses may be pre-
 .cribed, with tinctura opii; or the compound
tragacanth powder, with the pulvis cretae com
positus cum  opio, &c. ; and warm terebinthi-
nate epithems  or embrocations  should  be re-
peatedly applied to the abdomen.  Nourishment
of a  mucilaginous, gelatinous,  or demulcent
kind should be  taken  in small quantity  and at
short intervals ; and if deglutition continue dif-
ficult,  strong broths   and  animal  decoctions
ought to be administered  per anum.  For this
latter important and sometimes fatal affection,
the emollient linctuses and other means rec-
ommended for  acute and chronic inflammations
and stricture of the asophagus (art. (Esophagus,
y 43, et seq.), may be appropriately had recourse
to.   (See, also,  Stomach, Diseases of)
  [We have  treated three cases of poisoning
by sulphuric  acid, two of which died and one
recovered. The poison was drank from  a vial,
by accident in  every  case,  and the quantity
swallowed from one to three drachms.   The
symptoms were those detailed above.   Death
occurred  in one  case from the inflammation
extending down the trachea, causing all the
symptoms of croup, and causing death by suf-
focation, about the 5th of August.   In the oth-
er fatal case, death occurred on  the third day,
from acute gastritis.  In the case of recovery,
alkalies, as whiting, with abundance of muci-
lage, were freely and early administered.]
  158. s. Sulphate of Indigo.—Poisoning by this
substance  is  chiefly accidental.   Mr. Taylor
has observed that, as this compound is nothing
more than a solution of indigo in sulphuric acid,
the symptoms  and post-mortem appearances
caused by it are the same as those which have
been described  as produced by the latter sub-
stance.   Poisoning by it  may  be suspected
when, with these symptoms, the internal  sur-
face  of the mouth has  a blue colour, the vom-
ited matters also  having a deep  blue tint.  In
two instances, in which about an  ounce each
was swallowed, death took place: in one case,
eleven hours afterward, and in the other  in
seven hours and a half. It was remarked that
the urine which was passed had a bluish linge,
indicating  the absorption of some  portion of
this compound into the circulation.  The treat-
ment of poisoning by the sulphate of indigo is
not different from that  directed for the effects
of the mineral acids.
  159. C.  Oxalic .\cid.—Poisoning by this acid
is generally accidental or suicidal. Of nineteen
cases of poisoning by this substance in the cor-
oners' return for 1837 and  1S38, fourteen were
suicidal.  Owing to the resemblance of this acid
to Epsom salts, it has sometimes  been  taken
for them.   Mr. Taylor thinks that its intense-
ly acid taste prevents it from being often used
with criminal intentions, although he has known
several  instances of murder having been at-
tempted by it.
  1t30. a.  The symptoms are immediate, and so
intense as often to have destroyed life before
the  arrival of the practitioner.   If the poison
be taken in large quantity—from half an ounce
to an ounce dissolved in water—a burning acid
sensation  is  felt in the fauces,  throat,  and
oesophagus, followed immediately by vomiting.
In some instances the  impression  of the acid
on the stomach  has been so intense as to para-
lyze this viscus. and the parts associated with
it in  the act, and little  or no vomiting has oc-
curred, death, however, rapidly taking place ; 
POISONS-^Corrosive—Oxalic Acid.
379
in other cases,  the  vomiting has been inces-
sant until death.   The vomited matters are in-
tensely acid, and have a green, or nearly black,
colour, consisting of the alimentary substan-
ces, and  afterward  chiefly of altered  mucus
and blood.  Extreme  anxiety, pain, and  ten-
derness are felt at the epigastrium ; and often,
in both, hypochondria, followed by spasms, sin-
gultus, convulsions, collapse of  the features,
and of all the vital actions, by clammy  perspi-
rations and cold extremities.  A-Utending these
there are  often, also, stupor, unconsciousness,
a small, irregular, and  almost imperceptible
pulse, deep and slow respiration,  numbness of
the limbs, and death.
   161. In smaller quantity, and in somewhat
greater dilution,  the sensation of acidity, of
burning in the throat, and the vomiting varies
accordingly.  Should the patient survive some
time, owing either to the quantity of the poi-
son taken, to the presence of food in the stom-
 ach, or to the discharge of the greater portion
of the acid by vomiting, soreness  and constric-
tion of the throat, painful and difficult degluti-
 tion, irritability of the stomach, thirst, tender-
 ness at the  epigastrium, hiccough,  diarrhcea,
flatulence, and great depression of the vital pow-
 ers are the most  constant symptoms.  Sore-
ness of the mouth, swelling of the tongue, and
 numbness and tingling of the limbs, are often
 also experienced ;  the patient either dying  after
 two, three, or several days, or slowly and  alto-
 gether recovering.   But  recovery is generally
 attended and followed by more or less disor-
der, or tendency to  disorder, of the digestive
organs.
   162. b.  The quantity of oxalic acid which  may
destroy a human life has not been determined.
The immediate rejection or the retention of the
poison by the stomach, and the promptness or
absence of medical aid, necessarily determine
the result.  Mr.  Semple  recorded a case in
which two drachms, dissolved in water, were
swallowed.  Vomiting took place immediately,
and the symptoms had nearly disappeared in
about twelve hours.  A man swallowed three
drachms; vomiting instantly occurred,  and he
recovered in  a few hours.  A girl is stated by
Dr. Babinoton,  of Coleraine, to have taken
forty grains :  severe symptoms of gastric irri-
tation supervened;  but  although, as  in the
other cases, medical aid was procured,  the re-
covery was protracted.   Mr. Taylor  states,
that a smaller dose than  half an ounce  gener-
ally has not been fatal; although  it may be in-
ferred, from the  very dangerous effects  caused
by much smaller quantities, that much less  than
this may destroy life, if judicious  treatment be
not resorted to.   When the dose of this poison
is upward of half an ounce, death is common-
ly the result; but instances  of recovery  have
occurred where the quantity was much greater
than  this, and  judicious  treatment  has  been
promptly administered.
   163. c.  The period at which death may take
place varies  with the circumstances  already
alluded to.  Dr.  Christison mentions  a  case
where an ounce of this poison killed a girl in
thirty minutes, and  another where  the same
quantity was fatal in ten minutes, this being
the shortest period on record.  When the  dose
is half an ounce, or upward, death commonly
takes place within an hour  or two.  But in-
stances have occurred in which life has been
prolonged for thirteen or fourteen hours.  Mr.
Frazer has recorded a  case which was  pro-
longed to  twenty-three  days; irritability of
stomach, singultus, fever, and exhaustion being
the prominent symptoms.
  164. d. Appearances after Death.—The mucous
membrane  of the mouth, fauces, and oesopha-
gus is usually white ; but it is sometimes par-
tially covered  by the dark  matters  discharged
by the stomach.   This membrane may be read-
ily detached in these situations, as well as in
the stomach.  This organ  is commonly much
softened and pulpy, and contains a dark-brown,
acid liquid resembling coffee-grounds, from the
admixture of altered blood with it.   Blood-ves-
sels are  seen  ramified  distended by coagula-
ted, black blood.  In a case where  nearly two
ounces were taken, and death was rapid, the
coats of the stomach presented nearly as  car-
bonized an appearance as  that occasioned by
sulphuric acid.   The oesophagus presents sim-
ilar changes.   It is generally pale, seems as if
boiled in water,  and  its inner membrane is
raised in longitudinal rugae or folds, interrupted
by patches of abrasion.   The upper portions of
the intestines, especially the duodenum, are
sometimes  slightly  inflamed or softened, but
they are not otherwise remarkably altered.   In
Mr. Frazer's case, in which life was prolonged
twenty-three days, the villous coat of the stom-
ach and gullet was either softened or entirely
detached.   The muscular coat was  exposed in
several places, and was thickened, softened,
injected, and  inflamed.  This acid  has  not so
corrosive an action on the coats of the stom-
ach as the strong mineral acids, as it  rarely
entirely perforates these coats, although it soft-
ens them and destroys their physical as well as
vital cohesion.   In  some  instances  the inner
surface of the trachea has been found inflam-
ed, owing to its anatomical connexion with the
oesophagus.  In  a few cases the lesions have
been very slight, although the symptoms were
severe ; but little beyond softening of the coats
of the stomach having been remarked.
  165. e. Death is the result of the corrosive
action of this acid upon the organization of the
upper portions of the digestive canal, especial-
ly of the stomach, the nerves of the organ be-
ing more particularly affected.  But the  opera-
tion of this poison  is thus limited  only when
large doses of it are taken, and then the local
injury and disorganization and consequent vital
shock are sufficient  to destroy life.   It has not
been found to affect the larynx so as to threaten
suffocation.  When swallowed in smaller quan-
tity, or in states of dilution, it is manifestly ab-
sorbed, and acts upon the nervous system  and
on  the  blood  (y  25,  et seq).  Much of the
change observed, both in  the tissues of the
stomach and in the blood, in cases of rapid  poi-
soning by this substance, has arisen from the
action of such portions  of  it as have still re-
mained in,  or been imbibed by the  stomach at
the time of death,  the changes found  on in-
spection having been partly thus produced post-
mortem.
  [Dr. C. T. Jackson has reported an interest-
ing case of poisoning by oxalic acid, in the thir-
tieth volume of the Boston Med. and Surgical
Journal, p. 17.  A man, aged 30, took, February
1st. at half past eight A.M., about one third of a 
380                       POISONS—Corrosive—Alkalies.
tea-cupful, or about one ounce, of the crystal-
lized oxalic acid, mistaking it for Epsom salts.
He immediately perceived, by the  strong acid
taste, burning sensation in the throat, &c , that
he  had made a mistake, and  he immediately
drank a large quantity of warm water to ex-
cite vomiting, which produced the desired ef-
fect.  He also took ipecacuanha by the advice of
a physician.  This was followed by antimony in
emetic doses, and castor oil.   When  called at
half past eight P.M., Dr. J. found him in a state
of complete prostration ;  face, lips, throat, and
tongue swollen  and livid ; pulse almost extinct,
fluttering, and irregular; heart, in a continual
fluttering palpitation ;  great jactitation and dis-
tress, with  incessant vomiting.   The matter
evacuated by vomiting was a  thick,  grumous,
and jelly-like fluid, of a yellow  colour, mixed
with white flocculi.   He complained of no pain
at the epigastrium, or over the bowels, on pres-
sure,  but  the distress  and anxiety were very
great.   The matter first  brought up  by vomit-
ing was of a dark chocolate colour.  Dr. J. or-
dered carb. lime, siij., mixed with camphor and
opium, five grains: this was  given in divided
doses, but rejected ; an enema of soap and wa-
ter was also  given.   February 2d. face tumid,
and of a livid colour ; tongue swollen and livid,
pulse  130 ; urine entirely suppressed ; gave an
infusion of salts and senna;  vomiting contin-
ued for two or  three days, with  great distress
and anxiety; tongue  became  covered with a
brown coat, with a red, dry tip; great thirst,
no  pain.  The  case  was  treated  like one of
gastritis, with general and local bleeding, mor-
phia, &c.   On the 6th, his mind began to wan-
der, and petechiae appeared on the face, head,
chest, nates, &c., appearing as if sprinkled with
blood.   He continued to fail, and  died on the
10th, ten days after taking the poison.
  Post-mortem  Examination.—Muscles rigidly
contracted ; numerous petechiae ;  emphysema
of lower lobe of left lung ;  unusual infiltration
of serum in lungs ; left side of heart empty of
blood ; the right contained a  small  quantity;
gall-bladder distended with yellow bile; stom-
ach contained a yellow fluid, evidently coloured
with bile;  stomach remarkably corrugated; mu-
cous membrane very bright red, especially in
small curvature of the organ  and around the
cardiac orifice; numerous small ulcers in the
mucous membrane, which was much thickened
and soft;  the mucous surface  of the duodenum
was red, and also thickened, and studded with
ulcers ; also that of the jejunum and iiium con-
gested ; Peyer's glands not enlarged ;  small in-
testines contained soft, yellow, fluid faecal mat-
ter ; the large intestines contained scybalae of
faecal  matter;  mucous  membrane   healthy;
spleen natural; bladder contained some urine.]
  166. /. Treatment.—The antidotes against this
poison should be most promptly resorted  to.
The best  are chalk, calcined magnesia, or the
carbonate of magnesia.  These should be abun-
dantly mixed in water, or milk, or  in any olea-
ginous  or  demulcent fluid instantly  at  hand.
Lime-water  and  oil may also he given.  As
chalk is the  best antidote, Dr. Christison ad-
vises that even the  plaster of the apartment
should be hroken down in order to be given ;
but it would be difficult to reduce the plaster
in a very short time  to a powder sufficiently
fine to  admit of admixture, and of deglutition
in the existing state of the patient.   Free dilu-
tion—copious draughts of demulcents, emoll-
ient decoctions, dec, are generally of use ; but
they should be given in large quantities,  and
their rejection, by irritating the  fauces, should
be encouraged.  If dilution be not free and fre-
quent, it may be injurious, by  dissolving  the
poison  and by favouring  its absorption.   If
vomiting can  be  produced after the  antidotes
and much  fluid have been taken, it should be
encouraged by means of oleaginous and emoll-
ient fluids; but recourse to the  stomach-pump
is of doubtful efficacy, as it may  injure, or even
perforate the softened coats of the oesophagus
and stomach.  When it can  be  easily introdu-
ced, and when there is little or no singultus,
antidotes and demulcent fluids having been al-
ready freely swallowed, then  it may be of use,
if vomiting does not take place, for the removal
of the contents of the stomach,  and for the in-
troduction of remedial agents when deglutition
cannot be accomplished.  But it should not be
overlooked that  the  pharynx  and gullet have
sustained nearly as great an injury as the stom-
ach, and that the  too early use of this appara-
tus w ill prevent the antidotes and other medi-
cinal substances  which  should  be  swallowed
from  exerting  a salutary effect  upon those
parts.  As the salts which the alkalies form with
oxalic  acid are as injurious as this acid itself,
neither the alkalies nor their carbonates should
be given after poisoning with it.   The consec-
utive effects of this substance should be treat-
ed as those of other corrosive  poisons, or  as
the operation of this acid requires when given
in small or diluted doses, and when acting as
will hereafter be shown.  (See next Class )
  167. ii. Alkalies.—Ammonia, potash, soda, and
their carbonates—pearlash, soap lees.—a. The va-
pour of strong ammonia may rapidly destroy life,
when inhaled, by producing acute inflammation
of the  larynx and trachea, often extending  to
the bronchi and lungs, and all the symptoms of
violent croup.  When ammonia is held too near
the nostrils to rouse persons from syncope, its
vapour may act more or less as an irritant of
the respiratory mucous surfaces, and be injuri-
ous not only in this way, but  also in as far  as
it prevents a  due supply of air to the lungs.
  168.  b. The symptoms occasioned by the fixed
alkalies, when taken  in large quantities,  are
nearly the same  as  respects the caustic states
of these alkalies ; the subcarbonates and  car-
bonates being more mild in   their  operation.
Poisoning  by these   substances is  generally
caused by accident.  When the caustic alkalies
are swallowed, an acrid, corroding taste  and
pain, with a sensation of burning and excoria-
tion, are felt in  the  mouth and  throat; these
latter sensations proceeding along the oesopha-
gus to the stomach and epigastrium.   Vomiting
often occurs, and the matters thrown off usu-
ally consist of soft substances, resembling the
softened, detached portions of the villous tis-
sue, with mucus, often  mixed with dark, dis-
coloured blood, and  with  alimentary  articles
more or less altered, in the first  instance.
Both these and other associated symptoms vary
with the concentration and quantity of the alka-
li ;  but vital depression soon appears.   The
mouth, tongue, and throat  present a tumefied,
soft, flabby, and inflamed appearance ; the sur-
face becomes cold and clammy; the pulse feeble, 
POISONS—Corrosive—Alkalies.
381
small, and quick;  singultus  is often present;
the pain extends  to the  central and lower re-
gions  of the abdomen,  and  diarrhcea super-
venes and  becomes  urgent  and exhausting.
The symptoms are somewhat less severe when
the carbonates have been  taken,  unless the
dose of these has been very large and the solu-
tion very strong.
   169. c. Ammonia and its sesquicarbonate pro-
duces nearly the same symptoms as the fixed
alkalies; the chief differences being, that strong
solutions of the former  occasion a more vio-
lent  burning pain  in the  fauces, oesophagus,
and stomach than the latter, the larynx being
oftener  implicated.   But  poisoning  by ammo-
nia is not common, cases of it occurring chiefly
by mistake, which is most frequently discover-
fid before much of it is  swallowed; and then
 the  fauces,  pharynx, larynx, and  oesophagus
 are severally more  or less affected, according
 to the strength of  the solution.  Ammonia is
 not so productive of  vomiting as the  fixed al-
 kalies, when  taken  in  poisonous doses, the
 symptoms being more closely allied to  those of
 gastritis, associated with enteritis and oesopha-
 gitis ; and it seldom occasions diarrhcea.  In
 ;he more concentrated states ammonia also oc-
 jasions singultus and convulsions.
   170. d. The quantity required  of  these  sub-
 stances to  produce  death  necessarily varies
 vith the  concentration  of  the  solution, and
 •pith the state of the stomach as respects the
 juantity of aliments in  it, and other circum-
 stances.  The  caustic alkalies  are  fatal  in
 si.ialler quantity and  in less time than the car-
 bonates and the preparations  of ammonia.   Or-
 fila  adduces two instances in which half an
 ounce of  the  carbonate  of potash was fatal,
 the patients having lingered for several months.
 The exact quantity, however, cannot be assign-
 ed ; for a comparatively small one, if the alkali
 be caustic, or if it implicate the larynx, may be
 rapidly  fatal.
   171.  e. The duration of the symptoms, or pe-
 riod which usually elapses until  death occurs,
 maybe very short, especially as respects the
 caustic alkalies.   Mr. Taylor estimates  the
 shortest period at three hours ; and in  this case
 death was  caused by three ounces of a strong
 solution of the  carbonate of potash.   When
 the  substance attacks the larynx, as often oc-
 curs in  respect of the mineral acids, this period
 will also be short.   The more immediate effects
 of the caustic alkalies usually terminate fatally
 in two or three days ; the softening and disor-
 ganization of the villous  surface of the digest-
 ive canal, and the arrest of circulation in the
 vessels supplying this canal, terminating life in
 a very few days, and even in a shorter time, if
 the extent of injury  be such as to occasion se-
 vere vital shocks in addition.  When the injury
 is less, or the vital resistance to it greater, the
 patient may linger for weeks, or even months;
 the solution, abrasion, or excoriation of the vil-
 lous surface of the stomach, and of other parts
 of the canal,  being attended by pain and ten-
 derness in the hypochondria and other regions
 of the abdomen, with vomitings, anorexia, in-
 digestion,  diarrhoea,  and often,  also,  with dif-
 ficult or nearly impossible deglutition.  Owing
 to the injury or destruction of the digestive vil-
 lous surface, digestion and assimilation are im-
 paired or arrested, and  the  patient sinks from
the inanition thus occasioned by the local inju-
ry ; whatever amount of absorption of the poison
may have taken  place into the circulation, in
cases where the substance has been more dilu-
ted, and the local injury less, acting a very sub-
ordinate part in producing the ultimate result.
   172. /. The appearances after  death  consist
chiefly of a diffluent softening, abrasion, or de-
tachment  of large portions of  the villous sur-
face of the fauces,  pharynx,  oesophagus, and
stomach ;  and sometimes  also of parts of the
duodenum  and intestines.  The internal sur-
face of the canal, especially of the  stomach,
presents a  chocolate colour; and  the contents
are fluid, viscid,  and often dark  from  the ad-
mixture of exuded blood.   The softening of the
coats of the stomach sometimes extends to all/
the coats,  but especially to the more internal;
and much resembles the  gelatinous  softening
met with in the stomach in .rare instances, and
attributed to the action of the gastric juices
after death (see y 84-87);  but there have been
more tumefaction and darker discoloration in
the poisoning now being  considered.  When
death has  been  produced  by ammonia or  its
sesquicarbonate, the softening and tumefaction
have  been  attended by signs  of inflammation
and excoriation, inflammatory appearances ex-
isting also  in the trachea and larynx.
   173. g.  Of  the action  of the  alkalies and
their carbonates it  may be concluded that, in
their  concentrated  states, in  large quantities
they are fatal chiefly by their  local action, in
the way stated above (y 171, 172);  and that, in
weaker forms or  in small  doses, they are  more
or less absorbed,  as  demonstrated by the  com-
position of the  urine and other  secretions;
but they are generally eliminated by the emunc-
tories before they accumulate in the blood to a
very injurious amount.*
   174. h.  The treatment of the  alkaline poisons
consists in the immediate exhibition of fluids
containing vinegar, or any of the vegetable acids
which may be obtained with the least delay.
If any of these be not quite at hand, draughts
of beer or of malt liquors  ; or demulcents with
oil, or milk, gruel, &c, may be taken until  these
acids are procured.  A tepid infusion of cham-
omile flowers is afterward of use  in promoting
vomiting, and it may be given  with or  without
moderate doses of the sulphate of zinc.  The
stomach-pump may be more injurious than ben-
eficial, especially if the caustic  fixed  alkalies
have been taken, for the tumefaction and soft-
ening of the coats of the  oesophagus and stom-
ach are often so great as to render it difficult
to introduce the tube without causing lacera-
tion or injury.
   The treatment of the secondary effects  of
these poisons consists chiefly in removing the
effects which may be  inferred  from the symp-
toms  still  to continue.  At first demulcents,
oleaginous and  emollient substances,  may be
administered, and afterward gelatinous and far-
  * When injected into the veins, Orfila believed that the
alkalies caused death by coagulating the blood. I find it
remarked in my note-book, when detailing some experi-
ments with the alkalies, in which I was concerned in 1820,
that "the alkalies and their carbonates, when injected into
the veins, appear to u<#troy life by impairing organic ner-
vous energy, the irritability of the heart, and the functions
of the brain, and by their influence on the nervous masses
and structures while circulating in the blood-vessels and
capillaries." 
332
POISONS—Corrosive—Iodine and Bromine.
inaceous articles of food in small quantities
may be given.  An attempt may be made, with
caution, to restore the tone of the villous  sur-
face, by giving small doses of creasote with de-
mulcents, or of the pyroligneous acetic acid, or
the compound infusion of roses with small do-
ses of quinine, or of the sulphate of zinc, or such
of the tonic and astringent infusions or decoc-
tions as  may be found to agree the  best with
the stomach.   When the difficulty of swallow-
ing and continued irritability of the stomach
excite fears of abrasions of the villous coat of
the digestive canal,  and if diarrhcea warrant
the supposition that this lesion extends as low
as portions of the  intestinal tube, then astrin-
gents and tonics, vegetable  or mineral, as ei-
ther appears most  appropriate, should be given
in small but frequent doses, with small quanti-
ties of opium, in demulcent  and emollient ve-
hicles.   By attempting to support vital power
by suitable means, and to restore the tone of
those parts of the villous surface which have
been the least injured, nature will thereby be the
better able to reproduce in some  measure the
abraded portions, or in some way to supply their
functions.  In  other  respects the treatment,
the diet, and the  regimen should be adapted
to the features of particular cases, with a care-
ful observation of the juvantia and ladentta
   175.  iii.  Antimony—Chloride  ok.—Butter
of Antimony.—This is the only preparation of
antimony which I shall  notice as a corrosive
poison;  the other preparations of this metal
being more or less absorbed, and acting other-
wise on the system.  The chloride,  as  usually
employed, is a very corrosive liquid, varying in
colour, according to the quantity of iron it con-
tains, from a light yellow to a dark red.  Poi-
soning rarely occurs from  it.  Mr  Taylor,
however, refers to three cases which have been
recently  recorded: two were  caused by mis-
take, one intentionally;   and  in this last be-
tween  two and  three ounces  of this solution
were swallowed.
   176.  a.  The  Symptoms were in  many re-
spects  the same as those described above as
being caused by the caustic alkalies:  a burn-
ing pain in the throat, course of the oesopha-
gus, and stomach ; constant efforts to vomit;
collapse  of the features, coldness of the sur-
face and extremities, and faintness; a small,
weak, and frequent pulse; pains in the abdo-
men, with tenesmus, but no evacuations.  To
these succeeded drowsiness, convulsions, and,
in the  suicidal  case, death in  ten and a half
hours.   The  two  accidental cases recovered,
much smaller quantities  of the poison having
been taken.
   177.  b.  On inspection after death,  the  fatal
case presented the internal surface of the di-
gestive canal, from the mouth to the jejunum,
of a black and charred appearance.   The  mu-
cous membrane  was destroyed throughout this
extent: "there was none of this membrane, in
general, remaining, only a flocculent substance,
which could be easily scraped off with the back
of the scalpel."   The subjacent coats were so
soft as to be torn with the greatest ease.
   178.  c. The treatment should consist chiefly
of  copious draughts  of  water, or  emollients
and demulcents containing  sugar,  and,  after
free vomiting has been procured, with opium or
sirup of poppies.  If vomiting does not imme-
 diately follow the ingestion of this poison, Or-
 fila recommends that a decoction of cincho-
 na, or of willow or oak bark, or of powdered
 gall-nuts, should be freely taken as soon as pos-
 sible.  The treatment of this poison does  not
 differ from that  advised for the fixed alkalies
 as respects either these substances or those
 mentioned under that head.   See, also, the prep-
 arations of antimony  in Class v.—.\cro-seda-
 tive Poisons.
    179.  iv. Iodine and Bromine.—A. a. Iollint
 acts differently on the economy, according to
 the concentration of the tincture or solution of
 it  which may be used.  In a state of strong
 spirituous or ethereal solution it acts as a pow-
 erful corrosive of the tissues to which  it may
 be applied ;  but in weaker solutions, and in va-
 rious states of  combination, it  is  much less
 corrosive, or is merely an irritant, and is more
 or less copiously absorbed into the circulation.
 In these states it acts as an irritant  and alter-
 ative, or aero-alterative poison, in which class I
 have considered it and its preparations.
    180.  b. The fumes  of iodine, when inhaled,
 produce a violently irritating effect upon the
 respiratory passages, especially the larynx and
 trachea-  If the  vapour is concentrated, it oc-
 casions  constrictive  irritation  and inflamma-
 tion of these parts, which may be followed by
 asphyxia.   In  milder states it occasions  in-
 flammation of the air-passages,  with or with-
 out pneumonia.   I have  seen more than one
 case in which the vapour of  iodine had been
 resorted to in the treatment of pulmonary con-
 sumption,  with the effect of producing danger-
 ous bronchitis,  owing to  the strength of the
 vapour which had been inhaled.
   181. c. Applied externally, iodine,  in a con-
 centrated or pure state, or in that of a strong
 tincture, acts as a caustic, and changes the cu-
 ticle to an orange-yellow colour, causing des-
 quamation, and,  if allowed to remain, inflam-
 mation  and destruction  of the  tissue with
 which it comes in contact.  In weaker states
 of solution it acts as a desiccant of secreting
 or mucous surfaces, and inflames them more
 or less  intensely.  Hence,  if  injected, even
 in  these states,  into  mucous canals, or taken
 into the stomach, it would act as an  acrid cor-
 rosive poison.
    182.  d.  When iodine  is  swallowed in  a more
 or less  pure or concentrated form, it produces
 the most violent sufferings, especially if the
 quantity be large ; but the effects vary remark-
 ably with the state and contents of  the stom-
 ach at the time of its ingestion ; for if this vis-
 cus contain much bread,  potatoes, or farina-
 ceous or amylaceous articles of food, the iodine
 will be thereby rendered much milder in action
 by forming an iodide  of starch, as Dr. Pereira
 has remarked.  Spirituous solutions of iodine,
 or the iodureted solutions of the iodide of po-
 tassium,  when   swallowed  in  more or less
 strong  or  concentrated forms, cause a most
 acrid sensation, with constriction, burning pain,
 and dryness of  the throat,  descending down
 the oesophagus to the stomach,  where they
 produce lacerating pains and efforts  to vomit,
 extreme thirst, tenderness of the epigastrium,
 with anxiety, tremours, loss of strength, palpi-
 tations,  faintness, sinking  of the  pulse, suffu-
 sion of the eyes, and restlessness.   Dr. Jahu
1 mentions a case in which an  over-dose occa- 
POISONS—Corrosive—Iodine and Bromine—Lime—Phosphorus.          383
sioned violent pain in the abdomen, vomiting,
profuse bloody diarrhcea, coldness  and blanch-
ing of the skin, rigours, rapid pulse, &c.   In a
case noticed by Dr. Christison, a  drachm and
a half of the iodureted  solution of the iodide
of potassium produced acute pain  and burning
In the pit of the stomach, nausea,  followed by
vomiting of yellowish matters, which had the
taste of iodine ; by restlessness, headache, gid-
diness, and pallor of the countenance ; and by
recovery after five days.  In a fatal case re-
corded by Zink (Journ. Comp., t. xviii., p. 126),
the symptoms were restlessness, burning  heat
and  dryness  felt from  the  throat along the
course of the oesophagus to the stomach, un-
quenchable thirst, palpitations,  and a  frequent,
unequal, and weak pulse, violent priapism, co-
pious diarrhoea, parched tongue, tremours, and
faintness.  The patient  was bled ; the blood
was cupped and buffed.  He  died after  five
weeks.  In another case, in which  the tincture
of iodine caused slow poisoning and death, M.
Zink found the  following lesions :
   183. c. Appearances after Death.—The intes-
tines were distended with gases ; effusion had
taken place into the peritoneum; and adhe-
sions had formed between several of the vis-
cera.  The gullet was much reddened internal-
ly, and remarkably constricted.  The stomach
was distended, and was externally inflamed in
patches, and in one place apparently excoriated.
It was inflamed internally, and corroded  to a
great extent  near  to the pylorus; the perito-
neum covering the corroded part was  detached
 and perforated  with numerous small holes.
 The intestines were reddened  and  inflamed in
 places with patches approaching to sphacela-
tion.  The liver was enlarged,  and of pale red
 or rose colour.   The gall-bladder  contained a
 large biliary calculus.  The spleen seemed in-
 flamed in some places.   The pleura contained
 some serum.
   184. /.  The quantity of this poison required
 to destroy life depends upon the concentration
 of the solution employed, and  the nature and
 quantity of the aliments in the stomach. When
 the iodine is pure or in large quantity, in what-
 ever state it may be employed,  it acts as a cor-
 rosive or caustic poison, causing  death by its
 local action.   In states of weaker solution, or
 in combinations which weaken its  action, or in
 small doses often  repeated, it produces  sloio
poisoning, as will be shown hereafter.  It is then
 absorbed, and it accumulates in the  system, pro-
 ducing emaciation and various morbid changes.
 The quantity required or the time taken to pro-
 duce death has rarely been remarked in respect
 of this poison.   Dr. Gardner states that a
 scruple of pure iodine, in the form of tincture,
 destroyed a child  four  years of age  in a few
 hours.
   185. g. The treatment of the more  corrosive
states in which iodine may be given is not sat-
isfactory.  The stomach-pump should be early
employed, and vomiting encouraged by giving
fluids containing amylaceous  and  farinaceous
substances.  Starch enemata  should also be
thrown up, and demulcents taken frequently.
[Irritation should  be relieved by opiates.] In
other respects  the  treatment should be  the
same as recommended for gastritis.
   186 B.  Bromine is  but  little  known  as a
poison   Its vapour is  most  irritating when
brought in contact with the conjunctiva.—a.
When its vapour  is inhaled, violent cough, a
feeling of suffocation,  with dryness and con-
striction of the larynx, are occasioned, and are
soon  followed  either by inflammation of the
respiratory passages, or by  asphyxia.  Franz
had violent cough and sense of suffocation, fol-
lowed by headache, instantly after momentari-
ly breathing the vapour of bromine.
  187. b. When a watery solution is injected into
theveins, according to the experiments of Franz,
Barthez, Dieffenbach, and  Butzke, it appears
to coagulate  the blood, and causes immediate
death, preceded by convulsions.
  188. c.  Taken into the stomach, it is a more
corrosive  poison even  than iodine.  Butzke,
after  Swallowing a drop and a half of this sub-
stance in  half an ounce of  water, felt heat in
the mouth, oesophagus, and  stomach, followed
by colicky pains.  Two drops occasioned nau-
sea, hiccough, and increased secretion of mu-
cus.   (See Christison on Poisons, p. 1-5, and
Pereira's  Mat. Med.,  vol.  i., p. 250.)  From
these experiments it is evident that bromine
acts in a similar way to iodine in every respect;
but that  it is poisonous in  smaller quantities
than iodine, although the symptoms and changes
produced by  it in  the  digestive canal are the
same as  those occasioned  by that substance.
The treatment is the same for both poisons.
  189. v. Lime acts as  a corrosive poison when
taken into the stomach, or applied to a vital part,
in its  caustic and unslacked state; but it is rare-
ly so  employed, even accidentally ; two cases
of this kind only being noticed by medico-legal
writers.  It is evident, from its caustic action,
that the ingestion of it, or its introduction into
mucous canals, will be followed by corrosion,
and inflammation of the tissues with which it
comes in contact.  When employed in its quick
state, it  will even  decompose  or  destroy the
structures  by imbibing their watery or fluid
constituents.
  190. a.  When swallowed,  it occasions  heat,
constriction, and pain in the throat, descending
to the stomach, with unquenchable thirst, nau-
sea,  retchings, severe  colicky pains, constipa-
tion, and the  usual symptoms of corrosive poi-
soning, followed by nearly the same changes as
have  been already described, especially inflam-
mation and corrosion of the parts with which
it had come in1 contact.
  191. b.  The treatment should be the same, as
respects' antidotes, as that advised for poisoning
by the fixed alkalies ($ 174), especially an imme-
diate  recourse  to vinegar, lemon-juice, or any
vegetable acid, and to demulcent drinks.  Sub-
sequently,  if symptoms of  gastritis, or gastro-
enteritis are developed, vascular depletions, and
the usual treatment of these diseases, should be
prescribed.
   192. vi. Phosphorus, when minutely divided,
proves a violent corrosive  poison.  According
to the experiments of Magendie and Orfila,
when it is dissolved in oil  and  injected into the
veins, it occasions  almost instantaneous inflam-
mation of the bronchi and substance of the lungs.
   193. a.  It may be taken into the stomach either
as an empirical remedy or accidentally ; but its
effects on man have not been often observed.
It was at  one time much  employed, in small
doses, in medical practice, especially as an aph-
rodisiac, and it probably occasioned dangerous 
384                      POISONS—Corrosive—Metallic Salts.
symptoms  even when thus prescribed.  It is
generally slow in its  operation,  although it is
poisonous in very small quantities, particularly
when melted in warm  water or in oil.  The
most rapidly fatal case I find  noticed is that by
Dr. Flachslaxd.   A  young man took, at  the
recommendation of a quack, some of this sub-
stance on bread and butter, to cure general  de-
bility, constipation, and impotence.  He was
immediately seized with  violent pain in  the
stomach, continual retchings, discharges after
injections that shone  in the dark;  and he died
in forty hours.  The quantity of phosphorus ta-
ken was not known.  Dr. Christison states,
that a grain and a half proved fatal in a case
which was mentioned by M. Worbe.  A stout
young man, having taken  half a  grain without
injury, took a grain  and a half  in  hot water.
Seven hours  afterward he was  attacked with
pain in the stomach and bowels, with incessant
vomiting and diarrhcea, excessive  tenderness
and tension of the belly, and died exhausted in
twelve days.  M. Julia-Fontenelle relates  the
case of an  apothecary who, after taking in one
day first one grain of phosphorus, and then two
grains, without  experiencing any effects, swal-
lowed next day three grains at  once in sirup.
In the evening  he felt generally  uneasy from a
sense of pressure and constriction in the abdo-
men, which continued for three  days, when he
was seized with violent and continual vomiting
of matters  which had an alliaceous odour.   On
the seventh day, spasms, delirium,  and palsy
of the left  hand supervened, and death speed-
ily ensued.  It  is manifest  that, if applied to
wounds, or introduced into any  of the natural
canals, the effects would  be  very violent, and
even fatal after a longer or shorter period.
  191.  b. The morbid appearances after poison-
ing with this substance have been recorded only
in the cases observed by Worbe and Flachs-
land (y 193).  In the case of the  former, where
only one grain and a half of this poison was ta-
ken, the skin was generally yellow, and livid in
places.  The lungs were gorged  with  blood.
The  muscular coat of the stomach  was infla-
med.  The other coats near the two extrem-
ities of the organ were black.  In Dr. Flachs-
land's case, much fluid blood was  discharged
on making the  first incisions.  The omentum
and external surfaces  of the stomach and intes-
tines were red.   The villous coat of the stom-
ach presented an appearance of gangrenous in-
flammation, which Dr. Christison suggests to
have been black extravasation only ; and  the
duodenum  was similarly affected.  The  large
intestines were contracted to the  size of the lit-
tle finger, and the mesenteric glands were  en-
larged.   The kidneys and spleen were inflamed.
   195. c.  Treatment.—Large  quantities of  de-
mulcent liquids should be exhibited, and  mag-
nesia given to neutralize any phosphorous and
phosphoric acids which may be formed.  Vom-
itings should be early encouraged by large mu-
cilaginous draughts y  and inflammation allayed
by general and local depletions, or  the latter
only, or both, according to the peculiarities of
the case.  Dr. Pereira advises parts burned
with phosphorus to be washed with a weak al-
kaline solution, to remove any phosphorous acid
which may perpetuate the irritation.
   196. vii. Salts, Corrosive Alkaline.—Sa-
line  Caustics.—Of the alkaline salts, the  most
 corrosive are the bichromate of potash and the bi-
 noxalate of potash.  Several other alkaline salts,
 which  have usually been arranged with corro-
 sive poisons, exert their fatal influences other-
 wise than by any corrosive effect  they produce
 on the digestive canal; this effect never amount-
 ing to  more than irritation  and inflammation,
 which  are of themselves insufficient to cause
 death in the short period sometimes observed.
   197.  A. The  bichromate of potash is  exten-
 sively used  in dyeing.  Accidents may hence
 occur from it, although it may not he resorted
 to with suicidal or criminal intentions.  In a
 case in which a strong solution of it was taken,
 burning pain in the throat, violent vomiting,
 and the other symptoms  of corrosive poisoning,
 and death in five hours,  were occasioned.  On
 examination after death, extensive destruction
 of the  mucous membrane  of the  stomach and
 small intestine was  found.  Dr. Christison re-
 marks that, when this salt was first introduced
 into the art of dyeing, the workmen, who had
 their hands frequently immersed in its solution,
 were attacked with obstinate ulcers in the parts
 touched by it, and  that these sores gradually
 extended deeper and deeper without spread-
 ing, until they actually sometimes made their
 way through the arm or hand.
   198.  B. The binoxalate of potash, when taken
 into the stomach, produces the same symptoms
 and structural lesions as have been described as
 the consequences of the ingestion of oxalic acid;
 and the treatment of instances of poisoning by
 the bichromate of potash, or  by it, differs in no
 way from what has  been advised for poisoning
 with that acid (y 166).
   199. viii. Salts—Metallic—Several of these
 salts exert a corrosive action on the living tis-
 sues ;  and, when taken into the stomach, in
 states of strong  solution or in substance, they
 destroy life chiefly in virtue of this action ; but
 in smaller doses, and in  weaker solutions, they
 act differently, are more or less abundantly ab-
 sorbed, and  produce effects  which rank them
 under certain of the  classes of poisons to be con-
 sidered in the sequel.   It is chiefly with refer-
 ence to this corrosive and local action  that I
 have here to notice  them.
   200. A. Antimony.—The several preparations
 of antimony liable  to  become poisonous, with
 the exception of the chloride (v 175), act as ir-
 ritant and depressing agents, and are therefore
 treated of in the  Class Acro-sedative poisons.
   201.  B. Bismuth—Subnitrate of—Magistery
 of Bismuth—Bismutht trisnitras.—Poisoning by
 this substance has rarely occurred.  In the ex-
 periments of Orfila, forty grains of the nitrate
 of bismuth introduced into the stomach of a dog
 produced all the symptoms of corrosive poison-
 ing, and death in twenty-four  hours ; the villous
 coat of the stomach being reduced to a pulpy
 mass, and eroded in  parts.  The subnitrate was
 found  to  produce the  same symptoms and le»
 sions as  the nitrate, but a much larger dose
 was required.
   202.  a. In a case  in which  the trisnitrate was
 taken, in  the dose of two drachms, the patient
 was immediately attacked with burning pain in
 the throat, vomiting of brown matters, purging
,of watery stools, cramps, and coldness of the
 limbs, intermitting  pulse;  followed by inflam-
 mation of the throat, difficult deglutition, a con-
 stant nauseous metallic taste, hiccough, labori- 
POISONS—Corrosive—Metallic Salts.
385
ous breathing, suppression of urine, swelling,
and tension of the  belly,  salivation, delirium,
&c.  He died on the ninth day.
  203.  b. On inspection it was found that, from
the pharynx to the rectum, there were but few
points of the digestive canal free from change
The tonsils, uvula, pharynx, and epiglottis were
gangrenous, the  larynx  spotted black, the gul-
let livid, the stomach very red, with numerous
purple pimples ;  and the whole intestinal canal
was red  and gangrenous  in  places, especially
at the  rectum.  The endocardium was bright
red.  Probably in this case there was  partial
absorption  of the salt, which had thus inflamed
the endocardium ; if, indeed, the redness was
not merely the result of post-mortem coloration.
   204. c. Treatment.—No chemical antidote is
known to this poison.  Emollient drinks should
be given abundantly, and the poison evacuated
 from the stomach  as speedily as possible  by
 means of the stomach-pump, or otherwise.  Af-
 terward demulcent  enemata ought to be  admin-
 istered.   A strictly antiphlogistic  treatment
 should be adopted,  to prevent inflammation, or
 to remove  it if it have supervened.   Opiates in
 full doses, camphor, and demulcents should also
 be exhibited.
   205.  C.  Copper—The preparations and com-
 pounds of,  are violent  poisons; but, although
 they produce an active emetic effect when  ta-
 ken into the stomach, they act  in large doses
 more upon the nervous system than locally, or
 as corrosive or caustic agents.   These prepa-
 rations have seldom been given with a  crimin-
 al intention, owing to their acrid taste, unless
 with the view of producing abortion, and with
 this object the  sulphate has  been often taken.
 Poisoning by them is most  frequently  the  re-
 sult of accident.   When  swallowed in  the lar-
 gest quantities they sometimes occasion  the
 least serious effects, owing to their instant re-
 jection by vomiting.  They, nevertheless, often
 produce, either most acute and virulent poison-
 ing, or effects which are more slowly develop-
  ed, thereby occasioning a chronic form of poi-
  soning.  Even  in  the most  acute or rapid ca-
  ses, the lesions they produce on the digestive
  canal may be the least  remarkable, while in
  the slow or chronic form these lesions may be
  severe.
    206. a.  The symptoms, as respects the digest-
  ive organs, are nearly  the same as in other in-
  stances of corrosive poisoning ;  but the vomit-
  in" is most rapid and copious, and the  rejected
  matters present a remarkably blue or green col-
  our, sometimes with minute or broken crystals
  of the salt.  Abdominal pain is  acute, and is
  attended  by  diarrhcea,  extreme anxiety,  and
  spasms of the  extremities.   Jaundice  is some-
  times met with : a symptom rarely observed in
  other  cases  of acute  or corrosive poisoning
  Stupor, coma,  insensibility, convulsions  and
  sometimes paralysis, supervene early, and ter-
  minate life in periods varying from three or four
  hours to several days.   In the  ™™ chronic
  states  these symptoms  are developed and pro-
  ceed more slowly ; the discharges present a
  raenteh  hue, especially if  verdigris have  been
  faken  and the salt may be detected  in them.
  The  digestive  canal  evinces the most severe
  disorder • vomiting, coppery eructations, saliva-
  Uon  diarrhoea, tenesmus, dysuna or suppres-
  S of urine, cramps, convulsions, prostration

      III.              25
of strength, &c ,  continuing for several days,
or until death or recovery takes place.
  207. b.  On dissection,  of the chronic cases
especially, evidences of inflammation, in vari-
ous parts  of the digestive  canal, have been
found, generally attended by softening, tume-
faction, ulceration, and more rarely with perfo-
ration of  all the coats of the tube.  These le-
sions are often more remarkable in the intes-
tines  than in the stomach.  The digestive vil-
lous membrane presents a green colour, or even
minute particles of the poison.   These lesions
are not constant; but the nervous system be-
trays, in the great majority of instances, mark-
ed  functional disorder.  Therefore,  poisoning
with  the  salts or oxides of copper will be far-
ther considered under the Class Acro-sedative
Poisons.
   208.  c. Treatment.—The chemical antidotes for
the cupreous preparations have been stated by
Dr. Pereira to be the whites of eggs, given
abundantly, or  whatever may contain most al-
bumen.  In the absence of eggs, milk or wheat-
en flour should be employed.   Iron filings  have
been proposed  by Navier, Payen,  and Chev-
alier,  and subsequently by Dumas  and Ed-
wards ; the iron decomposing the cupreous salt,
and precipitating the copper in the metallic and
inert state.  The ferrocyanide  of potassium  is
also  said to be  a good antidote ; a drachm or
two  of it may  be  taken with safety.  Sugar
 was  proposed  by M. Duval :  its efficacy, al-
 though denied  by Orfila and Vogel, has been
 recently  contended for by Postel.  (Pereira,
 Mat. Med., vol. i., p. 776.)
   209. The efforts of the stomach should,  how-
 ever, be promoted in order to procure the dis-
 charge of the poison ; and, with this view, the
 whites of raw eggs, milk, warm mucilaginous
 drinks, &c, should be given frequently and lib-
 erally, and, as well as starch,  administered as
 enemata.  The stomach-pump may be of ser-
 vice  in  some instances; but, when vomiting
 follows freely  and abundantly the ingestion of
 these draughts,  it may be more injurious than
 beneficial.  Inflammatory symptoms should  be
 combated in the usual way, according to their
 severity and the peculiarities of the case.  Tho
 nervous symptoms require  a  recourse to ex-
 ternal derivatives, and the other means which
  will be mentioned in the sequel.  (See Class
  Acro-sedatives.)
    210. d. In the more chronic  cases of poison-
  ing with the  cupreous compounds, opiates in
  full doses, with or without creasote and cam-
  phor, may be  given in demulcent vehicles ;  or
  the sirup of poppies may be similarly exhibited
  or administered in  enemata, and be aided  by
  warm baths and external derivatives; but these
  means should not be resorted to until the poi-
  son has been evacuated from the stomach and
  bowels.
    211. D. Gold — Hydrochlorate of—Chloride
  of—Iodide of  Gold, and some other  prepara-
  tions of this metal, have been recently employ-
  ed  in medicine, especially on the Continent,
  and may, from accident or otherwise, occasion
  poisoning.—a. Dr. Christison states that the
  poisonous properties  of the chloride are pow-
  erful, and closely allied to those of the  hydro-
  chlorates of tin and nitrate of silver.  The chlo-
   ride of gold  occasions death in three or four
  minutes when injected into the veins, even in 
386                   POISONS—Corrosive—Metallic  Salts.
very minute quantities, and the lungs are found
after death so gorged with blood as to sink in
water.  (Orfila, Toxicol. Gener , t. i, p. 593.)
  212. b. If the chloride of gold be swallowed,
corrosion of the digestive  canal takes place ;
and the salt is so rapidly decomposed that none
is taken up  by the absorbents; and death en-
sues from the  local injury solely.  Even in do-
ses so small as a tenth of a grain, it has caused
much irritation of the stomach.  The form of
fulminating gold has produced alarming poison-
ing where it was used in  medicine.  Plenck
6ays that  it excites griping, diarrhcea, vomit-
ing, convulsions, fainting, salivation, and some-
times  even  occasions  death.   Hoffmann re-
peatedly saw it prove fatal, the most prominent
symptoms being vomiting, great anxiety, and
fainting.  In one of the cases the dose was
only six grains.
  213. c. Treatment.—The antidotes for the prep-
arations of gold are the  same as those found
most successful for poisoning by corrosive sub-
limate, especially the whites of raw eggs, or
albumen, large  draughts of milk, &c.   The gas-
troenteric  symptoms should  be  removed  by
vascular depletions, derivatives, emollient en-
emata, warm baths, opiates, &c.
  214. E. Iron.—None of the preparations of
iron fall under the class of corrosive or caustic
poisons, unless the tincture of the sesquichloride,
and it owes its injurious operation, when taken
in large quantities, to the  excess of acid, the
symptoms and  lesions produced by it being the
same as those occasioned by hydrochloric acid
(. 150).
  215. F.  Mercury.—The preparations of this
metal often cause poisoning, which may be ei-
ther acute and rapid, or chronic or slow, accord-
ing to  the quantity taken, to the repetition of
the doses, and  to the modes of employing them.
In large doses, the more active of these prep-
arations act rapidly,  and  are  corrosive  and
acute poisons ; but, in small or repeated doses,
their .effects are  chronic or slow, and they act
as acro-alterative poisons,  in which class I shall
consider this mode  of their operation, in con-
nexion with that of some other  preparations of
mercury.  It is  thus chiefly the acute or cor-
rosive action  of these preparations which I have
here to consider; the  chronic, or consecutive
effects, will tall under the class just referred to.
  216. a. The Bichloride of Mercury—Corrosive
Sublimate.— The poisonous operation  of this
substance has  been ably investigated by Orfi-
la, Christison, Pereira, Devergie, Beck,Tay-
lor, and others.  The symptoms caused by a
large  dose of the bichloride appear either im-
mediately, or in a very few minutes after hav-
ing been swallowed.   A coppery or metallic
taste  is felt in the mouth; and if the poison be
in a state of solution, sensations of remarkable
acridity, burning constriction,  and  corrosion
are felt in the  mouth, fauces, and pharynx, de-
scending to  the  stomach, where, in  whatever
state  it may have been taken, pain is very soon
occasioned by it; is increased on pressure, and
is followed  by nausea and vomiting, the mat-
ters thrown  up consisting of the alimentary
articles remaining in  the stomach, and after-
ward of stringy masses of white mucus, streak-
ed or mixed with blood.  To these supervene
difficult deglutition, the rejection of whatever
is taken into the stomach ; sometimes a sense
of strangulation or suffocation ;  the extension
of pain over the abdomen, and intolerance of
pressure; violent purging, and lacerating pains
of the bowels, followed by tenesmus and mu-
cous and bloody stools ; anxiety, restlessness,
and  short  or laborious respiration ; a quick,
small, and contracted pulse; burning thirst, and
a white, dry, constricted  state of the tongue
and  mouth ;  anxious  expression  of counte-
nance, at first with flushing, subsequently with
collapse and twitchings of the muscles of the
face ; suppression of urine or dysuria ;  cold
sweats, great debility and sinking;  sometimes
ptyalism ; sinking and irregularity of the pulse ;
and coldness of the extremities.   Death is oft-
en preceded  by stupor,  insensibility,  convul-
sions, or twitchings  of the limbs, or even by
paraplegia.
  217. Poisoning by this substance differs from
that produced by arsenic :  1st. The well-mark-
ed taste, and the acridity and irritation of the
throat and  aesophagus, produced by the former,
are much greater than by the  latter; 2d. The
symptoms are more violent and immediate upon
the ingestion of this poison than  after arsenic ;
3d. The  evacuations  are  oftener mixed with
blood, and  irritation of the urinary organs, or
suppression of  urine is more frequent than
after poisoning with arsenic.  The symptoms
caused by corrosive sublimate resemble, in the
most acute cases, and at the commencement,
an attack  of common cholera;  subsequently,
when the patient survives  two or three  days,
they resemble those of dysentery, especially as
respects the existence of tenesmus, and of rhu-
cous and bloody stools ;  and when ptyalism, or
affection of the salivary glands, is not present.
  218.  b. Appearances after Death—These are
confined chiefly to the digestive  canal.  The
mucous membrane of the throat  and oesopha-
gus,  and sometimes, also, of the mouth and
fauces, is softened, and of a whitish or bluish
gray colour ;  that of the cesophagus, especially
near the cardia, is partially corroded.   The
villous surface of the stomach often  presents
a slate-gray or grayish tint, arising from the
action  of the poison, as supposed, upon  this
surface during  life.  Underneath, the tissues
are more or less inflamed, sometimes in patch-
es, and large black ecchymoses,  or extravasa-
tions of blood, are often found underneath the
villous membrane.  In rarer  cases this mem-
brane is only simply inflamed.   The coats of
the stomach are corroded, discoloured  more
or less, and  often softened so as  not to ad-
mit of removal  without laceration.   Perfora-
tion, however, is very rare.  Similar changes
to the above  are met with in the small intes-
tines and in the large  bowels, especially in the
sigmoid flexure of the colon and rectum, but
not to so great extent as in the  stomach, al-
though sloughing ulcers are  more  frequently
met  with in these latter situations.   The co-
lon is generally very much contracted.   In ca-
ses which  have  not been very  rapidly fatal,
sloughing ulceration, dark discolouring of the
ulcers  or  in  their vicinity, and softening, are
met with in several parts of the digestive canal.
Various alterations of the  urinary organs are
occasionally observed; but these are  neither
constant nor uniform, with the  exception of
contraction of the urinary bladder, which is al-
ways observed.  The  epiglottis  and trachea 
POISONS—Corrosive—Metallic Salts.
387
are sometimes inflamed, and the endocardium
often presents  indications of inflammation.
The coats of  the stomach and intestines and
the collatitious viscera often yield mercury on
analysis.   Poisoning by this substance does not
delay the accession or progress of decomposi-
tion, as observed  in  respect  of poisoning by
arsenic.
  219. c.  The  quantity which  m.ay destroy life
varies greatly  with the circumstances adduced
above (y 51, et seq.).   The smallest quantity in-
stanced by Mr. Taylor is three grains, this hav-
ing been given to  a  child by mistake for calo-
mel ; but he believes that two,  or not more than
three grains, have proved fatal in an adult.  If
this quantity—even  two grains—be taken at
once on an empty stomach, I do not doubt that
it is capable of producing a fatal result, if med-
ical aid be not procured ; but I state this chief-
ly from much  experience of the medicinal ex-
hibition and properties of this substance.  When
this poison has been  taken on a full stomach,
or when free vomiting has followed the inges-
tion of it, or when medical treatment was not
long delayed,  very large quantities have failed
to  produce death.   A case is  recorded  by Dr.
Booth  (Medical Gazette, vol.  xiv., p. 63), in
which an  ounce was taken, and, owing to these
 favourable circumstances,  recovery was ef-
 fected.
   220.  d. The period  at which  death takes place
 varies,  in  the  acute  cases, from two or three
 hours to  five  or six  days. Mr. Illingworth
 (Med. Gaz., vol. xxxi., p. 557) met with an in-
 stance of death from the sublimate in from two
 to three hours.  Death from this substance in
 from ten to twenty-four hours is common ; but
 life may be prolonged for several, or even many
 days, although the dose of the poison has been
 very large, when medical  aid has been soon
 obtained.  In these,  the symptoms  of  slow or
 chronic poisoning have generally appeared ; and
 the effects—ptyalism, diarrhcea, tenesmus, &c.
 —described in connexion with the acro-altera-
 tive action of this and other  preparations of
 mercury,  have usually been observed.   Acute
 poisoning  by this substance is the result of the
 chemical  action, and  the destruction of the tis-
 sues caused by the contact of it.   The fatal is-
 sue is produced by the extent of lesion of the
 digestive  canal, aided by the shock  to vital
 power and nervous energy. Whatever  absorp-
 tion may occur in the circumstances more fa-
 vorable to this mode of operation and  in the
 more prolonged cases, will farther aid  this is-
 sue, owing to the  injurious influence which
 an excessive amount of the poison  in the cir-
 culation will exert upon the heart and nervous
 masses.
    221. e. The treatment of acute  poisoning by
 corrosive  sublimate consists of the  removal of
 the poison, of the administration of anHdotes,
 and the counteraction  and removal of the ef-
 fects produced.—(a) The removal of the poison
 from the  stomach is best procured by  the en-
 couragement of vomiting by means  of  copious
 draughts  of fluids, containing or consisting  of
 the antidotes about to  be noticed.   Mr Tay-
 lor  states that, "if vomiting do not  already
 exist it must be promoted by the exhibition of
 emetics "  But it may be urged against this
 advice that the circumstances are rare which
 admit  of emetics;  for they  may increase the
mischief in the stomach, or otherwise compli-
cate the case ; or time may be lost in waiting
for  their operation, which may not soon  take
place, unless they are of an energetic kind.  A
recourse to the stomach-pump is liable to the
objection  already  urged  against  it,  in cases
where the oesophagus and stomach  are  con-
stricted, corroded, or softened  by the poison
(y 174).  Swayed by these  considerations, I ad-
vise an immediate  recourse to such draughts
as are most  likely to promote vomiting, and
thereby the rejection of the poison, and to con-
vey at the same time the antidote which may
be obtained with the least  delay.
  222. (b) The antidotes are chiefly those which
more or less efficiently decompose the corro-
sive sublimate : these are albumen, the gluten
of wheat,  milk, iron filings, and meconic acid.—
a. Albumen appears to decompose  the  subli-
mate, so as to render it almost inert. Dr. Chris-
tison has adduced several cases proving the
remarkable efficacy of this antidote.  The cel-
ebrated Baron Thenard  swallowed  inadver-
tently a concentrated solution of corrosive sub-
limate ; but by the immediate and abundant use
of the whites of eggs, he  suffered no material
harm.  Raw eggs—both  the whites  and the
yolk—should be  taken  most abundantly, and
ought not to be withheld, even  although the
poison has been taken for a considerable time;
for this antidote is often  efficacious  notwith-
standing,  and is the one most to be depended
upon.   Peschier states that one egg is  suffi-
cient for every four grains of the poison ; but
no harm can  result from taking many, as they
will be thrown off by vomiting ; indeed, they
should be so given as to promote vomiting.
  223. p.  Gluten has also been recommended
by Professor Taddei.  It  may be prepared by
washing flour in a muslin  bag, under a current
of water ; but it will be preferable, when albu-
men cannot be procurred,  to mix flour in water,
and give it in abundance :  it will thus often pro-
mote vomiting (y 221), and act as an antidote.
Milk, in the  absence of albumen  or flour, may
be  likewise given, or gum-water,  linseed tea, or
sweetened water.  Iron filings are stated to be
useful, by reducing the sublimate to the metallic
state.  Meconic acid is also said to be an anti-
dote, by forming an insoluble meconate of mer-
cury.   But, as Dr. Pereira justly remarks, a
knowledge of this fact is of little practical value,
since the  acid is not generally procurable ; and
tincture of opium, which contains it, cannot
safely be used  in sufficient quantity ; for Dr.
Christison finds that five grains of corrosive
sublimate require  an infusion of thirty-three
grains of opium to precipitate the whole of the
mercury.   Mr. Taylor states, that  the  proto-
 chloride of tin, in the proportion of one part to
 fifteen  parts of water, has  been  recently pro-
 posed by M  Poumet as an antidote.  But the
 efficacy of this substance has not  been suffi-
 ciently tested in the human  subject.  These
 antidotes, even albumen, cannot be  expected
 always to be successful   The sooner they are
 given the greater is the chance of success.  Sev-
 eral instances, however, have been recorded of
 their failure, owing either to delay in their ex-
 hibition, or to the perfect  solution and quantity
 of the poison, or to other circumstances of the
 case.  Hence it will always he  proper to ex-
 hibit the  antidotes, as already advised (v 222), 
388
POISONS—Corrosive—Vegetable Acrids.
 especially the eggs, in large number, and in the
 way most likely to promote vomiting.
   221 (c) The effects produced by the poison, as
 far as these are indicated, should next attract
 the attention of the physician.  These approach,
 in some cases, to the more common forms of
 gastro-enteritis, or of dysentery, or even of per-
 itonitis ; but the vascular action is  genet ally
 less sthenic than in those, owing to the extent
 and severity of the injury sustained by the vil-
 lous membrane and nerves of the digestive ca-
 nal, and hence vascular depletions cannot be
 carried to the same extent as  in these diseases.
 They are,  however, generally required,  most
 frequently locally by leeches, rarely by venaesec-
 tion, or by both modes in the same case.   De-
 mulcents with opiates  should  be freely admin-
 istered, and emollient and anodyne enemata be
 thrown up.   Fomentations, rubefacient embro-
 cations, &.c, ought to  be applied  to  the abdo-
 men, and frequently renewed ; and warm baths
 resorted to occasionally.
  225.  (d) The diet, as  recovery  advances,
 should consist chiefly  of farinaceous articles,
 of light panada, gruel,  demulcent  drinks, milk,
rice-milk, or creams, and broths  made of the
flesh of young animals ; and flannels ought to be
worn  nearest the skin.
  226. /. The nitrates of mercury are corrosive
poisons.  They are easily dissolved  in water,
especially if there be a little excess of acid pres-
ent. Mr. Bigsley has recorded (Med. Gaz., vol.
vi., p.  329) the  case of a boy who  dissolved
some mercury in a strong nitric acid, and swal-
 owed  about a teaspoonful of the solution.   He
was instantly seized  with excruciating pain in
the pharynx, oesophagus, and stomach ; urgent
anxiety, cold skin, small pulse, colic, and purg-
ing.  He sank rapidly, and died in about  two
hours and a half.   The fauces, oesophagus, and
 stomach were found, after death, corroded and
inflamed.  The treatment  is the same for poi-
soning by these salts as for that  by corrosive
 sublimate.   The diluted proto-chloride of tin is
suggested as an antidote by Mr. Taylor.
  227. g. Bicyanide of mercury is a most active
 corrosive poison.  A  person swallowed twenty-
 three  grains of this substance, and was imme-
 diately attacked with all the symptoms charac-
 terizing the ingestion of corrosive sublimate ;
 and, oa inspection after death, the same lesions
 of the digestive canal were observed. The treat-
 ment is ajso the same  as that already recom-
 mended for poisoning by  the sublimate.
  228. h.  White precipitate—the ammonio-chlo-
 ride of mercury ; red precipitate—the  red oxide
 of mercury ; turbith  mineral—the subsulphate
 of peroxide of mercury;  cinnabar and vermilion
 —the persulphuret of mercury; and calomel—
 the chloride of mercury, are severally acrid poi-
 sons,  in very large or repeated doses, and  may
 even corrode the digestive canal; but their ef-
 fects  are uncertain as respects this mode of
 action, and therefore they will be  more appro-
 priately considered hereafter; when also  poi-
 soning by the external use of mercurial prepa-
 ations, and by other modes of employing them,
 will be noticed.
   229.  G.  Silver—Nitrate of—Lunar caustic—
 is a powerful corrosive poison, when  employed
 in substance or in strong solutions.   It rapidly
 combines with, and  is ultimately decomposed
 by the tissues, the acid corroding them.  It is,
 in these states, a local and disorganizing agent,
 and is  not absorbed unless it be employed in
 small and frequent doses.  There are very few
 cases of poisoning by it on record, and these
 have not been detailed with any precision.—a.
 The symptoms produced by this poison are most
 probably but little different from those caused
 by several other corrosive poisons ; but, judg-
 ing from  its effects in  large medicinal doses,
 diarrhcea is most probably not occasioned by it.
   230. b. Treatment.—The antidote for nitrate of
 silver is common  salt, which, acting upon the
 nitrate, forms nitrate of soda and  chloride of
 silver, which is innocuous. The contents of the
 stomach should  be removed, and the symptoms
 alleviated, by demulcents, opium, external de-
 rivatives, and  local bleedings ;  by emollients
 containing salt,  and  by anodyne enemata.
   231. H. Tin—the Chlorides or Muriates of .—A
 mixture of these is extensively used in the arts,
 and may hence  produce accidental poisoning;
 but instances of such an occurrence  are ex-
 tremely rare.  They appear to act as local cor-
 rosive poisons wtfien taken in large quantity,
 and to occasion the usual symptoms of this class
 of poisons.  They are decomposed  by many or-
 ganic substances, and then the treatment of poi-
 soning by them should consist of the liberal and
 frequent ingestion of albumen, milk, and demul-
 cents ;  and, after  the stomach has been com-
 pletely evacuated, of the administration of opi-
 um, emollient enemata, &c.
  232. /. Zinc—Chloride of.—a. This substance,
 now employed as an antiseptic, when taken into
 the stomach, or  applied to any living tissue, in
 states of strong  solution, is a  powerful caustic,
 or corrosive poison.  It may be inferred to pro-
 duce the usual symptoms of corrosive poisons,
 as I am not aware of an  instance of poisoning
 having been caused by it; and its effects may
 be treated by the administration of the carbonate
 of soda, or any of the alkaline carbonates, with
 albumen, demulcents, and other means already
 recommended for caustic and corrosive poisons.
  233.  b.  Sulphate of Zinc—white  vitriol—has
 been considered as a corrosive poison ;  but its
 corrosive and local action is very rarely so great
 as to occasion death, even when given in very
 large quantity, for it is  generally immediately
 thrown  off the stomach, and  occasions merely
 an irritant and astringent action ; and, with ref-
 erence to this action, it will be considered in the
 third class of poisons.
  234.  ix. Vegetable Acrids.—There  are nu-
 merous  vegetable  productions which produce
 poisonous,  or  at least injurious effects, when
 taken into  the stomach;  or when  applied ex-
 ternally, or otherwise employed. Many of these
 act chiefly locally,  inflaming and corroding the
 tissues; while others produce less local irrita-
 tion, but are absorbed to a greater  or less ex-
tent, actiug thus remotely and injuriously upon
the nervous centres and on vital organs.   Under
 this class, I shall very briefly notice such of the
 vegetable poisons as act chiefly on the digestive
villous surface when swallowed, and locally as
 respects the parts to which they may be applied.
  235. a. Anemone nemorosa—A. pratensis__A.
 Pulsatilla, and A. sylvestris, are severally very
 acrid poisons.   Bulliard states that  an old
 man with rheumatic gout applied the bruised
root of A.  Pulsatilla to the calf of  his  leg o'n
going to bed ; violent suffering, with sphacela 
POISONS—Corrosive—Vegetable Acrids.
389
tion of the part, ensued.  Animals have exhib-
ited marks of intense inflammation of the stom-
ach and rectum after having swallowed it.  A.
nemorosa is said to produce dysentery in sheep.
The inhabitants of Kamtschatka make use of
this plant to poison their arrows.  Robert and
Vauquelin extracted a fluid of an acrid taste
and pungent odour from the flowers of the A.
pratensis, which acted like  a caustic  on the
tongue.
  236.  b. Arum  maculatum—Wake-robin — A.
Dracunculus, and other species of arum are ac-
rid  poisons in the  recent state, and when not
acted upon  by heat.  They occasion a burning
pain and swelling  in the throat; difficult and
painful deglutition. Bulliard states that three
children, who ate of the leaves of the A. macu-
latum, were thus affected, and experienced hor-
rible convulsions.   Two of the three died aft-
er some days.  The Calla palustris, or Water
Arum,  excites a similar action  to the above.
  237.  c. Bryonia dioica—Bryony.—The root of
this plant occasions vomiting, violent pain, pro-
fuse alvine  evacuations, and  faintings.  Pyl
mentions a fatal case from taking two  glasses
of an infusion of the root to cure an ague. Tor-
mina and purging soon supervened, and killed
the patient.   It occasions violent inflammation
in the  large and small intestines, and  of the
stomach.  Brandes  imputes the  acrimony of
the plant to a principle which he has called bry-
onine,  which  induces intense inflammation of
the parts to which  it  is applied.
  238.  d. Caltha palustris—Marsh Marygold—
has been noticed by several writers as an acrid
poison, inflaming the oesophagus, stomach, and
bowels, even of the lower animals.  A  family
of five persons in Germany, after partaking of
it, were all  seized, in half an hour, with pain in
the stomach, sickness, vomiting, diarrhcea, and
dysuria; and, on the  following day, with a gen-
eral swelling of the body, and a copious erup-
tion.   They, however, all recovered.  In addi-
tion to the inflammatory action produced by it
in the digestive canal, it appears to be absorbed,
and to occasion general  vascular excitement,
and irritation of the urinary organs and skin.
  239.  e. Chelidonium majus—Celandine—has a
bitter and acrid taste, and causes inflammation
of whatever parts to which it  may be applied.
When  taken into  the stomach it  inflames the
digestive mucous surface, and is partially ab-
sorbed ; exciting the brain and nervous system ;
and causing congestion of the lungs.   These
latter effects, especially that on  the brain, are
more   remarkably  produced by  C. Glaucium
Clematis Vitalba (Virgin's bower)—C. Flammula
— C. erecta—C. integrifolia, are all acrid and
caustic.  When applied to the skin, they pro-
duce redness, pustules, and excoriations.  Sto-
erck and  Mueller  prescribed them in some
chronic affections, especially syphilis, rheuma-
tism, and scrofula, in small doses, in the form
of infusion ; continuing  their use for some
weeks  with alleged benefit.  M. Roques states
that they occasion dysentery in animals.  The
powder of the leaves, in doses of one, two, or
three grains, has also  been employed.  They
are exciting, diaphoretic, and alterative  in small
doses ; but in large doses they destroy life, by
the intense inflammation  they produce in the
whole  course of the digestive canal.
  340.  /.  Croton  Tiglium—Purging Croton.—
I The seeds of this plant have a burning, acrid,
 and nauseous taste.  They were formerly em-
 ployed as a hydragogue-purgative ;  but, on ac-
 count of the violence of their operation, were
 laid aside.  One seed is sufficient  for a dose,
 and even sometimes excites violent vomiting
 and purging.   More  recently the expressed oil
 of this plant has come into use.  Dr. Pereira
 met with a case of poisoning by inhalation of
 the dust of the seeds.  The patient had been
 employed for several hours in emptying pack-
 ages of the seeds.   He complained of loss of
 appetite, of a burning sensation in the nose and
 mouth, followed by pain at the epigastrium, and
 copious  lachrymation.  He became giddy and
 insensible, but recovered.  His bowels were not
 affected.
   241. The oil causes rubefaction, and a vesicu-
 lar or pustular eruption, when rubbed on the
 skin; and when rubbed on the abdomen, it often
 purges.  Wher^ swallowed in one or two drops,
 it produces a burning acrid  taste in the mouth
 and throat, and acts as  a drastic purge,  pro-
 curing watery  motions, and sometimes an in-
 creased  secretion of urine.  It  appears to be
 partially absorbed ;  but it evidently acts as a
 sedative irritant of the digestive mucous sur-
 face.  The only case of  poisoning which  is
 known to have been caused by it was that of a
 young man, ill of typhoid  fever, who took by
 mistake  two and a  half drachms  of the  oil.
 Three quarters of an hour  afterward the skin
 was cold, and covered with a cold sweat; the
 action of the heart  and pulse was scarcely per-
 ceptible ; the respiration difficult, and  the ex-
 tremities blue.  An hour and a half afterward
 there were excessive involuntary alvine evac-
 uations,  but no vomiting;  the  abdomen was
 tender to the touch; and a burning sensation
 was felt in the oesophagus.  The blueness ex-
 tended over the body ; the surface became in-
 sensible, and death took place after four hours.
 This oil, even in the usual purging dose, some-
 times acts violently, generally speedily, al-
 though not certainly, occasioning much depres-
 sion of the vascular  system, and a feeling of
 debility.
   242. g. Cucumis Colocynthis—Bitter Apple.—
 The spongy or medullary part of the fruit is a
 drastic cathartic, causing inflammation of the
 villous surface of the bowels, and bloody evac-
 uations.   This substance has caused death in
 several instances owing to mistake.  A woman
 swallowed a teaspoonful and a  half of colo-
 cynth powder, and died in  twenty-four hours.
 A person took two glasses of a decoction of
 colocynth, and died in a short time.  Vauque-
 lin discovered the active principle of this plant,
 and called it colocynthin.
   243. The symptoms are, at first, frequent al-
 vine evacuations ;  great heat and colicky pains
 in the bowels;  dryness of the throat, and un-
 quenchable thirst;  a small and rapid  pulse;
 redness of the tongue ; a fixed,pain around the
 umbilicus, and tenderness.  To  these succeed
 coldness of the extremities, cramps,  sinking
 of the powers of life,  and death.   On dissection,
 the whole digestive canal exhibits marks of in-
 flammation, which is often most intense in the
 stomach and large bowels, the  villous mem-
 brane of which is abraded, readily detached,
 or even ulcerated.  The intestines are studded
 with black spots or  ecchymoses; the inflam- 
390
POISONS—Corrosive—Vegetable  Acrids.
mation  sometimes  extends  through all  the
coats;  the peritoneum being inflamed, and ei-
ther adherent to its opposite surfaces, or cover-
ed by a false membrane, or  containing a whi-
tish fluid and florenti.
  244.  A.  Cyclamen Europaum is a violent  irri-
tant, exciting vomiting and purging. Bclliard
states that its root produces cold sweats, dizzi-
ness, and  convulsions ; the patient voids blood
both by vomiting and by stool, the super-pur-
gation and inflammation proving even fatal.
  245,  i.  Daphne Gnidium (Spurge-flax—Flax-
leaved Daphne)—D Mezereum(Mezereon).—The
bark of these plants acts as a corrosive poison
when applied to living tissues.   I have  fre-
quently employed the mezereon bark as an ex-
ternal  irritant, instead of  caustic  alkali, in
forming an issue.   When  swallowed,  it in-
flames the digestive  canal,  causing heat  and
dryness of the throat; salivation, abdominal
pains, frequent vomitings, bloody stools, giddi-
ness, and feebleness of the limbs ; and the le-
sions above  described (y 243).   The Daphne
Laureola is also poisonous, and produces nearly
the same  effects as the other species.
  246.  k.  Delphinium Staphisagria—Stavesacre
—Palmated Larkspur—D. tricorne.—The acrid
property of these plants is lodged in the alka-
loid, which Lassaigne and Fenuelle discover-
ed in them, and which is an extremely acrid ir-
ritant.   The local effects of these plants are
evidently  the most  striking.  They have been
found to  inflame intensely the digestive  mu-
cous surface when  swallowed, but not to  pro-
duce any  alteration of other organs.
  247.  I. Euphorbia Officinarum.—The stalk of
the various species of the genus Euphorbia fur-
nishes a milky juice, which, on being dried, is
called  euphorbium.  It is a gum-resin, which
contains an active  principle, styled euphorbin.
A teaspoonful of the gum-resin was adminis-
tered by mistake ;  and it occasioned a burning
sensation  in the fauces and  throat, rapidly ex-
tending to the stomach, and causing incessant
watery vomitings.   The pulse became remark-
ably rapid and irregular; a cold perspiration
broke out, and death took place after two days.
The body  was inspected eight hours after death;
the coats  of the stomach could be torn with the
greatest ease;  the  internal surface of the vis-
cus was studded with gangrenous spots; the
spleen was enlarged  aud much softened, and
the inner  coat of the aorta was beautifully in-
jected with blood,  and highly inflamed.   The
after lesion was probably caused by the partial
absorption of the poison in this case.
   248.  Many of the species of the genus Eu-
phorbia are poisonous, as the antiquorum, cana-
densis, Tirucalli, Peplus, helioscopia, verrucosa,
platyphyllos,  palustris, hibernica,  amygdaloides,
sylvatica,  cxigua, mauritanica, neriifolia, Esula,
heptagona, &c , and have been employed in poi-
soning spears, arrows, &c.  The species La-
thyris and Cyparissias are said by Lamotte to
have proved fatal when administered in a glys-
 ter.  A person allowed his closed eyelids  to be
 rubbed with the juice of the E. Esula: inflam-
 mation took place, and it was followed by the
 lost of the eye.  A boy six years old ate some
 of the  E. Peplus.   It produced vomiting, purg-
 ing,  spasms, a  weak,  small  pulse, inability
 to swallow, insensibility, cold extremities, and
 death.   On dissection, the tonsils, fauces, and
pharynx were seen very much inflamed.   The
villous membrane of  the  stomach and small
intestines were very red ; but that of the large
intestines much less so.  The urinary bladder
was very contracted.  The epiglottis  and la-
rynx were highly inflamed.  The lungs were
healthy.   The veins of the dura  mater were
congested.  The blood was fluid.  The brain
was healthy.
  249.  m. Gratiola officinalis—Hedge Hyssop—
acts chiefly locally, causing inflammation of the
part which it touches.   It has produced death
rapidly when an extract of it was injected into
the veins.
  250.  n. Hippomaiie Mancinella—Manchineel-
tree.—The wood of this tree, when green, ex-
cites inflammation  of the skin when rubbed
against it.   The dust of the wood is so acrid
as  to excite inflammation of the respiratory
passages, or asphyxia, when inhaled with the
air.  Dr. R. Madianna found that the juice ex-
cited inflammation  when  applied  even to the
sound skin.   Orfila and Ollivier applied this
juice to a wound in the cellular tissue with a
fatal result.  When given internally, it soon de-
stroyed life ; the stomach and intestines being
found, on dissection, very highly inflamed.
  251.  o. Jalropha  Curcas—Indian Nut.—The
seeds of this plant  are a violent poison, exci-
ting incessant vomitings, purging, severe pain,
vital depression, and death.   Its  fatal effects
are more rapid when it is taken into the stom-
ach than when introduced into the cellular tis-
sue. When swallowed, it produces intense in-
flammation of the digestive canal.  Mr.  Ben-
nett states that  it is used as a purgative by the
natives of the Philippine Islands, an over-dose
producing intense pain, vomiting, and purging ;
their only antidote being large draughts of cold
water.
  252.  p.  Juniperus  Sabina—Savine. — The
leaves and tops  of this plant contain an  acrid
poison, in the form of a volatile oil of a remark-
able odour.   They are acrid and irritant in the
state either of  infusion, powder, or tincture,
and yield a light yellow oil, in which the active
properties  of the plant chiefly  reside.   The
powder, or the infusion, or the oil has been oft-
en  taken in  excessive doses, in order to pro-
cure  abortion,  the  power of  accomplishing
which effect it does not possess  more than any
other violent irritant.   When  employed  with
this intention, it not unfrequently destroys the
life of the mother, and sometimes even before
an  abortion  is  procured.   Mr.  Taylor states
that in a case in which the savine powder was
taken with a fatal issue, he found a green fluid
in the stomach, which, with the oesophagus and
small intestines, was highly inflamed.   The
poison was  identified by  placing the minute
portions  of the  leaves found in the  stomach
under a  powerful microscope.   A girl, to pro-
cure abortion, took  a strong infusion of savine
leaves, which produced violent pain in the ab-
domen  and  strangury.  She  miscarried two
days afterward, and died  four days after  that.
On dissection,extensive peritoneal inflammation
was found.  The inside of the stomach was
very red, and checkered with patches of florid
extravasation (Christison, Op.  Lat.).  \\ hile
this substance acts locally, ii is also partially
absorbed, and, through the medium of the blood
and urine, affects the urinary organs. 
POISONS—Depressing—Digitalis.
391
  253. q. Momordica Elaterium— Wild or Squirt-
ing Cucumber.—The feeula deposited by the
expressed juice of the  fruit of this plant—ela-
terium—contains the active principle to which
the properties of the plant are imputed, and are
chiefly,  if not altogether, owing.   Drs. Clut-
terbuck,  Paris, Morries,  and Pereira have
examined this feeula, and found that its active
principle — elaterin or  momordicine — which  is
soluble in alcohol, is  a  very active purgative in
the dose of one twentieth  of a grain.   Elate-
rium—the feeula of the juice of the fruit—
when of the best quality, is a drastic and hydra-
gogue purgative in the dose of the one twelfth
of a grain.   Its  acridity is such that it inflames
and ulcerates the fingers  of those  who  pre-
pare it.   Although acting thus energetically as
a local  irritant, it appears  also to be partially
absorbed, and even to  have its irritant action
transmitted by  means  of the nervous system
to parts more or less remote.  When taken  in
a  large  dose, it produces violent hypocathar-
sis and very copious watery stools, being the
most energetic  hydrogogue purgative  known.
Even a  quarter of a  grain of the  purest kinds
of elaterium may produce this effect and  pro-
cure the discharge of several pints of fluid by
the bowels.   An over-dose occasions not mere-
 ly  violent griping pains in the abdomen, but
 also increased frequency of pulse, a dry tongue,
great thirst, and dampness and coldness of the
 skin. A female took, by the advice of a quack,
 in divided doses, two grains and a half of ela-
 terium  and sixteen of rhubarb. They  produ-
 ced incessant vomiting and purging, which did
 not yield to treatment.  She died in thirty-six
 hours.  On dissection, the villous membrane of
 the stomach and intestines was  intensely in-
 flamed.  The colon was contracted : the other
 viscera were healthy.  (Boston Med. Mag., vol.
 iii., p. 25.)
   254   r. Narcissus Pseudo-narcissus—Daffodil
 —Meadow Narcissus—The extract of this plant,
 applied either externally or internally, produces
 violent  retchings, followed by death, owing to
 intense inflammation caused by it in the stom-
 ach and intestines, even extending to the rec-
 tum.
   255.  *. Ranunculus— Several species of this
 genus of plants are  remarkably acrid and cor-
 rosive,  especially the R. acris, R. sceleratus,  R.
 Flammula, R arvensis, R. bulbosus, R. alpestris,
 R. aqualilis, &c.  The leaves, flowers, and ex-
 pressed juice irritate,  inflame, and ulcerate the
 external surface, according to the duration  of
 their application ;  and, when swallowed,  they
 excoriate the tongue, mouth, and throat;  cor-
rode and inflame the stomach, and tumefy the
 oesophagus  and pylorus, occasioning extreme
pain, retchings, &c.   (Plenck.)
   256.  t. Rhus  Toxicodendron—Poison Oak-
Poison  Ivy.—Fontana,  Alderson,  Barton,
Bigelow, and others, have noticed the intense-
ly  poisonous action  of this and several other
species of the  genus  Rhus.   A small  portion
of the milky juice applied to the skin excites
burning, swelling, inflammation, and small ves-
icles containing a sharp transparent humour;
and nearly the  same  symptoms  are produced
by touching the leaves.  Dr. Aldekson states
that sphacelation has followed contact with the
acrid juice of this plant in some cases.  Drs
Cuti eb and Bioelow  mention various noxious
effects to have followed the handling and the
burning of the wood of the  Rhus vcmix, or poi-
son sumach.  The inflammation produced by the
several poisonous species of this genus appears
to present peculiar characters, with a marked
disposition  to diffusion, tumefaction, and gan-
grene, or to assume the form I have described
when treating of  diffusive  inflammation of the
Cellular Tissue.  The leaves and juices of
these species have been employed in medicine
as excitants, and  are supposed to produce not
only intense irritation, but also considerable
stupefaction ; and hence it may also be consid-
ered as a powerful acro-narcolic poison.  (See
Class VIII.)
  [Poisoning by the  Rhus vernix is very com-
mon in the United States, and may occur from
touching or  smelling any part of the plant, and
some individuals are so susceptible as to be
affected by the volatile  vapour which escapes
from it: others handle the plant with impuni-
ty.   The cutaneous inflammation caused by  it
will generally yield to a wash of sub-borate of
soda (borax) or acetate of lead. In cases we
have witnessed, inflammation appeared on the
skin, in large blotches, in about 48 hours after
exposure to  it; chiefly on the face and extrem-
ities ; soon  after, small pustules appeared on
the inflamed parts, and  became filled with wa-
tery matter, attended  with an  almost insup-
portable itching and burning.   In two or three
days the eruptions suppurated, after which the
inflammation subsided, and in a short time the
ulcers healed.]
  257. u. Stalagmitis Cambogioides—-Habraden-
dron Cambogioides.—The gum-resinous exuda-
tion  from this plant occasions, in large doses,
nausea, vomiting, griping pains of  the bowels,
copious watery stools, &c.  In excessive doses
it acts as an acrid poison.   A  drachm caused
horrible retchings and purging, followed by syn-
cope and death.   The fatal effects consequent
upon taking a great number of Morison's pills
have been owing to the gamboge contained  in
them. The symptoms in these cases were vom-
iting and purging, pain and tenderness of the
abdomen, coldness of the extremities, and sink-
ing of the pulse.  On examination post mortem,
inflammation, ulceration, and sphacelation of
the intestines were found.
  258. v.  There are many other plants, as sev-
eral species of the  Rhododendron, Pedicularis,
Plumbago,  Phytolacca, Ricinus,  Sambucus, Se-
dum, Tanacetum, Pastinaca, &c, which possess
very acrid  properties,  and which,  when taken
into the stomach, occasion symptoms and le-
sions similar to those caused  by the plants al-
ready mentioned.  Others produce not merely
more or less inflammation and excoriation, but
also  other  functional  and  organic changes,
which rank them in the classes which follow.
   259. y.  1st. The action of the acrid vegeta-
bles is generally exerted upon the  tissues with
which they come in contact, in which they oc-
casion inflammation, excoriation, or corrosion,
ulceration or sphacelation, with the symptoms
usually attending these lesions, according to the
parts in which they are produced.  2d. The fa-
tal effects of these poisons are more certainly
developed when they are taken into the  stom-
ach than when applied externally, or introdu-
ced into the cellular tissue ;  for, in the former
case, they  affect a greater  extent of  surface, 
392                        POISONS—Depressing—Digitalis.
having an intimate connexion with the organic
class of nerves, and, through these nerves, de-
veloping a wider range  of  morbid symptoms
than in the latter.  3d. Some of these poisons,
in addition to  these local effects,  are partially
absorbed, and produce changes either functional
or structural—nervous or vascular—in other re-
mote organs, as the lungs, the urinary organs,
the nervous masses, &c.
  260.  z.  The treatment of the vegetable acrids
consists chiefly of the expulsion of them by en-
couraging vomiting, by means of mucilaginous
draughts ; and of allaying irritation by opiates,
external derivatives,  emollient  and  anodyne
enemata, and local depletions.   Opium may be
given in full or frequent doses, and rubefacient
embrocations or fomentations assiduously ap-
plied over the abdomen.  I have found the tur-
pentine  fomentations, opiates, starch enemata,
with the compound tincture  of camphor or sir-
up of poppies, the  most generally efficacious;
and, if  vital  depression  supervene,  camphor,
ammonia, decoction  of cinchona, or  aromatic
infusions  are  the  most  serviceable.  During
recovery,  the diet and regimen  advised during
convalescence from the effects of several cor-
rosive poisons should  be adopted (y 157-174). .
  261. Class II.  Depressing and Paralyzing
Poisons—Sedative Poisons.—There are sev-
eral agents which destroy life by the extent to
which they abstract the vital caloric, depress
the nervous energy, and lower the  action of
the heart and vascular system generally.  In
virtue of  these modes of operation, they de-
stroy vitality without  any very obvious pre-ex-
istent excitement, and without producing either
the appearances or the symptoms  or lesions at-
tending local irritation.  The effects of these
agents are manifested by the states of function
and of  vital manifestation and action, and by
no farther lesion than  may be attributed to fail-
ure or loss of function  or action; by the absence
of such  structural changes as are  calculated to
account for death,  conformably with  our ac-
quaintance with the extent  and consequences
of pathological conditions.  Of this  mode in
which certain poisons act, I have already taken
a general  view (y 28-30).  I shall, therefore, no-
tice as  briefly as possible those agents which
come under this class—which  destroy life by
acting  in  this  way,  and independently of such
structural lesions as are of themselves calcu-
lated to produce the result.  It may, however,
be  here remarked,  that  there  are  numerous
substances which, in  addition to  more or less
manifest lesions of structure produced by them,
act also as sedatives or depressants of nervous
energy  and vital action,  which produce more
complicated effects or associated results, and
which thereby constitute other classes  of poi-
sons, more especially the fifth class.
  262. A.  Acetic Acid,  in  various  states of
concentration or purity,  may be  so  employed
as to act as a sedative.  It has been considered
above (y  125) with reference to  its corrosive
operation, or to its employment in larger doses,
and in  states of strong concentration.  But
when taken in states  of dilution, and when the
use of it is continued for a  considerable time,
it acts  not only as  a sedative, but  also as a
slow poison.  These  effects depend in some
degree  on constitution, and the quantity of it
usually  taken; for,  in moderate doses, both
it and the mineral acids are tonics and refrig-
erants, and increase the appetite, while in  lar-
ger doses, or when too long continued, they
impair or otherwise affect the assimilating pro-
cesses, and even change the constitution of the
blood.   When very dilute acetic acid is taken,
especially during vascular excitement or in feb-
rile states, it allays thirst, lowers the heat of
surface, and increases the urine.  It is certainly
absorbed to a greater or less extent; and, both
locally and through the medium of the circula-
tion, it exerts some degree of astringent action.
I have met with several instances of disorder
from the protracted use of this acid, amounting
nearly, and in  one quite to that  observed in
the following case : A young lady enjoyed good
health, was plump, had a good appetite, but was
afraid of becoming too fat.   She was advised
to drink a small glass of vinegar daily: she did
so,  and her plumpness diminished;  but, after
some weeks,  she began to complain of a short,
dry cough ; her body became lean and wasted ;
her breathing short and difficult, and the usual
symptoms of tubercular consumption superve-
ned.  On dissection, all the  lobes of the lungs
were studded with tubercles. The long-contin-
ued use of acetic acid seems to favour the devel-
opment of several organic changes which origi-
nate in debility. Morgagni believed that it fa-
voured the production of schirrusof the pylorus.
  263. B. Acids—The Mineral.—The action
of these acids in large quantities, and in strong
and concentrated states, has been already con-
sidered  ($ 132, et  seq.);  in  which states they
act locally and as corrosives.  But in states of
weak dilution  they operate differently, theii
effects varying  with the  quantity and continu-
ance of the use of them.   Many years ago  1
made a series of experiments with these acids
in  different states  of dilution, and for various
periods;  and most of them were made upon
myself.   I found, 1st.  That the sulphuric,  the
nitric, and the hydrochloric acids were severally
absorbed into the  circulation when taken in
states of dilution short of producing corrosive
effects.   2d.  That, after periods varying with
the amount  and frequency of the  dose,  and
with the acid taken, the presence of  the free
acid could be detected more or less abundantly
in the urine.  3d. That sulphuric acid appeared
sooner in the urine than the nitric or hydrochlo-
ric, and  that the  nitric required  the longest
time to appear, and the largest doses; but as
to  this  particular,  I was not  quite  satisfied.
4th.  That the sulphuric acid evinced the most
decided refrigerant and sedative action, espe-
cially when much  diluted.   5th. That the  use
of these acids was  at first tonic and refreshing,
and to some extent astringent and diuretic ;  but
that, when continued for some time,  and when
they were more abundantly absorbed,  especially
the sulphuric, they then were depressing;  oc-
casioning indigestion,  weakness of the pulse,
and in my own case, after  the sulphuric acid
had been taken  some time, intermissions of the
pulse, and impaired  impulse of the heart,  the
urine at this  time containing  free  sulphuric
acid, or this  acid in excess.  6th.  That a  too
long continuance of these  acids,  particularly
of the sulphuric acid, not only impaired diges-
tion  and assimilation, but also weakened "the
heart's action, lowered  irritability, caused ema-
ciation, disordering the bowels, and the secre- 
POISONS—Depressing—Digitalis.
393
tions  poured  into  the digestive  canal.  7th.
That these acids act as refrigerant tonics only
when employed  for a short time in such quan-
tity as may render drinks agreeably acid ; that
they are most beneficially prescribed in this
manner, in order to remove a particular diathe-
sis or specific condition ;  and that they are slow
poisons when  long  continued in healthy  states
of the frame, the good effects often imputed to
them resulting either from other causes, or from
vital resistance and the efforts of nature.  8th.
They affect, when continued for some time, the
constitution  of the blood.  9th. The  mineral
acids, when thus employed, are excreted from
the blood chiefly by the kidneys and the skin.
  264.  C. Alkalies  and  their Carbonates,
when taken in states of weak solution, or con-
tinued for too  long a time, or in doses short of
producing the  effects described above (,  167, et
seq.), impair more or less remarkably vital pow-
er and vascular action.   These substances are
readily absorbed into the  circulation, whence
they are eliminated chiefly by the kidneys, and
slightly  by the skin.   The prolonged use  of
them may occasion slow or chronic poisoning,
owing to the effects produced by them on the
digestive mucous surface, and  on the urinary
organs;  for they  manifestly favour  the  too
rapid detachment or exfoliation of the epithe-
lium covering the villous and  mucous  mem-
branes of these  viscera,  while they  alter the
constitution of the blood, and  affect the healthy
states of the haemato-globulin.   When thus im-
properly employed, their operation as sedatives
tends rather to favour the origin and develop-
ment of organic lesions  and chronic diseases,
which may ultimately terminate  life, than  to
cause death in a more direct and immediate
manner.
  265. D. Cold.—The abstraction of animal heat
may, from its intensity or continuance, destroy
life.  Cold is a  powerful sedative, benumbing
the sensibility, weakening muscular  motion,
and lowering vascular  action.   It also favours
internal congestions,  especially of the lungs,
brain, and liver, and ultimately of the  large
veins and right side of the heart; these con-
gestions increasing the effects of cold on the
sensibility and on the vascular  system to a fa-
tal amount, unless judicious means  of counter-
action be  adopted.   The fatal  effects of cold
are favoured by repose  ;  by the  drowsiness,
somnolency, or lethargy  which  it induces, and
by  a  passive  submission  to this  feeling;  by
previous excesses in  spirituous liquors  or  in-
toxicating drinks, or even by the use of those
at the time of exposure, if active  exercise be
not taken.  But it is unnecessary to pursue the
subject  farther at this place  than  to  associate
its effects with other  injurious agents, for the
purposes of diagnosis, and of comparison with
the action of other sedatives, or even  with nar-
cotic poisons, as this  agent  has been noticed
above (y 28, 29), and  specially treated of with
reference to its effects and treatment.  (See art.
Cold.)
  266.  E. Digitalis.—Digitalis purpurea  has
been usually  classed  with narcotics, or acro-
narcotics ; but it is more properly a sedative
than a stupefying agent,  as this latter property
is either not at all, or imperfectly evinced ; and
whatever narcotic effect may be considered as
actually produced by  it,  in any instance, is to
be imputed entirely to the depressed, paralyzed,
or departing manifestation of cerebral function.
The irritation caused by digitalis in the digest-
ive canal is not great, does not proceed to in-
flammation, and is attended by marked depres-
sion of vital power.   The effects  produced by
it on  the  heart obviously  depend  upon  the
quantity taken,  the  rapidity  of its absorption,
or the accumulation of it  in the  system,  and
upon the other  peculiarities of the case,  and
particularly upon  those connected with  the
constitution of the patient.   In many its inges-
tion, even in a very  large and  poisonous dose,
produces acceleration of the pulse—sometimes
remarkable  acceleration ; but  the pulse is al-
ways then weak, compressible, or small, the ac-
celeration being manifestly, as  in other  cases
of great quickness  of pulse, an evidence of
extreme depression  of  organic nervous influ-
ence  and vital power.  But, as the irritability
of the heart and other muscular parts become
impaired with the depression  of  the  organic
nervous  influence upon which it depends,  the
increased frequency  of the heart's action,  if it
have  occurred, subsides more or less rapidly
into remarkable slowness and irregularity, with
or without intermissions, until the action ceases
altogether.
  267. The noxious  operation  of  digitalis is
manifested in all animals.  One drachm of the
powder acts as  a sedative  in  horses affected
with inflammation.  Two ounces destroyed  this
animal in twelve hours.   The influence of  this
poison on the heart of the horse is various.  At
first, the action of this organ is sometimes ac-
celerated ; in other instances it is not affected ;
and in some it is retarded.  It generally occa-
sions diminished muscular  power, convulsive
movements, tremours, and loss of sensibility.
Of the numerous writers who have discussed
the operation of digitalis, there  is none who  has
estimated it so accurately as Dr. Pekeira, or at
least so conformably  with my own experiments,
and with my observations of its effects during a
period of thirty years.  Many years ago, I tried
the effects of it  upon myself in large doses, in
different forms of preparation ; and in practico
I have pushed it,  in some instances, as far as ap-
peared compatible with the safety of the patient.
  268 a. Symptoms.— Dr. Pereira has distin-
guished three grades  of operation of foxglove,
or of poisoning by this plant;  and  I shall adopt
the division.—(a) The first degree is that usual-
ly produced  by  small and  repeated doses,  and
consists chiefly of nausea or loss of appetite ;
of alteration of the  heart's action and of the
pulse, which hecomes irregular, or accelerated,
or slower than natural; of depression of spir-
its, of impaired  strength, and of increased  se-
cretion of urine.  These symptoms observe no
regular order, sometimes the diuresis, at oth-
ers nausea, and occasionally the affection of
the circulation being the first to appear.  The
influence of digitalis  on the circulation is by no
means uniform.   In  some cases  the pulse is
accelerated  or rendered  full  and soft; in oth-
ers it is slower or irregular ; in many it  is in-
termittent ;  and  in others it is  not materially
affected.  A  small dose, in some instances, re-
duces the frequency  of  the pulse,  and renders
the pulsation irregular or intermittent, or both ;
while a very large dose  may be taken without
any material effect upon the action  of the heart. 
394
POISONS—Depressing—Digitalis.
In the summer of 1816, I took, while in good
health, two drachms of the tincture at one dose;
and, finding  no farther effect from it  than loss
of appetite and slight depression, I took anoth-
er drachm three hours afterward.   I find in my
note-book that the pulse was not affected by it
during that  and the subsequent  day,  farther
than it was readily accelerated by the least ex-
ertion, and that very slight nausea, but no drow-
siness, was  produced by it.  Dr. Withering,
in one case, found the pulse fall to  40 pulsa-
tions in a minute, and Dr. Fogo, in another, to
36.  The lowest I have seen it from the use of
foxglove  was 44 ; but 50, or even lower, is not
infrequent.  The slowness is sometimes pre-
ceded not only by  acceleration, but also by in-
creased fulness and softness.  Even  when the
pulse is  much slower than  natural, in the re-
cumbent   posture,  it generally  rises very re-
markably above the usual frequency in the sit-
ting, and  still more  in the  standing position.
This  is owing to the weakened state of the
heart, caused by the digitalis, an increased fre-
quency of contraction being required to compen-
sate the  loss of power, especially in positions
unfavourable to an abundant supply of blood to
the brain, by which  the  cerebral  energy may
be developed and the nervous influence of the
heart thereby re-enforced and increased.  This
effect of  position upon the action of  the heart
of a  person under  the  influence of digitalis
should be kept in recollection, and he should
not be allowed suddenly to assume a  sitting or
standing  posture ; for the  heart, already re-
markably weakened, is unable to act sufficient-
ly, or to overcome the increased obstacle which
either of these postures furnish to it, especial-
ly when  it loses the usual supply of cerebro-
spinal  nervous influence, or even when  it ex-
periences a diminution of that supply.  Owing
to  these  conditions,  and  to  insufficient  atten-
tion being paid to them, a patient may be seized
with fatal syncope while  he is under the ope-
ration of this substance; and  there is every
reason to believe that this occurrence has ac-
tually taken place  oftener than once in these
circumstances.
   269. The  influence of digitalis on  the pulse
is more remarkable in debilitated and anaemia-
ted persons  than  in the plethoric or  robust.
Sometimes no effect is produced on  the pulse
in respect of number, force,  or regularity, until
nausea, vomiting, or headache is experienced ;
and occasionally  a comparatively  moderate
dose may occasion these  symptoms.  Shroek,
as quoted by Pereira, experienced  from two
grains of foxglove nausea, headache;  small,
quick, and soft pulse ;  dryness  of the throat ;
giddiness, weakness of the limbs; and some
hours afterward his vision became dim, with a
sensation of pressure on  the eyeballs.
   270. The cumulative effect  of  digitalis is one
of the  most  important facts to be kept in view
in connexion with the use of small and repeat-
ed doses of this plant. After an indefinite time,
during which  the foxglove has  been  thus em-
ployed without any very marked effect, or with
a slight effect merely, dangerous symptoms, in
some instances terminating  in death,  have sud-
denly appeared.  These generally consist of re-
markable irregularity, frequent intermissions,
or extreme  weakness  and  slowness of the
heart's action ; giddiness ; pallor of  the coun-
tenance ;  nausea ; vomitings ;  watchfulness ;
impaired sensibility;  and sometimes convul-
sions.   Dr.  Pereira  and Dr. Holland, how-
ever, consider this cumulative effect very rare.
But this depends upon the time during which
the digitalis  has been exhibited, and the amount
of the dose.  Early  in the present  century,
when this plant, especially the infusion of  it,
was given in large doses, and very indiscrim-
inately, in dropsies, I met with several instan-
ces of the cumulative operation of it in most
dangerous forms;  and two of these occurred
in patients for whom I had myself prescribed
it, and  in whom  I  had watched  its  effects.
One of these perfectly recovered from both this
operation of the remedy and from the disease
for which it  was prescribed (dropsy); the oth-
er also recovered from  this effect, and  was
partially benefited by  the  medicine ; but the
disease—tubercular  consumption—ultimately
terminated  as usual.  Salivation is  an occa-
sional consequence of the use of digitalis  in
repeated doses ; and it may occur even after a
few moderate doses,  as noticed by Withering,
Barton, Pereira, and myself.
   271. (b) The second grade of poisoning by dig-
italis is that which is most frequently produced
by too large  or too long-continued doses.  The
symptoms are described with great accuracy by
Dr. Pereira.  They are usually nausea or ac-
tual vomiting,  slow and often  irregular pulse,
coldness of the  extremities, syncope, or  ten-
dency to it,  giddiness, confusion of vision, and
loss of muscular power  The sickness is some-
times attended by purging, but  oftener  by dy-
uresis, occasionally  by  neither.   The patient
complains  of a  sensation of weight, pain or
throbbing of the head, especially the forehead;
of giddiness, of weakness of the limbs,  and
watchfulness.  He sees objects dimly, or of a
green or yellow hue ; or he sees motes, sparks,
or mists before his eyes.   The pulse is feeble,
sometimes accelerated, at  other  times slow,
but is affected by the slightest exertion.   There
is remarkable tendency to syncope upon raising
the head from the pillow, and to profuse cold
sweats; sometimes delirium, stupor, salivation,
and loss of sensibility  supervene.   There  is
much difficulty in assigning the quantity of the
drug capable of producing these effects, wheth-
er taken in a single dose or in divided quanti-
ties.  Much  will depend upon the state  of the
plant, the kind of preparation, and the consti-
tution  of the patient.  I may,  however, here
state, as the result of experiment and observa-
tion, that very large doses—three or four times
the usual doses of either of the preparations,
or even more—may be given without any effect
during inflammatory  action; that febrile ex-
citement, physical exertion, and a high range
of temperature seem to suspend the action of
even very large quantities of the drug ; while
the depressing passions, cold, the contempo-
raneous use  of antimonial preparations, of col-
chicum, or of refrigerants, manifestly accelerate
and heighten their effects.
   272. (c) The third or fatal grade of poisoning
by digitalis  is characterized by retchings, pur-
ging, griping pains in the bowels, remarkable
faintness, cold sweats, anxiety, and depression
of spirits, collapsed  features, vertigo, dilated
pupil and disordered  vision ; a slow, feeble, ir-
regular, and small pulse ; extreme physical de- 
POISONS—Depressing—Preparations op Lead.                  395
pression and exhaustion, inability to sustain a
sitting or upright posture, involuntary evacua-
tions, low delirium, insensibility, convulsions,
stupor, and death.
  273. b. The appearances after  death by digi-
talis have not been accurately observed. There
is, perhaps, no drug which has been employed,
either medicinally or criminally, the  operation
of which has been more inaccurately described
than this  has been.   Digitalis  produces  but
slight irritation of the digestive mucous sur-
face, the nausea, retchings, &c, sometimes ob-
served resulting more  from the efforts of na-
ture to throw off a depressing and poisonous
agent than from any inflammatory action pro-
duced by it, these  symptoms depending upon
the reaction of vital organs upon an injurious
influence affecting the ganglial or splanchnic
nervous system rather than  upon irritation.
The symptoms which  have  been  imputed  to
narcotism and to congestion of the brain arise
from  very different states ; for the  giddiness
complained of,  the  convulsions  even, and  all
the symptoms which  may be  referred to  the
brain, I am convinced, by careful observation,
are results of impaired circulation in this or-
gan, of weakened nervous energy, and of a de-
ficiency of blood in the vessels within  the head.
I  have always found  the carotids  pulsating
weakly ; the head cool, and the features sunk ;
and it is well known that convulsions as often
result from a  diminution  of blood within  the
cranium as from congestion or excess—perhaps
oftener.  Doubtless, when convulsions occur,
this state is altered, and congestion is the con-
sequence ; so that, when convulsions precede
dissolution, a congested state of the vessels of
the brain and of its membranes will  be found.
Digitalis acts  as a  poison, and even as a med-
icine, by depressing the organic or ganglial ner-
vous energy, and consequently by lowering  ir-
ritability and the tone of vascular action.  The
manifestations of life in the several organs are
thereby similarly affected, the functions of ab-
sorption and of urinary secretion being the least
disordered. The ultimate result is, that the de-
pressed states of organic nervous power and of
vascular action primarily caused by digitalis, im-
pair the cerebro-spinal influence, and the func-
tions of sense and of muscular motion depend-
ing upon that influence ; and that these states
severally act and react on each other when the
poison is energetic, or  its operation not coun-
teracted, until the action  of the heart ceases
altogether.
   274. c. The treatment of poisoning by digitalis
must  depend  upon the circumstances of the
case.   If the symptoms are produced by a large
quantity of the drug taken at once, and if there
be reason to infer that it still remains even in
part on the stomach, the removal of it  either
by the stomach-pump or by vomiting should be
procured.  The sulphate of zinc is the most suit-
able emetic in this case, and it should be given
in a full emetic dose with powdered  capsicum,
and vomiting should be encouraged by means
of warm diluents containing stimulants, as am-
monia, camphor, &c. When the poison is evac-
uated from the stomach, or when the  symp-
toms  are consequent upon repeated doses of it,
ot result from its cumulative influence, an  im-
mediate recourse to stimulants, as brandy, am-
monia, camphor, opium, cardiac tinctures, cap-
sicum, should be had ; and mustard poultices,
blisters, or other rubefacients ought to be placed
over the epigastrium.  Strong coffee or green
tea may also be  freely given.  In the instances
of cumulative poisoning by this plant which oc-
curred in my practice (f 270), camphor and am-
monia, with capsicum, were chiefly employed,
and green tea for drink.   The noxious effects
of digitalis, however produced, are not readily
removed, but require the lapse of several days
before they entirely disappear, the disorder of
the pulse  and the affection of the eyes being
the last to depart.   During the treatment of
the effects of this poison, the patient should be
kept in a recumbent position, a change to the
sitting posture being allowed only with the ut-
most care.
  275. F. Lead.—The preparations of lead are
severally poisonous.  The metal itself is not
injurious, if it remain unchanged ; but when re-
duced to an oxide or a carbonate, it becomes
injurious.   Small shot have been swallowed in
order to remove obstructions in the bowels,
and evacuated without producing  any inconve-
nience.   Dr. Bryce (Lancet, Dec. 31, 1842) has
recorded a case, however, of a man who took
three  ounces of small shot (No. 4).   On the
third day  he complained of great depression
and anxiety, with sunken features, coldness of
surface, dizziness, and numbness in the arms
and legs.   These symptoms continued to  in-
crease ; purgations were  administered to over-
come  the obstinate costiveness, and in a fort-
night  he recovered.  In this  case  the metal
was either oxydized or reduced to a salt in the
stomach or intestines.   The chief compounds
of lead which have been  found injurious  are,
the carbonate, the acetate and sub-acetate, the
chloride, the iodide, and the oxide, combined ei-
ther with vegetable acids or with fatty substan-
ces ; and either  of these may produce acute or
chronic poisoning.
  276. a.  Acetate of Lead — Sugar of Lead.—
This salt is productive of acute or chronic poi-
soning, according to the dose, the repetition of
it, or the mode of its administration.   Orfila
found that, in large doses, it caused pain, vom-
iting,  and  death ; and that  when  its action
was slower,  and absorption took place, para-
lytic and convulsive symptoms appeared.  Ow-
ing to the disposition of the salts of lead, and
especially the acetate, to combine chemically
with the tissues, the villous surface of the di-
gestive canal, in cases of acute poisoning with
this salt, is whitened or otherwise discoloured
by  it.  Injected into the veins, or applied to
wounds, it affects the nervous system, causing
vertigo, paralysis, or coma, and  convulsions,
and congestion  of the lungs.
   277. b. The symptoms produced by the  in-
gestion of this  salt vary with the dose.   Ten
grains taken daily for seven days caused a sen-
sation of tightness in the breast, a metallic
taste of the mouth, constriction of the throat,
debility,  sallow  countenance, slow respiration
and circulation,  turgid and tender gums,  ptya-
lism,  numbness  of the fingers and toes, pains
of the stomach and bowels, costiveness, hut no
nausea.   These symptoms are  described by
Dr. Laidlaw, and agree with the symptoms  I
have myself observed in cases where large do-
ses of this substance have been taken  for sev-
eral days.  When  much larger  or poisonous 
396
POISONS—Depressing—Preparations or Lead.
doses,  as  three  or  four drachms or  upward,
have been swallowed, a pricking, constrictive,
and peculiar pain is felt in the throat and in the
course of the  oesophagus;  pain, anxiety, and
distressing aching are felt at the epigastrium,
and diffusing themselves over the abdomen ;
vomiting takes place, and is attended by par-
oxysms of colicky  pains, which are  not in-
creased by pressure, as in cases of inflamma-
tion, but, on the contrary,  are relieved by it.
Aching and anxiety, with  a sensation of con-
striction of the  abdominal  contents  towards
the spine, are experienced in the intervals be-
tween  the severe paroxysms of pain ; the bow-
els are constipated ;  the skin  is cold, and the
strength prostrated.  Giddiness, coma, convul-
sions,  and  death supervene, if suitable aid  be
not administered.  This very acute form of lead
poisoning  is,  however,  comparatively rare.
Much more frequently, after suffering for sev-
eral days  with  the  abdominal  symptoms, the
parietes of the abdomen being at first retract-
ed, and subsequently tense and distended with
air, owing  to the paralyzed state of the mus-
cular coats of the intestines, the patient com-
plains of cramps or loss of power of the mus-
cles of the extremities, or of numbness or com-
plete paralysis.  The bowels continue consti-
pated ; vomiting occasionally takes place, pre-
ceded or attended by severe paroxysms of pain ;
torpor, coma,  or convulsions  supervene ;  or
death takes place suddenly or unexpectedly.
  278.  c. The effects of this salt often pursue
a more chronic course, and  then are in all re-
spects  similar to those described when treating
of painters' colic.  (See art. Colic, y 25, et seq.)
Dr. A.  T. Thomson (Med. Gaz., vol. x., p. 689)
has contended that the acetate of lead does not
become poisonous until it is converted in the
body into  the state of a carbonate; but there
is no proof of the carbonate having a more del-
eterious influence than the acetate.   Dr. C. G.
Mitscherlich has even shown that the acetate
is  not  less injurious  than the  carbonate, espe-
cially when mixed with acetic acid, in which
form it is more energetic  than when  given  in
the neutral state.   (Taylor, op. cit., p  169 )
  279.  d. Sub-Acetate—Diacetale of Lead—Gou-
lard's Extract of Lead.—This substance has caus-
ed death in a few instances,  and is a more pow-
erful poison than the neutral salt, probably ow-
ing to  its containing  a larger quantity of the
oxide.   Mr. Taylor  states that two cases  of
poisoning by Goulard's extract occurred in 1840
in two children of four and  of six years of age.
The quantity taken was not  great, but both died
in thirty-six hours, with symptoms very closely
resembling those of pestilential cholera.  The
bodies  were inspected (y 285).   Mr. Marshall,
however, mentions a case of recovery from two
fluid ounces of this extract.
  280.  e. Carbonate of Lead—White-lead Cerusse.
—It is insoluble in water, but still possesses
poisonous properties, a decided proof, as  Mr
Taylor remarks, among numerous others, that
insolubility does not  prevent a substance from
exerting a poisonous action on the system. The
gastric and biliary secretions, or the  presence
of a free acid in the digestive  canal,  may dis-
solve a sufficient quantity to be deleterious.  In
& case  reported by Dr. Snow, a child, aged five
years,  ate  a portion of the  carbonate, ground
up with oil, not larger than  a marble.  During
three days, pain in the abdomen and constipa-
tion  alone were complained of.   On the third
day the symptoms were greatly aggravated, and
vomiting occurred.  The child died ninety hours
after the injection of the poison ;  some very
offensive stools,  of a greenish-black colour,
having been  passed  just before death.  A fe-
male, aged thirty-three,  took, by mistake, for
magnesia, from six  to  eight  drachms of  the
carbonate of  lead.  Five hours afterward, Mr.
Cross found her in a cold perspiration, breath-
ing heavily, with a frequent, small,  constricted
pulse.   There  were vomiting, dryness of the
throat, anxious expression of countenance, and
severe colicky pains.  The extensor  muscles
became  paralyzed, and the flexors rigidly con-
tracted.  Sulphate of magnesia, with dilute sul-
phuric acid and castor oil, were given her, and
very dark evacuations were procured.  In four
days she was convalescent.
  281. These cases sufficiently illustrate the
symptoms of the acute form of poisoning by car-
bonate of lead.  The chronic form of poisoning
by this substance, characterized by severe par-
oxysmal pains in the bowels, constipation, pa-
ralysis, &c, is identical with painters' colic.  (See
Colic, y 25, et seq.)  This form of poisoning is
frequently caused by the absorption of the poi-
son either by the lungs, or by the skin, or both.
It has been found that, where the carbonate of
lead was ground in a dry state, both  the labour-
ers and  animals have died from its effects, ow-
ing to its diffusion in a state of impalpable pow-
der in the air.  Even the air of a newly-paint-
ed room, especially when it is slept in, will, in
some constitutions, produce  acute  or serious
effects ;  but the chronic operation of this agent
is most common.   The  diagnostic symptoms
of this latter form of poisoning have been fully
stated in the article  referred to ; but recently
Dr. Burton has shown, that  blueness of the
edges of the  gums, where they join the bodies
of the teeth,  generally attends, or even  pre-
cedes, the usual symptoms of this  form.  Dr.
Chowne, however, contends that the presence
or absence of this sign is not connected with
the effects of lead.   Chronic poisoning by the
carbonate of lead is not infrequently caused by
water which has passed through lead  pipes, or
been kept in lead cisterns, especially  if these
have been  new, and if the water contain  car-
bonic acid.   Hard water, or  water containing
the sulphate of lime,  or any of the neutral salts,
produce little or no action on  metallic lead.
(■See Guy's Hoxp. Rep., vol. iii, p. 70.
  [As most of our large cities are supplied with
water from lakes or  streams  conducted to res-
ervoirs,  and hence distributed, through iron or
lead pipes, to the inhabitants, it becou es a ques-
tion of great importance whether lead should be
employed  for  such a purpose.  The following
facts are worthy of record in  this connexion :
  "The salt of lead  formed by the  contact of
water with the metal is the  carbonate.  This
salt is produced either by the action of water
containing carbonic  acid, or by water contain-
ing little or no saline matter.   The carbonate
is mixed with a small proportion of the hydra-
ted oxide of lead.  In the case of pure water,
the free access of atmospheric air is essential
to the change, for distilled water deprived of
its gases by boiling, and excluded from the air,
has no action on lead.  When rain, or distilled] 
POISONS—Depressing—Preparations of Lead.
397
or very soft water is left in contact with pure
lead, with the free access of air, a white  pow-
der collects in a few minutes around the metal,
and this goes on increasing till, in a few days,
white, pearly scales are formed, which either
float on  the water, or fall to the bottom of the
vessel.  The formation  of the  carbonate and
the corrosion of the metal go on as long as the
air has free access to the water.   At the same
time a small quantity of lead is dissolved.
  " On the other hand, various saline substan-
ces held in solution in water have the effect of
preventing the formation of the carbonate. In-
deed, all the neutral salts possess this power in
a greater or less degree.  Sulphate of lime af-
fords the most complete  protection, so small a
quantity as one part in 5000  effectually pre-
venting the formation of the carbonate.  Some
kinds of river water, as that of the Thames and
the water  used  in  Edinburgh, contain saline
matters in sufficient  proportion to render the
use of lead perfectly safe.   The same remark
applies to most spring waters.  But the waters
of some rivers and  springs are so destitute of
saline matters as to act powerfully on lead.
   " It may be stated, then, as a general result,
that the action of water on lead, and the con-
sequent danger of conveying and preserving it
in pipes or cisterns  made of that material, va-
ries directly as the purity of the water.  It fol-
lows that we may render the  use of lead for
such purposes perfectly safe by the artificial ad-
 mixture of saline matter with the purer kinds
 of water.   Sulphuric acid, by forming an insol-
 uble sulphate of lead, is also an efficient pro-
 tection.  The use of lead is attended with  most
 danger when it is employed to  collect or pre-
 serve rain or snow water, or spring water of
 unusual purity, and the danger is increased by
 the use of leaden lids to  cisterns, the pure wa-
 ter rising by a natural process of distillation,
 and collecting on the lid.
   " There is one cause which greatly facilitates
 the action of water  on lead, and which may act
 with sufficient energy to neutralize the preserv-
 ative effects of saline matter, and be even in-
 creased by  its presence, namely, the galvanic
 action excited by the contact of some other
 metal with the lead, or of the solder used for
 joining the sheets of lead.  It must, moreover,
 never be forgotten that carbonic acid, if present
 in  the water, will  completely counteract the
 preservative effect of the salts above mention-
 ed.  We cannot, indeed, too strongly deprecate
 the use of lead for cisterns and water pipes un-
 der any circumstances."
   The Croton water of New York contains only
 about four grains of solid matter to  the gallon,
 and is consequently so pure as to act upon lead
 with great rapidity.   The same remark will ap-
 ply to the water about to be supplied to the city
 of Boston.   Mr. Ewbank, of New York, has in-
 vented a process of tinning lead pipe, which is
 said to render it perfectly safe  against the ac-
 tion of water.  But it is evident that if any por-
tion of the pipe remains untinned galvanic ac-
tion will be set up, and  the lead dissolved still
more rapidly.  On the  whole,  iron pipes only
should  be employed  for this purpose   See my
appendix to Towers's Illustrations of the Croton
Aqueduct; New York and London 1843J
   282 f Iodide of Lead.—Pulmbi Iodidum— As
this substance is employed in medicine, it is ne-
cessary that  the injurious effects produced by
it should receive attention.  It is a fine yellow
powder,  sparingly soluble in  cold  water, but
readily soluble in boiling water.  Twenty-four
grains of the  iodide were given to a cat, in two
doses, with an interval of four hours between
them.  The animal suffered violent  colic, and
died in three days ; but no  signs of irritation
were  observed after death.  Iodide  of lead  in
doses of from five grains to thirty were given
to a bulldog.   On  the fifteenth day the animal
refused food, and kept in the recumbent posture.
He died on the eighteenth day,  having swallow-
ed altogether upward  of ten  drachms of the
iodide.  During the whole period he had  only
three  or  four intestinal  evacuations.  I have
employed this substance both internally and ex-
ternally ;  but it has not, in the form I have
prescribed it, produced any marked signs of ir-
ritation.
  283. g. The effects of the chloride of lead and
of the chromate of lead I have not observed; but
there  is every reason to believe that they would
be poisonous  in large doses, the latter especial-
ly.  The sulphate of lead has usually been con-
sidered as inert by Orfila  and others.   The
nitrate of lead acts in a similar manner to the
acetate.
  284. h. The Oxides of Lead.—The yellow ox-
ide, and the brown oxide—peroxide—are but lit-
tle  known unless  to chemists.   Litharge and
minium  (red-lead) are much used in the arts,
and have caused  poisoning accidentally.   Li-
quids  used for culinary or dietetic purposes, es-
pecially if they contain  a free  acid, may be-
come  impregnated with  oxide of lead, derived
from the glaze of the vessel in which they are
kept forming poisonous salts.   Litharge glaze
may also be dissolved by alkaline and fatty sub-
stances.   All newly-glazed vessels yield traces
of lead on boiling in them acetic acid or caustic
potash;  the  oxide of lead being dissolved  by
the acid or alkali.   Litharge was formerly much
employed to  remove the acidity of sour wine,
and convey a sweet taste ; an acetate, or some
other vegetable salt of lead being in these ca-
ses formed.  Many years since, a fatal epidem-
ic colic prevailed in Paris owing to this cause.
The adulteration was discovered by  Fourcroy.
 Wine thus adulterated is known  by its being
blackened fry hydro-sulphuret of ammonia.   Ci-
der, new rum, and sugar are sometimes the me-
dium of conveying the salts of lead, owing to
lead  or  its oxides being employed  in certain
parts of the apparatus or substances  used in
their  manufacture.   Dr. Trail found that, when
new rum is kept in oaken casks, the tannin of
the oak  is slowly dissolved by the  spirit, and
the lead  is precipitated in  an insoluble form,
 the spirit thus becoming wholesome.
  285. i. The appearances observed  after  death
 from lead poison  have  been  very loosely de-
 scribed;  and those which have  merely  been
 the results of congestion, of the coagulation of
 the blood  in the veins and venous  capillaries,
 with  more or less discoloration from the chem-
 ical action of the poison, have been stated to
 have been inflammatory.   Dr. Mitscherlich
 found that, when the  dose  of the acetate was
 large, the villous  surface of the stomach was
 chemically changed by  it—softened, corroded,
 and  reduced to a whitish colour, owing to the
 combination of the salt with the tissue.  When 
398
POISONS—Depressing—Hydrocyanic  Acid.
given in a small dose, the acetate was decom-
posed by the gastric secretions, and exerted no
corrosive action on the villous surface.   When
this salt was reduced to a state of an albumin-
ate and dissolved by acetic acid, death took
place with great rapidity ;  but the stomach was
not found corroded.  This effect was produced
by the neutral  salt only, and not when the dose
was small, or when  the poison was combined
with an acid.  (Taylor.)—In the cases of poi-
soning with Goulard's extract mentioned above
(y 279), the villous membrane of the stomach
was found by Dr. Bird of a gray colour, but oth-
erwise perfectly healthy.   The  intestines were
contracted, in  one  instance more so than in the
other.   In a case of acute poisoning by this ex-
tract that terminated fatally in forty-eight hours,
the villous coat of the digestive canal, from the
oesophagus downward, was softened, and was
said to present inflammatory appearances.  The
mucus on the internal surface of the canal con-
tained much of the poison.   The changes ob-
served after death from the chronic form of poi-
soning by lead are described at another place.
(See Colic, § 25, et seq.)
  286.  k. The  modus operandi of the prepara-
tions of lead deserves attention.  These prep-
arations, according to their physical conditions
and modes of administration, may  act  locally
or remotely, or in both ways.  Certain of them,
as the neutral acetate, by combining with the
tissues,  may  act chiefly  locally, and be only
slowly  absorbed.  Their  remote action may
arise from  their absorption from the digestive
canal, from the skin, or from the lungs.   When
thus absorbed, to such an amount as to affect
the organic nervous and vascular systems, the
following effects appear :  the temperature of
the body sinks, the pulse becomes smaller and
slower,  the capillaries are  somewhat constrict-
ed, the secretions from mucous  surfaces dimin-
ished, and haemorrhages, where they exist, are
checked. ' This  sedative and constringent op-
eration  is manifested chiefly in exhaling and
secreting surfaces and organs.  If the poison
continue to be absorbed, the nervous and mus-
cular systems are more  or less affected, and
the nervous and muscular systems of organic
life are  the first to betray disorder;  as evinced
by  anxiety at  the epigastrium, colicky  pains
through the abdomen, especially in  the  course
of the colon,  spasm  of the muscular coats of
the bowels, impaired secretion, and constipa-
tion.  As the  effects proceed, pain  extends to
the spine and  to the limbs, spasms affect the
muscles, especially of the extremities, or par-
tial loss of sensibility or of the power of mo-
tion, or  of both,  appears.   Ultimately the palsy
becomes more  or  less  complete, or giddiness,
sopor, coma, or convulsions supervene, or even
death takes place preceded by either of these.
  287.  Thus a sedative and an astringent action,
and subsequently morbid sensibility, followed by
spasm, and next by palsy,  are produced by the
absorption  of these poisons.  These  effects
generally appear to a  greater or less  extent,
first, in  the organic or involuntary, and extend
to the animal  or voluntary, nervous, and mus-
cular systems.   But occasionally they are only
slight in the former, although severe or even
fatal in  the latter; or they are most severe in,
or altogether  limited to,  the former.   There
can be no doubt of these effects being produced
by the presence of the poison, in the state ei-
ther of an oxide, or of a salt, or in some other
form or compound, in the blood, and in the tis-
sues.  Orfila  detected lead in the urine of a
female who swallowed  an ounce  of tho ace-
tate ; Tiedemann  and Gmelin  in the blood of
animals  poisoned by it; Mr.  Taylor  in  the
milk of a cow poisoned by the carbonate;  and
Professor Cozzi, Wibmer, and others, in the
blood, muscles, and viscera, after painters'colic.
  288. I. Treatment.—The more acute form of
poisoning by any of the preparations of lead re-
quires the exhibition of demulcents or diluents,
holding in solution some sulphate—as of soda,
magnesia, potash, or alumina.   If vomiting does
not follow the free exhibition of these, the sul-
phate of zinc may be given,  or the  stomach-
pump  be  cautiously  had recourse to,  or  the
throat or fauces may be tickled. If the patient
has  been poisoned by the acetate, the carbon-
ates should be avoided, as they would increase
the activity of  the poison, while the sulphates
would render it inert.   Albumen  and casein,
the  albuminous principle of milk,  precipitate
the oxides of lead, and are, therefore,  excellent
antidotes when given in large quantities.  The
treatment should be somewhat different in ca-
ses of acute poisoning by the carbonate of lead.
Mr» Taylor remarks, that the alkaline sulphates
should not be employed as antidotes for these,
since it requires long digestion at  a high tem-
perature for these  salts to react on the carbon-
ate of lead,  and even then the decomposition
is only partial.   He suggests, therefore, the ad-
ministration of an alkaline sulphate mixed with
vinegar, or some weak vegetable acid, such as
lemon-juice.   Emetics  or the stomach-pump
should also be employed.  Afterward  the bow-
els ought to be  duly evacuated, and oleaginous
and demulcent  enemata thrown up.   If irrita-
bility of stomach  continue, opium should be
given, and the  colicky and paralytic symptoms
ought to be treated  as advised in the  article
Colic (y 60-68).
  289. G. Hydrocyanic  Acid and the  Cyan-
ides.—Oil of bitter Almonds, &c.—Prussic acid,
since its operation  has  been  more generally
known, especially as respects its rapid and  un-
erring effects, has been frequently employed for
self-destruction, and in some instances even for
murder.  Death has also occurred from  it, ow-
ing to accident.  In 1837-8 there were twenty-
seven cases of poisoning by it. nearly all of
which were suicidal.   This substance has been
variously classed by writers on Medical Juris-
prudence ; some have viewed it as a narcotic, be-
cause it produces insensibility in  fatal  cases.
Others have considered it as an irritant poison,
because it often produces spasms or convul-
sions, although no evidence of irritation is fur-
nished by it on the  tissues.   But spasms or
convulsions  attend all intense  impressions on
the nervous  system, especially when these im-
pressions destroy life. Others, again, believe it
to be both narcotic and irritant, or narcotico-ir-
ritant; and, not being content with  imputincto
it a single properly which it does not  possess
assign to it two properties of which it  is equal-
ly devoid ;  for  no one  becomes unconscious
from it, or is spasmodically or convulsively af-
fected  by it. if, indeed, they be so affected at
all,  until life is  departing or about to depart
As it, therefore, annihilates the manifestations 
POISONS—Depressing—Hydrocyanic Acid.                    399
of life in a few seconds, and in a way in which
no irritant or narcotic ever acts, however en-
ergetic, comparing its action with theirs ; and
as there are no other terms which convey the
idea of  its mode of action  better than  sedative
or paralyzing, I am obliged to adopt them,  as
indicating the privation of sensibility and all vi-
tal action, the chief properties evinced by  it,
when applied in a poisonous dose to a living
body, as indicating the annihilation of life.
  290. Common hydrocyanic acid is a mixture
of the pure  or anhydrous acid with water, and
sometimes with alcohol.  As it is kept in shops,
it varies from 1-3 to 6 5 per cent, of the anhy-
drous acid.   The two chief forms in which it is
kept are  that of the London Pharmacopoeia,
which contains 2 per cent., and that of Scheele,
 which contains from 4 to  5 per cent, of anhy-
 drous acid.
  291.  a. The symptoms caused  by  poisonous
 doses of this acid vary with the mode of exhib-
 iting it, and with the quantity up to a  certain
 amount;  but, beyond that, the effects are tol-
 erably uniform.   Inhaling  the vapour of hydro-
 cyanic  acid produces death more rapidly than
 any other mode  of employing this poison.  Dr
 Pereira caused the almost instantaneous death
 of a rabbit  by applying its nose  to a receiver
 filled with the vapour.   This acid also acts rap-
 idly when applied to an abraded surface  or to a
 wound.  Sobernheim states that an apothecary
 at  Vienna died  within an hour  after the  en-
 trance of the acid into a wound in the hand
 produced by the glass vessel in  which it was
 contained.  Even when applied  to the sound
 skin it produces some degree of action.  After
 applying Scheele's acid to the fingers  a short
 time, I experienced  numbness, extending con-
 siderably above the place of application, that
 continued for several hours, and on one occa-
 sion the whole day.  Dr. Christison says that
 M. Robiquet's fingers  were numb for several
 days after their exposure for some time to  the
 vapour of the acid.   Judging from these facts,
  this acid cannot be viewed as devoid of influ-
  ence upon the unabraded or whole skin.
    292. b. On mucous membranes this poison acts
  with rapidity and certainty.   Mr. aNunneley,
  whose researches into the operation of  this
  substance have  been most extensive, states,
  that when  applied upon  a mucous membrane,
  as the conjunctiva, the rectum,  or the vagina,
  prussic acid acts with as great rapidity as when
  swallowed   A knowledge of this is of impor-
  tance, as poisoning may be effected in this way,
  and detection of the crime would be very diffi-
  cult.   The  action of  the acid  on  the lungs,
  when  air impregnated with  it is breathed, is
  not only rapid,  but certain in its effects, and is
  one of the easiest modes of exhibiting it,  but
  the most difficult, after a few hours, to detect,
  as the odour, being so diffusible, is very soon
  dissipated.
    293 c. When swallowed, prussic acid produ-
 ces almost instantaneous effects, if the quantity
 be sufficient to destroy life, or  if the  stomach
  be not loaded with food, which may  intercept
 a large portion of it, and delay its operation.*
  [* Hydrocyanic acid never operates instantaneously, as
we believe, there always elarwm? a sufficient interval for
it to reach the lirain through the medium of absorption.
This fact has been abundantly proved by the experiments
of Mr. Blake.]
But the symptoms produced by a dose hardly
or barely sufficient to cause death are different
from those observed when the quantity is large,
and death very  rapid.  The  effects  are more
rapid and certain in young and delicate persons;
in weak  constitutions, and when the stomach
is empty, than in the middle-aged and the ro-
bust, and when the stomach contains more or
less food.—(a) A small, poisonous dose occasions
a bitter, warm taste, which is soon followed by
sensations of faintness and giddiness.  The res-
piration becomes slow, difficult, and spasmodic,
the pulse small or imperceptible ; and insensi-
bility supervenes, often  with convulsions;  a
state resembling an epileptic paroxysm being
sometimes produced.  The pupils are either con-
tracted o-[.dilated, and the eyes staring.  If the
treatment about to be recommended  be resort-
ed to in this state, recovery usually takes place
rapidly, vomiting often occurring.
   294. (b) In a  large or  rapidly fatal dose, the
phenomena are such as hardly admit of obser-
vation ; death follows so quickly, and is attend-
ed by so few symptoms, excepting the cessa-
tion  of sensibility, of breathing, and of the
heart's action.   In the  case of a chemist  in
my vicinity who took more than an ounce of
Suheele's preparation, death must have occur-
red in a  few  seconds, neither spasms nor con-
vulsions having  been observed.  In a case com-
municated by Mr. French to Mr. Taylor, sev-
en drachms of the common prussic  acid were
taken, and  about two  minutes afterward he
was found lying on the floor insensible.  There
were  no convulsions of the limbs  or trunk;
but  a slight flickering motion  was observed
about the  muscles  of  the lips.   Respiration
seemed  to  cease for some seconds;  it was
then renewed in fits, expiration being deep and
slow.  The deceased took the poison while as-
cending the stairs ;  his body was found on the
landing ; the bottle had rolled some distance
from him ; the stopper was lying in another di-
 rection.   Simon relates a case in which  an
 ounce was  taken ;  the  symptoms were the
 same.  The hands and feet were cold, and  no
 pulse could be felt.   The finger-nails are  often
 of  a livid  colour, and  the hands clinched.
 When the dose is large, the odour of the acid
 is generally exhaled from the mouth.
   295. d. The utterance of a scream or shriek
 has been said to be indicative of poisoning by
 this  acid;  but  Mr.  Taylor states  that this
 symptom does not occur in the human subject;
 and Mr. Mills, the deputy coroner, says that
 his inquiries show that it does not occur. There
 is merely a gasping for breath, or a  low moan-
 ing or  sobbing noise.  Mr. Nunneley found
 that the shriek or cry did not occur in  more
  than about one  half the number of cases of an-
  imais, and only in one third very loudly.  When
  it was uttered  in animals, it was of a peculiar
  kind, and  so indicative of distress  as to give
  an idea of consciousness on the part of the an-
  imal of impending death ;  it was characteristic
  of the poison.   When the dose of prussic acid
  is small but still fatal  in the human subject,
  convulsions  have  sometimes been  observed;
  hut they have not been met with when the dose
  has been large  and death  rapid.   In these lat-
  ter oases the symptoms have been scarcely no-
  ticed, but  are probably the  same  as seen  in
  the lower animals, namely, imperceptible pulse, 
400                   POISONS—Depressing—Hydrocyanic  Acid.
insensibility, a few deep and slow respirations,
and  death.  Mr Nunneley's experiments, as
well as the  history of several  cases  in which
large quantities of this poison have been swal-
lowed, show that death is seldom so rapid as
to prevent volition and voluntary motion being
exercised for a few seconds afterward ; but in
a few seconds death often takes place without
a struggle.  The most rapidly fatal case  with
the particulars of which I am acquainted, was
that of a gentleman whom I knew, and which
occurred in 1828. Above an ounce of Scheele's
acid was taken.  Instantly upon swallowing it,
he mult have repented of his act, for he hasti-
ly called out, brandy, ammonia, repeating the
words, fell down, and never moved afterward.
In some few instances, Mr. Nunneley found
the action of the poison  so  expeditious as to
prevent the slightest exhibition of voluntary
motion ;  but in the majority of warm-blooded
animals and dogs, about twenty seconds elaps-
ed before the symptoms were manifested ;  thus
allowing,  presuming  that  a similar  interval
would occur in man, sufficient time for several
acts being performed, which were supposed by
many to have been doubtful, if not impossible,
after the ingestion of the poison.
  296  e. It has been supposed that  this  acid
possesses an accumulative property; that  after
having been taken for some time, in moderate
doses, without any apparent mischief, it  may,
without any remarkable increase of  quantity,
suddenly give rise to all the effects of poison-
ing.   Mr. Taylor states  that one case is re-
ported which renders  this opinion probable,
and  another has been communicated to him
which tends to confirm it.  Dr. Lonsdale, who
has  paid some  attention to this matter,  does
not admit that prussic acid possesses this prop-
erty, on account of its volatility and  diffusive
influence ; and although I have very frequently
prescribed this substance, I have not seen any
proof of an accumulative influence.  Mr. Tay-
lor  states that serious effects  have  followed
slight alterations made in the dose ; but I have
never met with such.  The  proper test is  to
observe whether or no such effects follow the
persistence in the use of the same dose.   It is
very important,  practically, to determine the
question.
  297. /.  Post-mortem Appearances.—In cases
of suicide or accident, the  vessel which  con-
tained this poison will generally be found  near
the body.  But the person poisoned may have
thrown it from  him upon swallowing its  con-
tents.  The  body commonly exhales an odour
of prussic acid for some time after death ; but
if it  has remained exposed for some  time be-
fore  it is seen, and especially if it be exposed
to  the open air, or in a shower of rain, the
odour may not be perceptible.  Putrefaction is
said  to be accelerated after death by this poi-
son.   This appeared to have been the case in
two  instances which I had occasion to observe.
Mr. Taylor doubts this effect.   Orfila states
that  in  most sudden  deaths,  from  whatever
cause, putrefaction is, cateris paribus, acceler-
ated. Externally the body is commonly livid ;
the  nails  are blue, the hands  clinched.  The
jaws are closed ; and there is some foam about
the mouth, especially when death has been pre-
ceded by convulsions.   The face is bloated and
tumid ; the eyes prominent, shining, and glassy;
 and the veins are congested with dark blood.
 The stomach and alimentary canal are gener-
 ally in a natural  state ;  the  internal surface
 being  sometimes  red or congested,  as often
 seen after sudden  death.  The lungs  are  gen-
 erally  more or less congested.   The  brain is
 usually congested, especially in the less rapid-
 ly fatal cases, and when convulsions have pre-
 ceded  death.  The blood is sometimes foum"
 quite fluid, in others thicker or semi-coagulated
 It is generally of a dark colour;  but Mr. Tav-
 lor, quoting Heller and Metzdorff, says that
 it is occasionally red, or even of a pinkish  hue.
 Other  changes noticed by writers  may be view-
 ed as accidental.  Indeed, there is  no  organic
 alteration observed that can account for death
 from this poison.   Those now  stated — and
 they are the chief met with—are  slight, and
 are seen in other cases of sudden death.  Life
 is so soon destroyed by this agent as not to al-
 low of any  change beyond simple  congestion
 taking place.  In a case reported by Dr. Geo-
 ghegan, where an ounce of the acid was swal-
 lowed, a patch of dark-red extravasation  was
 found under the villous coat near the pylorus.
 In a case recorded by  Mr. Pooley, the blood
 was of a very dark colour ; but the  lungs were
 not congested ; in  one by Mr. Hicks they were
 much congested ; while in another by Mr. Nun
 neley they were only partially congested.  In
 an instance reported by Mr. Crisp, the abdom-
 inal and thoracic viscera were all healthy, the
 blood imparting to them a purple  hue.   (Tay-
 lor.)
  298.  On opening the stomach the odour of
 prussic acid  is frequently perceptible, and if
 the quantity taken  has been  large, the odour
 may continue for several days  after death.  If
 the inspection has been recent after  a large
 dose, the  odour is often perceived  in  all the
 cavities, and even in the blood.  This odour has
 a distant resemblance to that of bitter almonds;
 but it is accompanied with a peculiar impres-
 sion of acridity on  the nostrils and back of the
 throat.  But this odour—the diluted odour of
 bitter almonds—may be perceived  by some per-
 sons, and not by others; or it  may be entirely
 absent. It may not be present, or not perceiv-
 ed in a very sensible manner in the  dead body,
 if the dose of the poison has been small ; if the
 patient has survived a short time after it has
 been taken ; if it be masked by other odours ;
and if  the body has been dead some  time, or
has been exposed to the air, &c. (y 297).
  [In a case which  occurred  in this city  this
day (March 22d, 1848), where  a gentleman of
middle age took a large quantity of hydrocyanic
acid, and died in his chair, the body presented a
livid appearance.   The pupils of the eyes were
much dilated, and the muscles  of the body very
rigid.  On opening  the chest, the lungs were
 found of a dark colour  and  much  congested
 with blood, and presented the appearance of
 liver when cut.   The liver was of a dark  col-
 our, and congested.  The left side of the heart
 was empty.   The right side contained a little
 fluid blood.  The stomach contained  about a
 gill of dark, bloody fluid, which emitted a strong
 odour of prussic acid.   The mucous  membrane
 was of a dark-red colour, softened  and corru-
 gated.   The  intestines  were  of a red  colour.
 The existence of prussic acid in  the stomach
 was so evident that there could be no  doubt it 
POISONS—Depressing—Hydrocyanic Acid.                    401
was the cause of death.  In two other cases,
the odour of the acid was evident on opening
the cavity of the chest, as well as the stomach ]
  299.  g.  Relation between  the Rapidity of the
Effects  and the Quantity and Concentration of the
Poison.—Dr. Christison has shown, that be-
yond a certain dose  the \yeak and the strong
acids appear to act with equal rapidity.   Ex-
periments on animals and facts observed in the
human  subject, show that a dose of the poison
sufficient to  cause death may have this effect
in as short a time as  a very much larger one ;
that a  drachm of Schef.le's acid may cause
death as rapidly as three or four times the
quantity, especially if the poison be  taken on
an empty stomach, and if the person be weak,
or debilitated  by  disease.  It hence  follows,
that if  two drachms  of this acid be  fatal in a
given time, it cannot be inferred that twice or
four times the quantity will be fatal in one half
or one  fourth of that time.   Mr. Nunneley
states,  " that, wnen called to a person  poison-
ed by this acid, we  cannot,  merely  from the
length  of time he has survived, or the evidence
of the symptoms, determine any thing with cer-
tainty as to the degree of concentration or di-
lution of the acid, nor, except within wide lim-
its, much  as to the absolute quantity  taken."
(P. 83.) He, moreover, found that concentration
does not heighten the effects of this poison, but
that dilution  to a moderate extent even renders
them more speedy, probably from bringing the
poison  in contact with a larger extent  of sur-
face at the same instant.  It may happen that
a dose  just sufficient to destroy life may fail, or
be longer in  producing its effects, owing to its
interception  by the food on a full stomach, or
by other circumstances pointed out above ; but
a quantity sufficient to destroy life under any
circumstances may have this effect with as
great rapidity as three or four times that quan-
tity.  Hence there is no relation, beyond a cer-
tain amount, between the rapidity of the effects,
and the quantity or concentration of this poison.
   300.  h. Quantity required to destroy Life.—Dr.
Geoghegan relates an instance  of a quantity
of the acid having been taken equal to twenty-
seven  drops of the dilute acid of the  London
Pharmacopoeia (at  two per cent.) without any
effect, the dose having been gradually raised to
this amount; but when the dose was raised to
thirty-six drops, the patient in two minutes was
seized with the usual symptoms, and nearly lost
his life.  The quantity of anhydrous acid swal-
lowed in this dose was only about two thirds of a
grain;  but, as this substance had been taken in
gradually  increased doses, the probability of
an  accumulative  effect having  here resulted
should be taken into  consideration: a question
of great practical  importance, but one which is
solved  with difficulty.  Mr. Hicks furnishes, in
the case which he has reported, the  smallest
dose which has been determined with accuracy
as productive of death.  A healthy adult female
took a  dose  equivalent to nine tenths of a grain
of anhydrous  prussic acid, to forty-nine drops
of the  dilute acid of the pharmacopoeia, and to
twenty-five  of Scheele's  acid.  She  died in
twenty minutes.   In a case observed by Mr.
T. Taylor, a stout, healthy man swallowed ex-
actly the same quantity by mistake, remained in-
sensible for four hours, when he vomited, and
began  to  recover.  The vomited matters had
    III.             26
no odour of the poison, and hence  absorption
of it had probably taken place.  This quantity,
nine tenths of a grain of anhydrous acid, or one
grain, may therefore be viewed as sufficient to
destroy human life, although a somewhat small-
er dose may have this effect in certain circum-
stances, or a somewhat larger dose may fail of
producing it in others.  Mr. Taylor thinks that
the largest dose from which an adult has recov-
ered was in a case reported by Mr. Nunneley.
The'person swallowed forty minims of an acid,
at 3| per cent.  The man  was for a short time
conscious,  got  into  bed  after  taking  it,  and
spoke.   He felt his jaw become stiff, and then
remained insensible until roused by the  cold
affusion,  .\lthough recovery took place in this
case, still the inference just stated as  to the
quantity  which may destroy life, remains un-
affected by it.
  301.  i. The period at which death takes place
differs  in different cases, although the dose ta-
ken may have been the same.   This may he ex-
pected from the different circumstances above
shown to influence the operation of poisons. In
the seven cases which occurred in Paris, from
the same dose of the poison given to each at the
same time, death took place after periods vary-
ing from fifteen minutes to three quarters of an
hour.  It is only when the dose is just sufficient
to cause death that an individual survives from
half an hour to one hour;  but I know of no
case in which the period  was longer than an
hour.  In one instance, in which seven drachms
were taken, death took place within five min-
utes ;  and in another, where  an ounce  was
swallowed, within ten minutes.  In the case
referred  to as that  in which the smallest fatal
dose was observed,  death occurred in twenty
minutes.  When  the quantity is two drachms
or upward, the  period  of death varies from
two  to ten minutes.
  302. But it  is necessary to  distinguish be-
tween  the periods  at which insensibility and
absolute death take place  ; for, although death
does not commonly ensue until after a few min-
utes, insensibility, the loss of volition and con-
sciousness may occur in a few seconds.  Dr.
Lonsdale states, that a drachm of Scheele's
acid would affect an ordinary adult within the
minute, and three or  four drachms within ten or
fifteen seconds.  When the  acid is stronger,
and  the quantity larger, he believes the annihi-
lation of the sensorial functions to be immedi-
ate.  Mr. Taylor remarks,  with reference to this
topic, that while, as a general rule, insensibility
may supervene from a large dose in a few sec-
onds, the individual occasionally retains a pow-
er of performing certain acts indicative of con-
sciousness, volition, and locomotion, for a few
seconds.
  303.  k. Diagnosis  of poisoning by  Prussic
Acid.—But little  is  required to be said as to
this topic, after what has  been already advan-
ced.  The effects of this poison will be readily
distinguished from those of opium or of other
narcotics or acro-narcolics,  as  the coma caused
by these poisons is seldom seen until after the
lapse of a quarter of an hour, or twenty min-
utes ;  while insensibility from  this acid, even
in small doses insufficient to cause death, is
very rarely delayed beyond two minutes.* Be-
sides, the patient may be roused from the nar-
cotic influence of opium  or other narcotics; 
402                    POISONS—Depressing—Hydrocyanic Acid.
but he cannot be roused from that produced by
prussic acid until he entirely recovers from it.
Convulsions furnish no diagnostic evidence.
In poisoning by this acid, a fatal issue always
occurs within an hour, more frequently within
a quarter of an hour;  while poisoning by the
substances  referred to seldom  terminates  fa-
tally before a period varying from six to twelve
hours.  The odour of the acid, when  perceiv-
ed, is also an important diagnostic proof (y 297,
298).
  304. It is of the greatest importance that the
effects of this poison should not be confounded
with death from epilepsy, apoplexy, or disease of
the heart, in either  of which death may take
place within the period in which  prussic acid
proves fatal.   A post-mortem  examination will
generally furnish the diagnosis, when no other
evidence can be obtained, or can  be depended
on, especially as regards apoplexy and cardiac
disease; but as respects epilepsy the proofs
may be incomplete, unless the odour of prussic
acid be present.  It may likewise  be important
to determine whether the  poisoning by this
acid has been suicidal or accidental, especially
if the life of the individual be insured.  In gen-
eral, the several circumstances  observed in
connexion with the case are such as at once
explain  the nature of it;  but there  are no
means by which suicide may be mor& secretly
perpetrated  than by that  now  discussed.   As
to this topic, I must refer the  reader to what
has been stated by Mr. Taylor and Dr. Chris-
tison.
   305. I. Modus operandi.—The local and pri-
mary operation of this  poison is certainly upon
the nerves  of the part.  This is shown by the
numbness produced by it when  applied even to
the unabraded  skin.  In some experiments  I
made with  it many years ago, it was  found to
impair the  irritability of muscular parts, and
in some instances to destroy this property alto-
gether in those parts  to which  it  had been  ap-
plied.  It also in these experiments caused dil-
atation  of the capillaries, with congestion and
stagnation of the blood in them.  That the lo-
cal impression made upon the nerves, more es-
pecially upon those of the cerebro-spinal sys-
tem, is rapidly transmitted to the brain, medulla
oblongata, and spinal cord, cannot be doubted ;
for the abolition of the functions of those parts
of the nervous system is generally so instanta-
neous, especially when  the stomach is empty,
that jt cannot be imputed altogether to absorp-
tion  of the poison, although  absorption un-
doubtedly takes place  very rapidly,  and  de-
stroys life :  the insensibility resulting more im-
mediately from the impression of the poison,
the arrest of the heart's action, and death pro-
ceeding consecutively from the absorption of it.
That this poison is absorbed is fully proved by
the detection of it, by chemical agents, in  the
blood, and by the odour of this fluid in the cav-
ities when  they are opened, and in several vis-
cera ; thus showing that its operation on organs
remote from the part to which it is applied, and
the death of the individual, take place mainly
through this channel;  that the heart is para-
 lyzed, and its action altogether arrested by the
 presence of the poison in the blood.  There is,
 however, sufficient reason to believe that the
 very decided and immediate impression produ-
 ced by it upon the  nerves of the  part to which
 it is applied is rapidly propagated to the medulla
 oblongata and brain, through the medium of the
 nerves, before  the poison reaches the nervous
 centres, or heart, by the medium of absorption,
 or through  the channel of the  blood ;  for Mr.
 Ncnn-eley found that, " when the acid was ad-
 ministered by  the rectum or the vagina, both
 hind legs of the animal were sooner affected
 than the anterior part of the body."  (P. 76.) •
   306.  The cause of death, in cases of poison-
 ing by prussic  acid, appears, after the best at-
 tention I can give the subject, and after much
 experience of its medicinal effects, to result as
 follows:  1st. The deleterious impression made
 by the poison upon a sufficiently large surface,
 or to a certain amount, being transmitted by
 the nerves to the medulla oblongata or its vicin-
 ity, causes insensibility, and, if that impression
 is not of overpowering or annihilating  intensi-
 ty, convulsions also.   2d. That the deleterious
 impression is less violently, or more slowly de-
 veloped or extended through the ganglial ner-
 vous system ;  and that, before life is destroyed
 by the impression made on the nervous system,
 absorption of  it, to a greater or less amount,
 into the circulation takes place ; and, 3d. That
 the presence of the poison in the blood entirely
 abolishes the already impaired  respiratory and
 circulating functions by its action upon the ner-
 vous centres, and on the heart itself.  The poi-
 son may thus  be viewed as acting primarily
 upon, and through the medium of the nervous
 system, and consecutively, by  absorption and
 through the channel of the circulation ; the
 latter completing what  the  former mode may
 have failed of  accomplishing.
   307.  m.  The chemical combinations of hydrocy-
 anic acid- are more or less poisonous—(a) Cou-
 lon, Robiquet, Schubarth, and Magendie have
 demonstrated the poisonous action of the hy-
 drocyanate of ammonia, and of the hydrocyanate
 of potass.  A dog was killed  in twenty minutes
 with twenty drops of the diluted acid neutral-
 ized by ammonia;  and another in three hours
 by twenty-five drops  neutralized by  potash.
 Nevertheless,  ammonia is one of the best an-
 tidotes to the action of this acid, when admin-
 istered after the poison.  Orfila relates a case
 in which six grains of the hydrocyanate of po-
 tassa proved fatal within an hour in the human
 subject, when  administered in an injection.
   308.  (b) The deleterious  properties  of the
 ferrocyanates or triple prussiates are much more
 doubtful than those of the former.   Some ex-
j perimqnters with  it have found that the ferro-
 cyanate of potass is poisonous in large quanti-
 ties ; while others state that it possesses little
 or no deleterious property.  Wollaston, Mar-
 cet, Emmert,  Macneven, and Schubarth say
 that a  drachm, or even two drachms,.of this
 substance may be given with impunity to man
 or the lower animals.
   309.  c. The sulpho-cyanic  acid, a substance
 analogous in its nature to the ferrocyanic acid,
 was once supposed, like it,  to  be a  poison of
 great activity; but this, Dr. Christison adds,
 admits of some doubt.  Dr. Westrumb con-
 siders  it  more poisonous in the form of sulpho-
 cyanate of potassa.   Wimber  reports that Soem-
 mering found  both this acid and the salt to be
 poisons of great energy ; for half a drachm of
 concentrated sulpho-cyanic acid given to a dog
j occasioned  immediate  death,  and  the same 
POISONS—Corrosive—Hydrocyanic Acid.                    403
quantity of the salt killed another in one min-
ute.   These substances  require farther inves-
tigation.   They are certainly more energetic
than they have been viewed by Dr. Christison.
Dr. Westrumb  detected  this salt in the blood
and in the viscera.
  310. (d) Cyanide of potassium is a poisonous
salt much used in electro-gilding and  plating.
It is  a solid, sometimes  a chalky-looking,  at
others a crystallized substance, and  without
odour until put into water, .when it is freely
dissolved, forming an  alkaline solution, from
which prussic acid  is abundantly evolved.   It
is used medicinally on  the  Continent.  Mr.
Malaguti states that a dog was killed in a few
minutes after taking less than three grains of
the cyanide  in  solution,  and that the  largest
dose that should be given to the human subject
is five sixths of a grain.   A person was killed
at St. Malo by too large a quantity of it having
been prescribed.   Another person died at Bres-
lau after fifteen minutes from taking a  dose of
a mixture containing fifteen grains of this sub-
stance.  The symptoms were the same as those
produced by the pure acid.
  311. n. Various vegetable  substances  contain
hydrocyanic acid, and are  poisonous in conse-
quence.   The plants which have been found to
yield  hydrocyanic acid belong to the division
Drupacea, of De Candolle's natural order Ro-
sacea.  They are the bitter almond, cherry laurel,
bird cherry, "peach, and the mountain ash.  ^The
poison is procured from these, according to Dr.
Christison, in two forms : as an essential oil,
and as a distilled  water.   The distilled waters
yield  hydrocyanic acid, and an essential vola-
tile oil, which also  retains much of this acid,
which is peculiar, and which requires  farther
investigations into its constitution and effects ;
but I must refer the reader to Dr. Pereira's
Materia Medica, where  the subject is fully dis-
cussed.   (See vol. ii., p.  1536.)
  312. (a) The volatile  oil of bitter almonds, and
even the bitter almonds themselves, are poison-
ous, and owe this property to prussic acid, none
of which, however, exists already formed in the
kernel of the fruit, nor  is it produced unless  by
the agency of water on the kernel.  Evep the
mastication of the kernel produces the poison
which destroys life.   Mr. Tayeor found that
mere trituration of the  almond kernel with
water produced hydrocyanic acid.  There are
instances on record, wherein these almonds,
when eaten  in  large quantity, have produced
dangerous symptoms, and even death.   The vol-
atile essential oil is  a most act>ive poison ;   its
deleterious action depending entirely upon the
hydrocyanic  acid which is intimately combined
with it.   Five  pounds of the almonds  are said
to yield about half an ounce of the oil,  and the
quantity  of  anhydrous  acid  contained in it
varies, according to Dr. Christison, from eight
to fourteen per cent.   It  is thus at least four
times as strong as the dilute prussic acid of the
pharmacopoeia.   Sir B. Brodie,  happening  to
touch his tongue with a rod which had been dip-
ped in this oil, suffered almost instantaneously
an indescribable sensation at the pit of the stom-
ach, feebleness of the limbs, and loss of power
over the muscles ; these effects being, however,
quite  transient, but sufficiently evincing  the
raDid  propagation of the deleterious impression
through the medium of the nervous system.
  313. Several instances of poisoning by this
oil are recorded; and some have been noticed
by  Christison, Pereira, and  Taylor.   The
last of these writers adduces the following:  A
druggist  swallowed  by mistake  half an ounce
of " almond flavour."  In half a minute he fell
down in a state of syncope, his face being deadly
pale, and his pulse imperceptible.  After some
time he rallied, and  vomited  some undigested
food and  bile strongly impregnated with the
odour of bitter almonds.   Delirium, with  slight
convulsions, came on.  He then became sensi-
ble, and conversed upon  his condition ;  but he
again gradually relapsed into delirium, his eyes
being prominent and brilliant.   In a few min-
utes he again  became sensible, and slowly re-
covered.    The quantity  of " almond  flavour"
which  he had  taken contained about half a
drachm of essential  oil.   In a case which oc-
curred to  Dr. Bull of  Hereford, seventeen
drops of the oil destroyed the life of a woman
aged forty-nine in half an hour.  Mr. Taylor
here justly remarks  upon the disgraceful state
of medical police and legislation in this country,
in the fact of a most virulent  poison being sold
for  the purpose of  flavouring  pastry  and li-
queurs ; but Mr. Taylor  cannot surely be ig-
norant that British legislation does not concern
itself with means which either  destroy or pre-
serve human life, until public opinion or an over-
whelming necessity compels  attention to such
matters, and then they become objects of dis-
gusting jobbing  and  disgraceful  traffic, the
measures which they produce benefiting chiefly
the subservient supporters of a political party,
the members of a clique, the satellites of power,
and the worshippers  of mammon.
  314.  Even a very small dose of this oil may
cause fatal effects.   Mr. Taylor, among other
interesting cases, gives the following:  A girl
about eight or nine  years of age  swallowed
about a teaspoonful of " ratafia," composed of
one part of the essential oil of bitter  almonds
and seven parts of spirit.  About seven  drops
of the oil were taken.   When seen immediately
after the accident there were complete insen-
sibility, closed eyelids,, brilliant and glassy eyes,
dilated pupils, quick pulsation of the carotids,
no pulse at the wrist, relaxation of the muscles
of the extremities, and rigid contraction of the
muscles of the lower jaw.  Cold affusion with
stimulants, stimulating frictions, and emetics
were employed.  Vomiting was induced ; the
ejecta bad a strong smell of prussic acid ; and
the child recovered.  (Smith, in Lancet,  June,
1844.)  In a fatal case of poisoning by this oil,
no odour was perceptible about the mouth when
the body was found ;  but upon inspection, a pow-
erful odour of prussic acid escaped from the
cavities.   All  the viscera were in a healthy
state.  (Med. Gaz., April 7, 1843.)  The vapour
of this oil, although it may  cause vertigo or
stupor, is not  likely to produce death unless it
be inhaled for a considerable time.
  315. (b)  Laurel wafer—Cherry laurel water—
is a very weak solution of prussic acid, contain-
ing about a quarter of  a grain per  cent, of the
strong acid.   In  large doses it produces the
usual effects of prussic acid.   Cherry laurel was
formerly much used for flavouring liquours and
sweetmeats.   Almost  every  part of the  plant
is poisonous, especially the leaves and kernels,
but the pulp of the cherry is not.   Cherry laurel 
404
POISONS—Depressino—Hydrocyanic Acid.
oil is a weaker poison than the oil of bitter al-
monds, and contains about three per  cent, of
the anhydrous acid.  Coullon relates an in-
stance of the death of a child from the applica-
tion of the leaves to a large sore on the neck.
The distilled water and the oil of this plant are
poisonous when introduced into the rectum, or
into the cellular tissue, or injected into a vein,
and when thus employed, or when swallowed,
they occasion giddiness, palsy, insensibility,
convulsions, and death ; thus acting in a similar
manner to the pure acid.
  316. (c) Peach flowers and kernels, and the
fresh young shoots  of the plant, are poisonous.
Coullon adduces two  fatal cases of poisoning
with peach blossom.   But the effects are different
from those produced by pure hydrocyanic acid,
as the peach blossom acts more as an irritant
of  the  digestive canal,  and causes,  in addi-
tion to insensibility and convulsions,  efforts to
vomit, and violent purging.  A  medical man
swallowed half an ounce of a liquid prepared
by  digesting gin on a large quantity of peach
kernels.   He became  giddy,  and had violent
constriction of the fauces, and dimness of sight.
He vomited and recovered.  (Taylor.)  There
are other plants which yield a distilled water
and an  essential oil containing more or  less
prussic'acid ; but as these are not used, at least
in this country, I shall only refer to Dr. Chris-
tison's  excellent work respecting them.
   [We have in this country the Prunus Virgini-
ana (wild cherry), Prunus nigra (black cherry),
and Prunus  Caroliniana, all containing hydro-
cyanic acid ;  besides the  Amygdalus Persica, or
peach (its  kernels, leaves, and flowers),  Sor-
bus (mountain ash), &c.
   The leaves of the wild cherry are often pois-
onous  to animals, as  calves  and sheep, and
birds are intoxicated by its berries.  An oil may
be obtained by distillation from the bark, which
proves  extremely destructive to animal  life.
Mr. Praeter, of Philadelphia, supposes this oil,
when purified, to be  identical with the hydruret
of benzale (purified  oil of bitter almonds) of
Liebig  and Mohler, and that its deleterious
properties are due  to prussic acid alone.  Chil-
dren have been known to be poisoned by eating
freely of the fruit of the wild  cherry.   The
symptoms observed have been vomiting, stupor,
dilated  and insensible pupil, loss of strength,
small  and frequent  pulse, pale skin,  clinched
 jaws,  inability to  speak or swallow,  and  cold
extremities.  Aqua ammonia is one of the best
remedies in  these  cases, with mustard cata-
plasms to the stomach and extremities.  Birds
are sometimes  intoxicated by this fruit, and
easily caught.  The bark of the  black cherry
has proved poisonous in several instances when
 infused in cider.  The kernels of the peach are
 often distilled for  the  purpose of impregnating
 cau de  noyeau, which proves  poisonous when
 taken in any quantity.]
   317. o. Treatment of Poisoning by Prussic Acid
 and its  Compounds.—(a)  The remedy which is
 most efficacious in the treatment of the effects
 of these poisons is fortunately one which may
 generally be obtained without delay, namely,
 cold water, the affusion of which upon the head, oc-
 ciput,  and nape  of the neck rouses the patient
 from his insensibility more rapidly than any
 other means.  This treatment was first recom-
 mended by the author of this work in the Lon-
don Medical Repository for July, 1825.   It then
attracted no attention, and was not even no-
ticed by any of his contemporary editors.  Dr.
Herbst, of Gcittingen, however, in 1828, three
years afterward, recommended the same rem-
edy, and the recommendation was then noticed
in the British  medical journals.  The author,
however, asserted his prior claims in the ninth
and tenth volumes of the Medical Gazette.  Dr.
Herbst made  several experiments on animals
to show the efficacy of this  treatment, which
has now been  tested in many cases in the hu-
man subject. It is, of course, the more success-
ful the earlier it is  employed;  but as long as
respiration and the heart's action continue, it
should be resorted  to and repeated according
to its effects.   The presence of convulsions,
or of general palsy in addition to insensibility,
should not prevent  the  administration of it.
Indeed, convulsions and spasms may furnish
grounds for hopes of success from  it; and in
cases where the insensibility and general palsy
have  been extreme, the occurrence of convul-
sions or spasms has been indications of com-
mencing benefit.   The water should be about
the temperature  of spring  water; should be
made to fall in a full and large stream upon the
head—the vertex, occiput, and neck, and be
repeated at short intervals, according to its ef-
fects, and in a similar way to that advised by
the author for poisoning by opium.  (See Lond.
Med. Repos., vol.  xviii., and  hereafter.)
  31§. (b) Ammonia has been considered by
many as the most energetic antidote.  It  was
advised by Mr. John Murray, and may be em-
ployed by inhalation, or in any other manner,
according to the state of the case. When given
internally, the strong aqua ammonia should be
diluted with twelve parts of water.  It is most
advantageously employed when the patient  is
roused,  or even partially roused, by  the cold
affusion ;  and  then the inhalation of the vapour
of ammonia, if properly managed, is more  effi-
cacious than the ingestion of the remedy, which
may not be accomplished, or even  attempted,
when insensibility, convulsions, and spasms of
the muscles of the jaws are urgent.
  319. (c) Chlorine has also been advised as an
antidote  for this poison  by Riaux,  Buchner,
Simeon, Cottereau, and Valette. Orwla con-
siders it the most efficacious antidote  of any
hitherto  advised.  Unfortunately, the patient
may be dead  before the antidote can be  pro-
cured in almost every instance in which it will
be required.   The excellence of a remedy will
avail the  patient but little when it cannot be
procured, or when he is  no  longer capable of
breathing or swallowing it when it reaches  him,
even when  it  has been procured with the ut-
most rapidity.
   320. The means, therefore, upon which  con-
fidence may be placed are the cold affusion, the
inhalation of  the vapour of diluted  ammonia,
or of chlorine, when it can be obtained in time,
and the ingestion of stimulants.  As this poi-
son is usually taken with a suicidal intention,
an excessively large dose is generally swal-
lowed ; and this excessive quantity often pre-
cludes success from any of the means already
mentioned, or from any other.  The immediate
evacuation  of the stomach by the  stomach-
pump, or the  administration  of a zinc emetic-
conjoined with cordials and stimulants, as cap- 
POISONS—Exciting and Exhausting—Alcohol.
40'5
sicum, &.c, ought not to be overlooked.  As
this poison and  its compounds cause  conges-
tion of blood within the cranium, blood-letting
or cupping on the nape of the neck may prove
most  beneficial in some cases, where this ef-
fect  appears most urgent, and  the habit of
body admits of this practice. But it should not
be overlooked that blood-letting may accelerate
the absorption of the poison ; and therefore the
stomach should be emptied in the first  place, if
it be considered that much of the poison still
remains in it.
  321. H. Zinc—Oxide of.—This substance is
not productive of serious effects even when
taken in large quantity.   Owing to  its insolu-
bility, its absorption must be slow.   When ta-
ken internally for a long time, it  acts as a slow
poison,  and produces  a tabes sicca.   A gentle-
man, for the cure of epilepsy, took daily twen-
ty grains of the oxide, until he had consumed
3246  grains,  which must have been a course
of five months' duration.   At the end  of this
time he was pale, wasted  away, almost idiotic,
and the surface of an earthy hue.  His tongue
was thickly coated, the bowels constipated, the
inferior extremities cold  and oedematous,  the
abdomen tumid, the superior extremities cold
and  shrivelled, and the  skin dry like parch-
ment ; and the pulse about sixty, thready, and
almost imperceptible.  Under the use  of pur-
gatives, a light,  nutritious diet, and  tonic and
diuretic medicines, he rapidly recovered;  but
still remained subject to epileptic attacks.—
(Brit, and For. Med. Review, July, 1838.)
   322. J. The Vapours of Ether, [of Chloro-
form], and of Alcohol, when inhaled  into the
lungs until they are imbibed bythe blood circu-
lating in the  bronchial surface and lungs, pro-
duce a paralyzing influence upon the cerebro-
spinal nervous influence, the vapours of  the
 ethers  paralyzing or  altogether suppressing
 sensibility ; and the vapour of alcohol affecting
more especially voluntary motion, or both vol-
 untary motion and sensibility.*  Owing to these
effects, the consideration of these agents might
have fallen under the present class ;  but I shall
 notice them  more particularly under the class
of stupefying  or narcotic poisons.
   323.  Class III.  Excitants—Stimulants—
 Exciting and Exhausting Poisons.—There are
various substances which are simple excitants
or stimulants, as respects either the  nervous
influence or vascular action, and which, when
taken in moderation, are  in no  way injurious,
unless a too frequent recourse-be had to them.
If, however, those be administered in excessive
doses, they may produce injurious or even fatal
results, owing either to  excessive stimulation
or to its consequences, especially exhaustion,
congestion, effusion, and other changes in vital
organs.  Fatal effects, however, from most of
the substances comprised  in this class, are com-
paratively rare ;  and  when they produce these
effects, they operate  more or less upon, or
through the medium of the blood, and  thereby
seriously affect the functions of the brain, heart,
and  lungs.   It is not improbable that certain
~ r*We-reirard the effectTof ether and alcohol, when in-
haled in thi for... of vapour at  least, as exactly identical,
and both occasioned chiefly by the carbon and hydrogen
which enter so largely into their composition, combining
with the oxygen of the blood, thus substituting carbonic
Tcid ami wate? for the stimulating portion (oxygen) of the
vital fluid.]
excitants  may act so  energetically upon  the
nervous system, and, through them, upon  the
vitality of the frame, as rapidly to exhaust or
destroy the influence  of these systems, and
vitality in all  its  manifestations.  ,\n intense
electric shock, or lightning, may produce this
effect; and we may conceive a  shock from
a galvanic battery of such violence as imme-
diately to  occasion the same result.  In these
cases the  agent acts upon and through the me-
dium of the nervous systems, although the blood
and vascular system, and the muscular struc-
tures, may manifest  the chief or only lesions.
  324. i. Alcohol—spirits of wine, spirituous
liquors, such as gin, whisky,  brandy, rum, and
arrack, have been taken in so large quantities
as to produce not merely intoxication, but even
death, in a few hours.  The  poisonous opera-
tion  of alcohol has been  ably investigated by
Dr. Christison.  In the article Drunkenness,
I have described  the slowly-developed effects
and ultimate results  of habitual drunkenness ;
and the articles Delirium Tremens and Gran-
ular  Degeneration of the Kidneys are  illustra-
tions of certain other forms of slow or chronic
poisoning by spirituous and other  intoxicating
liquors.   It will be necessary for me, therefore,
at this place to notice only the more acute forms
of poisoning by alcohol and its compounds.
  325. A.  The symptoms  of the  more  acute
states of poisoning by alcohol are, violent  ex-
citement of the nervous functions, and of the
passions  or emotions ; flushed face ;  excited
vascular action, followed by giddiness ; confu-
sion  of thought; various mental affections, va-
rying with the character of the individual; de-
lirium ; dozing, passing into  profound somno-
lency,'which, after several hours, is interrupted
by headache, sickness, vomiting, and terminates
in a heavy or stupid headache, giddiness, or
nervous exhaustion.   Such is the more favour-
able  course of severe intoxication ; but a more
unfavourable result may accrue, either during
the stage of vascular excitement, or in the fol-
lowing period of congestion, the  somnolency
deepening into profound coma, terminating in
death.  Dr. Christison furnishes the following
illustrations of this  state of poisoning: Two
brothers drank in half an hour three bottles of
porter, into which twenty-four ounces of whis-
ky had been secretly mixed by a companion
in order to intoxicate them.  In the course of
drinking,  both became  confused ;  and fifteen
minutes after finishing the last bottle one of
them fell down insensible, and had no recollec-
tion  of what happened  for twelve hours ;  but
he recovered.  The  other staggered a consid-
erable distance for an hour, and then became
quite insensible.  In four hours he was coma-
tose ; the breathing stertorous and irregular;
the pulse eighty, and feeble ;  the pupils dilated
and  not contractile, and deglutition impossible.
He remained in this state till his death, which
took place fifteen hours after this debauch.
  326. In this  state of acute alcoholic poison-
ing,  an apoplectic tendency may be developed
into a true apoplectic seizure;  and the usual ap-
pearances of apoplexy be found within the cra-
nium after death, this seizure occurring  either
in a simple form, or associated with paralysis,
especially hemiplegia.   This result takes place
either during  the somnolent stage—this state
passing into profound coma—or a partial re- 
406
POISONS—Exciting  and Exhausting—Alcohol.
covery from somnolency occuis, and apoplexy,
either gradually or suddenly, appears after the
effects of intoxication have nearly or altogether
passed off.   An individual reached his home in
a state of intoxication ; he became lethargic,
and died in the course of twenty minutes.   On
examining the body, Dr. Alison could not dis-
cover any  morbid appearance, except some
watery effusion in the ventricles  and on the
surface of the brain. The contents of the stom-
ach had a strong  smell of spirits.  This case,
however, presents a more rapid course than is
usually observed when intoxication passes di-
rectly into coma and apoplexy.  A man drank
thirty-two ounces of rum in the afternoon, and
was comatose most of the ensuing night. Next
morning, although very drowsy, he was  sen-
sible when roused ; and in the evening he was
convalescent.  But, two days afterward, he be-
came delirious, and in two days more coma-
tose  and apoplectic.  No other morbid appear-
ances than congestion were found in the brain.
  327.  In some instances, the lethargy and in-
sensibility caused by acute intoxication are at-
tended by violent  convulsions, which have  pre-
sented either an hysterical or an epileptic form.
I was called to a female who had drunk a large
quantity of spirits in  a short time.   She  was
muscular and robust,  violently convulsed, un-
conscious,  and occasionally  she  uttered the
most distressing screams.  Recourse was had
to the  cold  affusion  on the head, the convul-
sions assumed more of the hysterical charac-
ter, and the coma was diminished and soon
ceased.  In another case, also of a robust fe-
male, whom I attended with Mr. Lambert, con-
vulsions of an epileptic character appeared du-
ring  the insensibility caused by the ingestion of
a large quantity of spirits.   When I saw her
the symptoms were exactly those of a violent
epileptic  attack, and,  as  in  the  former case,
characterized by  the  strong  smell of spirits.
The  convulsions continued for a longtime, and
then passed into violent phrenitic  delirium,
which was  not removed for several days ; but
recovery, complete and lasting, followed  cold
affusions and copious local depletions.  A med-
ical  student, after  drinking  four  bottles of
Champagne, during and after dinner, besides
some other wines and liquors, became phre-
nitically delirious.  Violent convulsions super-
vened and recurred at intervals, during which
the phrenitic symptoms continued.  I saw him
about thirty hours after his debauch ; the ma-
niacal delirium, and the brief attacks of convul-
sions, recurred almost hourly, attended by the
most intense indications of vascular determina-
tion to the brain and its membranes. The treat-
ment about to be recommended was adopted,
and he recovered.
  328.  B. A still more acute state of poisoning
than the above, by alcoholic liquors,  is some-
times met with.  When these liquors are swal-
lowed in  large quantity, in  a very short time,
there is seldom much  preliminary excitement.
Coma occurs in a few minutes, and gradually
assumes an apoplectic character.  The face is
livid  or pale, sometimes ghastly ;  the breathing
stertorous,  and with a spirituous odour; the
pupils dilated and insensible, sometimes con-
tracted ; and death often takes place in a few
hours.   Tetanic convulsions occasionally ap-
pear in this form, although not so frequently as
in the preceding.   Instances of this rapid form
of poisoning have been  recorded  by Orfila,
Bedingfield, Marx, and others.  Dr. Christi-
son mentions an instance of a man  who drank
■at once a bottle of whisky.   He died in  four
hours with symptoms of pure coma.
   329. The effects  of alcoholic liquors  are
greatly heightened, and often to a fatal extent,
by exposure to cold  either after or  during the
ingestion of the poison;  and intoxication  and
insensibility more  rapidly result.  This is  ow-
ing not only to the sedative influence of cold,
but also to the partial or complete arrest of the
excretion of the spirituous vapour by the lungs
and skin.  Most of the accidental deaths which
have occurred in  this country from exposure
to cold during intemperate weather have been
caused by a too  free  use of spirituous liquors
just previously to  such exposure, insensibility,
coma, and death supervening.
   330. Numerous  instances have occurred, es-
pecially in this metropolis, of various liquors
containing alcohol, especially malt liquors, hav-
ing been made the vehicles  of other poisons,
and given with the intention of robbery or mur-
der.  The poisons  thus administered have been
usually  opium or  prussic acid, especially the
tincture of opium.   Such cases may be recog-
nised by the fact that the effects are of a much
more severe character than  could result from
the quantity of alcoholic fluid which had been
taken.  In these cases it is often very difficult
to decide whether the symptoms are caused
more by the alcoholic liquor than by the poison
with whieh it was  drugged.
   331. C. The appearances observed after fatal
acute poisoning by alcohol consist chiefly of in-
creased vascularity of the internal  surface of
the stomach, sometimes with ecchymoses, the
villous membrane  presenting either a bright
red.oradark brown, or some intermediate hue;
of congestion of the brain ; of an increased
quantity of fluid in the ventricles and between
the membranes ; and sometimes of  effusion of
blood in the substance of the  brain, or between
the membranes, or of a bloody serum in the
latter situation.  When death takes place  rap-
idly, a strong odour of spirits may be perceiv-
ed in the contents  of the stomach ;  and in less
rapid cases this  odour has been said to have
been perceived in the serum effused within the
cranium ;  but this  may not be felt if some time
has elapsed before the inspection has been made.
(See art. Dri nkenness, y 8.)
  332. D. The quantity required to destroy life
cannot be determined.   Much depends upon
the age, habits, &c., of the individual, upon the
state of the stomach, and upon the  treatment.
Young persons, not accustomed to spirits, may
be killed by a comparatively small quantity.
Mr. Taylor adduces  the  following:  A boy,
aged seven years,  swallowed three  ounces of
brandy ; shortly afterward he was observed to
stagger.  He was sent to bed, and vomited vio-
lently.   In  about four hours he was in a po-
fuse perspiration, and his head, face, and neck
were very red.  Half an hour afterward he was
found insensible, strongly convulsed,  and  the
skin cold.  He died in about thirty hours.  Ad-
diction to spirituous  liquors often enables  the
system to  tolerate a large  quantiu  without
much effect.  A large, powerful young man
thus addicted, in the presence of the author 
POISONS—Exciting and Exhausting—The Ethers.
407
swallowed for a bet a bottle of rum within half
an hour.   He was hardly affected by it.   .A. full
stomach  previously to the ingestion of spirits
also affords a greater tolerance of this poison.
  333. E.  The period which elapses from the
ingestion  of the spirits until death occurs also
varies with the circumstances just mentioned.
Mr. Taylor states  that  the shortest  period
which he has seen reported occurred in a case
of a man who  swallowed  a bottle of gin for a
wager.  In a quarter of an hour afterward he
became intoxicated, and soon after that insen-
sible, and  died in half an hour, although a large
quantity of the spirit had been removed by the
stomach-pump.  Dr. Chowne adduced  an in-
stance of  a boy, aged eight years, who was
found insensible half an hour after having ta-
ken about half a pint of gin.  The liquid drawn
off his stomach seven hours afterward had no
odour of gin, nor was the odour of it percepti-
ble in his  breath.  He was insensible and mo-
tionless ; the limbs relaxed and powerless, the
face pale, and the surface cold.  The  pulse was
quick and  feeble.   He died, without rallying or
recovering consciousness, sixty-seven hours af-
ter taking the poison.  On inspection, the brain
was found healthy.  There  were slight effu-
sion of serum, and distention of the veins of
the pia mater.   The stomach was pale.   No
exact period can be assigned for the fatal ter-
mination of the effects of this poison, this ter-
mination  depending  chiefly upon the absorp-
tion of the spirit into the circulation, and upon
the rapidity and extent of the absorption ;  the
quantity accumulated in  the blood, especially
when the  kidneys, lungs, and skin do not rap-
idly excrete it, suppressing the cerebral func-
tions and  impairing the irritability, and  ulti-
mately arresting the action of the heart.
   334. F.  Treatment.—The contents of. the
stomach should be withdrawn by the stomach-
pump as speedily as possible ; and the cold affu-
sion ought to be resorted to immediately, in or-
der to remove the symptoms of intoxication, or
the insensibility or coma  which may have  al-
ready appeared.   Previously to 1822, the treat-
ment of dangerous cases of poisoning by alco-
holic liquors, as well as those by narcotics, was
not understood, and was certainly far from being
successful.  In July of that year, cases demon-
strating the good effects of the cold affusion on
the head  in poisoning by  these  agents, were
published  by Mr. Wray and myself (Lond. Med.
Repos., vol. xviii.); and the efficacy of the prac-
tice in cases of poisoning by spirits has been
vouched for by Dr. Ogston in an able memoir
on intoxication.   He states that,  where the
temperature of the head  is steadily high, and
that of the surface not much reduced,  it is a
safe and efficacious remedy.
   [We have resorted to this treatment with the
greatest  success,  by turning a stream of cold
water upon the head from a pitcher for a con-
siderable  time ;  in this way vomiting will often
be brought on, and the patient relieved from all
symptoms of intoxication]
   335 Having  removed  the contents of the
stomach and used the cold affusion, the liquor
ammonia? acetatis with the ammonia in excess
should be freely given in camphor water.  Ca-
ses  are  comparatively rare which  admit of
blood-letting or even of  local depletions.  In
young robust,  and plethoric persons not ac-
customed to intoxication, and when the affec-
tion of the brain  is of a phrenitic character,
then vascular depletions  are often  required;
but they should be resorted to with caution,
and their effects carefully watched.  When the
insensibility and coma are profound, and when
they resist the cold affusion on the head, the
liquor  ammoniae acetatis, with  the carbonate
of ammonia and camphor water, should  be giv-
en ; and if deglutition cannot be effected, they
ought to be conveyed into the stomach by the
stomach-pump, or administered in enemata.
Warmth, and the promotion of a free perspira-
tion, are always beneficial.   In  other respects
the treatment is the same as described in the
articles Drunkenness, and Delirium with tre-
mour ;  the more chronic states of poisoning by
alcohol being there discussed, especially under
the former of these heads.
  336.  ii.  The Ethers—especially the sulphu-
ric, the nitric, and hydrochloric—may  occasion
dangerous or fatal effects when taken in exces-
sive quantity, or when their vapours are too
long inhaled.—A. When taken  into the  stom-
ach, the operation of the  ethers is analogous
to that of spirituous liquors.  M.  Orfila per-
formed several experiments with them on the
lower animals ; but as these were accompanied
with placing ligatures on the oesophagus, little
importance can be attached  to the results.  I
am not acquainted with any  dangerous effects
which  have occurred  from swallowing  any of
these ethers ; and I believe that they may be ta-
ken in  larger doses than they are  usually pre-
scribed, and be productive, in certain states of
disease, of much benefit.
  337.  B. The inhalation of ether, especially the
sulphuric, has lately come into  vogue for the
abolition of sensibility, in  order that surgical
operations may be  performed with comfort, and
even pleasure, to the patient.  But it  appears
doubtful to me, after witnessing several instan-
ces of the inhalation of ether, whether or not
the risks  contingent  on it  do  not more than
compensate for the escape from  pain during an
operation.*   The inhalation of ether to the ex-
tent of annihilating,  even for  a short period,
the sensibility, must necessarily be attended by
changes in the nervous system ;  and  even in
the. blood, otherwise a most important function
—and  one presiding over and directing all our
animal functions—could not be entirely sub-
verted for a time ; and it may be inferred a pri-
ori that congestions of the  brain  and medulla
oblongata, congestions and  inflammations of
the bronchi and of the lungs, and alterations
of the  blood, especially as regards the red glob-
ules and fibrin, will result from  the passage of
so large a quantity of ether into  the circulation
as is usually required to produce insensibility  ;
and I  believe that these results have actually
accrued already, in  some instances,  from the
practice ; and that, although matters may have
  [* As ether has lieen employed thus far, we believe this
remark perfectly just; but it remains to be proved whether
ether may not  be used, like other medicinal agents, with
such prudence and caution that its benefits may preponder-
ate over its evils.  Its use, as well as that of chloroform, is
at least justifiable, where, in severe operations, the danger
of sinking, from the shock of the operation, is greater than
that from inhaling these powerful agents—presuming, of
course, that they prevent the shock, which is generally
conceded.  In the ordinary operations of dentistry and mi-
nor surgery, they should,  in our judgment, be entirely
abandoned.] 
408
POISONS—Exciting and Exhausting—Camphor.
 proceeded favourably as respects the operation,
 congestive bronchitis or congestive  pneumonia
 has nevertheless been  developed by it; while
 the absorption of purulent matter, and the oc-
 currence  of  phlebitis,  after great operations,
 have been favoured by it, by lowering the  gen-
 eral amount of vital resistance, by  affecting
 the constitution of the blood,  and by weaken-
 ing the tone of salutary vascular reaction.
  338. The attempts recently made  to intro-
 duce the  inhalation of ether into general prac-
 tice for the alleviation of the pains of parturi-
 tion, as well as for trifling operations and un-
 important occasions, are fraught with some
 danger; and I am confident that a farther ex-
 perience will prove my predictions to be  cor-
 rect.   I may here explicitly  state what the
 danger is, as regards the puerperal state;  name-
 ly,  the supervention of convulsions, of hemor-
 rhage, maniacal delirium, puerperal fevers, sink-
 ing of nervous power in various ways, but es-
 pecially in the form of cardiac syncope, and in-
 flammations of the respiratory organs, or of the
 brain.
  339. Instances were, a few years  since,  pub-
 lished of a druggist's maid-servant having been
 found dead in bed, owing to the air of her apart-
 ment having been loaded with the  vapour of
 nitric ether by the breaking of a jar  containing
 a large  quantity of this substance.   She  was
 found lying on  her side, with her arms folded
 across the chest, the countenance and posture
composed, and her whole appearance that  of a
person in deep sleep.  The stomach was found
red  internally,  and  the  lungs were gorged.
 The brain was not examined.   A young man
 was found completely insensible from breath-
ing air  loaded  with sulphuric ether, and re-
mained  apoplectic for some  hours.   I am ac-
quainted with an  instance of similar effects
having accrued, from the vapour of strong spir-
its having been  inhaled while the person  was
transferring the contents of a  large cask  into
bottles.
  340.  C.  The treatment of insensibility caused
by ether is not materially different  from  that
produced by ardent spirits.  The cold affusion
on the head and neck is the most to be confi-
ded in, if the case be in any way alarming.
  [To this should be added external revulsives,
as mustard, &c, and internal stimulants in the
form of ammonia, camphor, &c.  Exposure to
fresh air,  and friction, are by no means to be
neglected]
  341.  iii. Camphor.—There are few substan-
ces the action of which is more variable, ac-
cording to the  dose, the mode of exhibition,
state, and constitution of the patient, &c, than
camphor.  Henqe its operation has been differ-
ently described, and its employment in disease
has  not been always judicious or  beneficial
 Having been in the habit of prescribing it, oft-
 en in large doses,  in various dangerous disea-
 ses, I was induced, on two occasions, to take a
 considerable quantity, in order to ascertain its
 effects from my own sensations; and on sev-
 eral other occasions I have taken smaller do-
 ses.  These experiments were made chiefly in
 1823 and 1824,  and the results were published
 in the London Medical Repository for  Septem-
 ber, 1825.
  342. A. The  vapour of camphor is injurious
 to insects; and  when long inhaled  by man, it
 occasions headache, pallor of the countenance,
 slight irritation of the respiratory mucous sur-
 faces, followed by slight reaction of the circu-
 lation, especially in the brain and lungs.  Lo-
 cally, on the denuded  dermis, or on the mucous
 surfaces, it  appears to impress  the nerves  of
 the part; and, after rendering the part at first
 pale, it increases capillary injection and red-
 ness, and develops moderate vascular reaction
 in it.  Whether applied to the skin denuded of
 its cuticle, or taken into the stomach, or inject-
 ed into the rectum or other mucous  canals,
 camphor is  readily absorbed into the circulation,
 and is eliminated from it chiefly by the lungs
 and skin, and not perceptibly by the urinary or-
 gans, although it is believed to affect those or-
 gans.
   343. B.  The  primary action of camphor is
 exerted chiefly through the medium of the ner-
 vous system; but consecutively, and  as it be-
 comes absorbed into the circulation, its action
 is more fully manifested on the brain, on the
 heart and vascular system, and  on the lungs,
 especially on the bronchial mucous surface,  as
 it is eliminated by the respiratory organs from
 the blood.   The  following  are the results of
 my experiments with this substance, above al-
 luded to ($ 341).
   344. Camphor produces effects varying with
 the dose, and the period which elapses  from
 the administration of it.  When taken into the
 stomach, triturated with oil, or divided minute-
 ly by means of mucilage, magnesia, &c, fif-
 teen grains  produce the effect of half a drachm
 given in the form of pills or bolus, or less mi-
 nutely divided ; and this latter quantity some-
 times produces, especially when the stomach is
 empty, and taken in  oil or much diffused  in
 mucilages,  &c, and in certain constitutions,
 very severe effects.   Given, therefore, in do-
 ses of from fifteen to thirty grains, diffused  in
 mucilage, it produces the following effects,
 which, as they are progressively different, may
 be divided into three stages.
  345. a. In the quantity just mentioned, cam-
 phor occasions a peculiar sensation of heat and
 constriction in the throat, and along the oesoph-
 agus  as  it is swallowed, followed by a simi-
 lar feeling,  attended by slight anxiety, at the
 epigastrium and region of  the stomach.  The
 sensations of internal heat and of concentra-
 tion  or constription in this situation  continue
 for some time, and are attended by slight thirst,
 a more  constricted  and slightly accelerated
 pulse, and  a colder state  of the  extremities.
 The surface of the body also becomes  cooler,
and a sense  of chilliness and of coldness, great-
er than the  actual loss of temperature, is pro-
duced ; yet  there is, at this time, a feeling of
internal warmth and excitation, as if the ener-
gies of more remote parts were drawn towards
the stomach.  To these sensations are added
pallor of the countenance,  vertigo, pandicula-
tion or slight rigours.  The head  is cool, the
 action of the carotids somewhat diminished,
 and the respiration slow or natural.
  346. b. In from one to two hours, the con-
 striction and diminished action of the surface
 and extremities have  passed off, and replaced
 by more or less reaction and determination of
 blood to the head and periphery  of the body.
 The pulse becomes fuller and stronger; animai
heat is increased; the features  are more de- 
POISONS—Exciting and Exhausting—Camphor.                 409
veloped, and the colour returns or is increased;
the vertigo, pandiculation, chilliness, and  rig-
ours having disappeared.  Shortly afterward,
headache, flushed  face, excited pulse, some-
times noises in the ears, various but slight af-
fection of sight, watchfulness or slight mental
excitement,  or delirium and disturbed sleep,
in some instances,  are experienced.
  347. c. These effects having continued a few
hours, the excitement of the pulse and of the
brain  subsides ; the heat of the skin passes into
a free perspiration ; the pulse becomes slower
and softer, and a refreshing sleep terminates
the headache and slight disturbance of the brain
and organs of sense;  and the nervous and mus-
cular  systems remain composed.  These are
the usual effects of a large  dose (from fifteen
to thirty grains)  of this  substance  upon  a
healthy person, when it is not repeated. Where
smaller quantities are taken  every four, or five,
or six hours, the effects constituting the second
stage are chiefly manifested to an extent in
proportion to the amount of the doses.   When
dissolved in oil or in spirits, it appears to act
with greater activity, and  to be more readily
absorbed into  the  circulation,  where,  if  the
dose be large, or if the doses  are repeated at
short intervals, it acts energetically upon the
nervous system, over-exciting  the brain,  and
causing maniacal delirium,  and even  convul-
sions and death. It seems also to possess an-
tiseptic properties.
   348. C.  The smallest quantity which  has
produced symptoms similar  to the above,  cal-
culated by their severity to cause alarm, is one
scruple.  I  have often, however,  given  this
quantity, and repeated it a second and a third
time at intervals of sJaX and  eight hours,  with
marked benefit, in low and malignant states of
fever.  When  given  in an  enema, and  in  a
state of minute division, it often  acts  with
great rapidity,  and sometimes with great se-
verity.  Dr. Christison adduces a case where
half a drachm was thus administered, and se-
vere  nervous  symptoms  were  produced.  I
have  often  prescribed as  much as this,  but
never more, in an enema, for insensibility or
profound coma, and either alone or with asa-
fcetida; and it has sometimes been efficacious,
but never injurious.   In a case of most pro-
found and protracted coma, in which degluti-
tion was abolished, to which I was called with
Mr. Kingdon and another practitioner, this sub-
stance, administered in an  enema, in a  very
large dose,  roused the  patient, and procured
ultimate recovery.  Mr.  Taylor adduces  a
case  by Dr. Siemerling, in which a man, aged
sixty-nine years, swallowed two drachms for the
relief of rheumatism.  Three  hours afterward
he resembled a drunken person.  He complain-
ed of burning heat in the  throat and stomach,
of throbbings  in the head,  and pains in the
course of the spine;  of ringings in the  ears,
and dazzling light  before his eyes.  To these
succeeded subsultus tendinum, and insensibili-
ty, and profuse perspiration.   This last  state
was,  however, of short duration ; and he slow-
ly recovered.
   349 Dr. Wendt mentions a case in which
eight scruples were taken dissolved in  spirit,
the largest dose hitherto mentioned.   Vertigo,
dimness of sight, delirium, and burning pain  in
the stomach,  but no  vomiting, were the  only
symptoms.  The man  who took this  quantity
was an habitual drunkard; but he  recovered.
I have often found that drunkards may take
large quantities of this substance without pro-
ducing any  unpleasant symptom; and I have
given it in very large doses (from ten grains to
one  scruple) with opium for the delirium of
drunkards, with  marked benefit.
  350.  D. The appearances occasioned by poi-
sonous doses of camphor have not been observ-
ed in man.  According to the  experiments of
Orfila and  Scudery, the mucous membranes
of the stomach, duodenum, and urinary organs
were inflamed, and the  membranes of the brain
injected.   The  other  appearances were less
constant.  All the cavities had a strong  smell
of camphor.
  351.  E. Treatment.—-When  the  effects of
camphor  are not very  severe, they soon pass
off.  But when they become alarming, whatev-
er of this substance may still remain in the
stomach should be removed by an emetic or by
the stomach-pump, and demulcents with opi-
ates, or henbane, or poppies, and the cold af-
fusion on  the head, or  the shower-bath, ought
to be resorted to,  if maniacal  delirium super-
vene.  If  convulsions  or insensibility  appear,
the cold affusion, injections with asafoetida or
ammonia, and other stimulants may be admin-
istered.    If  strangury  occur, demulcents and
emollient enemata  are generally of the greatest
service.
  252. iv.  Chelidonium majus and C. glaucium
produce inflammation of parts to  which they
are applied ;  but  they appear to be partially ab-
sorbed, and  to act upon  the nervous system,
causing delirium  in cases where  they  have
been partaken of by mistake.  In M. Orfila's
experiments, they  occasioned remarkable con-
gestion of the lungs, whether taken  into the
stomach or applied to wounds.
  353. v.  Heat,  in its various forms and appli-
ances, may be very briefly considered under the
present category,  as it may become  more or
less rapidly  injurious,  or  even destructive of
life.—a. Atmospheric heat, or the temperature of
an apartment,' may be  so  high as to interfere
with the respiratory functions ; to impede the
decarbonization  of the blood; to  excite, and
ultimately to exhaust, the nervous energy; to
change the  state of the blood ; and, lastly, to
disorder all  the excreting functions, and to ar-
rest the  vital actions.   When,  with a high
range of temperature, the living body is expos-
ed to a stagnant  state of  the air,  when there is
not  a sufficiently  rapid renewal of the atmo-
sphere, then the noxious effects are produced
with a rapidity co-ordinate with the degree of at-
mospheric stillness ; and asphyxia is produced
with proportionate celerity.  But when the ele-
vation of temperature is not so great,  although
still high, nor ventilation  so imperfect, then the
deleterious changes are less rapid, and assume
a slow form, inducing various chronic affections,
more especially of the liver, stomach, and bow-
els, and often also of the spleen.   Fatty liver,
various states  of enlargement  and   chronic
change  of this organ, bilious  fever,  &c, are
not infrequent consequences of this cause, and
very frequently occur, even among the inhabi-
tants of cold regions, who shut themselves up
in close apartments, warmed by stoves, during
the cold seasons. 
ND CoNSTRINGINO.
410                     POISONS—Exciting

  354. It is important to remark, although the
circumstance must  be obvious, that  the air,
when raised to a high temperature by the usual
means resorted to in factories—by heated air,
by steam, or hot water transmitted  through
metal pipes to different parts of the building—
readily becomes stagnant, and that  due venti-
lation is  with difficulty preserved in connexion
with this mode of warming, although the great
numbers of persons  usually employed  in these
places require a more than usually rapid renew-
al of the air.  The consequences are, that the
persons there employed rapidly  vitiate, or even
poison the air which  they breathe, independent-
ly of any deleterious miasm which may be gen-
erated by the articles, materials, apparatuses,
or appliances used in these manufactories.*
  355. b.  Warm Baths, Vapour Baths, Fumigating
Baths.—Medicated baths, and various natural
warm or mineral baths, although beneficial when
appropriately resorted to, may nevertheless be-
come, owing to their exciting and exhausting
influence, most deleterious  in  various  states
of the system, even in health, and still more so
in several  diseases.   What is a most  success-
ful medicine  when  judiciously  employed, be-
comes either a rapid or a slow  poison when it
is not appropriately prescribed.
  356. Heat applied  to the external surface in
such excess as to produce scalds  or burns, es-
pecially when an extensive surface is implica-
ted,  is productive of danger or death,  not so
much by the extent or severity  of the local in-
jury, as by the sympathetic development of in-
flammation of mucous or serous surfaces and
its consequences.
  357. c  The injury produced  by swallowing
hot or boiling fluids  is dangerous or fatal, ac-
cording to the amount or seat  of local  lesion.
When the fluid  is of a temperature as high as
200° or 212°, it rarely gets lower than the up-
per part  of the gullet, and the injury is  gener-
ally limited to the pharynx, epiglottis, and la-
rynx.  Accidents sometimes occur from drink-
ing hot or boiling water from a teapot or ket-
tle ;  and Dr. M. Hall has adduced the  accounts
of four such which  occurred to children ; and
in all cynanche laryngea  was produced.   Two
of these cases terminated by suffocation, one
was  relieved by tracheotomy, but died soon af-
terward, an,d the fourth recovered after having
been nearly choked.   (Trans, of Lond.  Med. and
Chirurg. Soc, vol. xii., p. 1.)
  358. vi. A. Ipecacuanha has been considered
by some  as an irritant, and by others as an acro-
nurcotic;  but, strictly speaking, it  cannot be
viewed as either—not as an irritant, as it does
not irritate or inflame the capillaries of the sur-
faces to  which it is applied ;  nor as a  narcotic,
  * [The present mode of warming apartments by means
of close and air-tight stoves is, forthe same reason, highly
injurious, and ought to be abandoned, and either the open
grate, the Franklin stove, or  fireplace  substituted.  In a
late visit to the Massachusetts General Hospital, we were
exceedingly gratified in finding cheerful fires in open fire-
places in the different wards, although the building is chief-
-y warmed by heated air.   We were informed by Dr. WaR-
RE.n that, since open fires had been introduced, erysipelas,
which was formerly a frequent disease in the hospital, had
entirely disappeared. Wounds, also, sooner healed, and pa-
tients recovered more speedily from accidents and other dis-
eases ; puerperal females, also, had a more rapid convales-
cence, and altogether the effects were  in the highest de-
gree beneficial.  We trust that the same mode of ventila-
tion will be introduced into our other  hospitals, and that
more attention will be paid to  the subject iu all our public
and private buildings, especially school-houses andchurches.]
for it does not stupefy.   Its impression is pri-
marily upon the nervous organization  of the
part to which  it is  applied, and is  rapidly fol-
lowed by  muscular contraction  or  reaction,
when the quantity of the substance is such as
to produce an impression sufficiently strong to
develop this effect.   The susceptibility of the
influence of this substance is remarkably great
in some persons—so much  so  as to  occasion
the most  distressing effects.  When  this sus-
ceptibility is great, even the presence of a few
grains of ipecacuanha in the same apartment
as the person  thus constituted  is sufficient to
produce a sense of suffocation, tightness in the
chest, nausea, depression, or faintness,  or oth-
er disorder,  varying with the  idiosyncrasy of
the individual; but the most frequent  affection
is one resembling asthma.  I  have met  with
several persons who are thus affected  by the
odour of ipecacuanha, or by the impalpable pow-
der of this substance, when any of it is inhaled;
and seen two instances of most distressing suf-
fering produced by it.  It is not unusual,  also,
even  when  this susceptibility of the effluvium
of the drug does not exist, to meet, in the course
of medical practice, with persons upon whom
very minute doses  of any of the preparations
of ipecacuanha produce  more or less  distress,
especially nausea, retching, and depression.*
  359. B.  Emetia [or Emetina.]—The  active
principle,  or alkaloid of ipecacuanha, whether
taken into the  stomach or applied to a wound,
occasioned, in  the  experiments of  Magendie,
death after some hours, preceded by  vomiting
and coma, the  lungs and stomach being found
inflamed.
  360. C.  Treatment.—It  is rarely that  any
thing more than time is required to remove the
effects of ipecacuanha ; for an over-dose of it is
prevented from becoming injurious by its im-
mediate  rejection from  the stomach.   It is
chiefly when, owing to  idiosyncrasy,  its more
distressing effects are produced, that treatment
is requisite.  In the cases which I have treat-
ed, an open, free, and warm air, camphor with
henbane taken  in demulcents, and a  warm mus-
tard poultice applied over the lower part of the
sternum and the  epigastrium,  soon  removed
the disorder.  When  nausea,  retchings, and
depression occur from small doses of this sub-
stance, or when the operation of  it  becomes
exhausting or too prolonged, then small doses
of ammonia and creasote, or this latter in an ar-
omatic and emollient draught, will afford relief.
  361. Class IV.—Exciting and Constring-
ing Poisons.—Nervous and Muscular Excitants.
—Although numerous medicinal substances act
more especially upon both the nervous and the
muscular or  contractile  systems, yet there are
comparatively few of them which  act  so vio-
lently upon these systems as to produce death,
unless they  are employed improperly  in  the
treatment of diseases, and aggravate existing
morbid conditions, by interrupting the salutary
efforts of nature, and  by arresting or  prevent-
ing the evacuation of hurtful or contaminating
matters.  Several substances, while they more
or less excite the nervous and contractile tis-

  * [The late Dr. Uriah Turner of this city, a gentleman
of high nervous temperament  and groat genius, and who
was liable to severe attacks of asthma from inhaling the
smallest quantity of the odour of ipecacuanha, fell a victim
to an attack of this kind,  induced by swallowing a few ipe-
cacuanha pills by mistake.] 
POISONS—Exciting and Constringing—Alum—Nux Vomica—STRYCHr
411
 sues, become materially or chemically combin-
 ed with the parts with which they are brought
 into contact, more especially with mucous mem-
 branes, by  which  they are  readily imbibed
 Tannin, gallic acid, and the gallates, krameria,
 alum, kino, catechu, solutions of several of the
 mineral salts, &c., while they excite nervous
 and contractile  parts, and  thereby produce a
 tonic effect,  are  partially imbibed by, or com-
 bined with, the tissues to which they are appli-
 ed ;  and although this latter operation  is not
 very manifest in the living textures, it is suf-
 ficiently demonstrated in dead animal matter,
 which is thereby preserved from decay for long-
 er or shorter periods.  The constringing influ-
 ences of these and  of similar substances are
 displayed more upon the exhaling and secreting
 surfaces to which they are applied  than upon
 remote  structures and organs; but when the
 quantity  is  more considerable, or  when  the
 dose is often repeated, they are  then  more
 abundantly imbibed and absorbed into the cir-
 culation, and act more  or less  energetically
 upon the nervous centres and contractile parts.
 Most of these substances, however, are not
 poisonous unless they are taken in excessive
 quantities, or are employed inappropriately in
 certain states of disease.
   362. But there are some of them  which ar«
 among the most virulent poisons in nature, and
 are exceeded only by prussic acid in their poi-
 sonous influences.   These substances act chief-
 ly by exciting the nervous  systems, the  ex-
 citement being propagated to the spinal cord,
 and  reflected thence upon the muscular sys-
 tem, the irritability of contractile parts  being
 inordinately excited, and being followed by va-
 rious consequences, according to the persist-
 ence or the exhaustion of the excitement, and
 to the parts  more especially affected.   These
 substances generally increase  the  sensibility,
 and  in this respect chiefly they differ from nar-
 cotic or stupefying poisons.  They do not para-
 lyze or diminish muscular  contraction, but, on
 the  contrary, inordinately excite this function,
 so as frequently to become incompatible with
 the continuance of life, tetanic asphyxia being
 often the more immediate cause of death.  They
 produce no  visible change in the  tissues to
 which they are  applied,  or in the  alimentary
 canal; or, if  any change is observed, it is acci-
 dental, not  necessarily connected with the op-
 eration of the poison, and insufficient to ac-
 count for any portion of  the phenomena or
 symptoms they produce.  They act chiefly by
 being absorbed, and-through the medium of the
 circulation, upon the nervous centres, more es-
 pecially upon the spinal cord; and they owe
 their activity to  an alkaloid principle which is
 poisonous in an extremely small dose.
  363. i. Alum.—Sulphate of alumina and potash
 can hardly be considered as a poison, although
 it may prove injurious when taken in very large
 quantity or in various disorders.  It acts as an
 excitant and astringent, and  is absorbed  into
 the circulation ; whence it is excreted  chiefly
 by the kidneys.  Its beneficial operation in lead
colic is owing to its  exciting the organic ner-
 vous and muscular structures of the digestive
canal.  M. Orfila has detected this substance
in  the stomach, liver, spleen, and urine.
  364. ii. Nux Vomica—Strychnia,  &c.—Sev-
eral species of the genus Stryehnos,  namely, <S.
 nux vomica, S. Sancti Ignatii, or St. Ignatius's
 Bean, S. Colubrina,  S. Guianensis, S. Tieute,
 which yields the Upas Tieute, an Indian poison,
 &c, are extremely  active poisons,  and owe
 their activity to an alkaloid principle which has
 been called Strychnia or Strychnine.   This sub-
 stance has an intensely bitter taste, perceptible
 even when  one grain is dissolved in 80 lbs. of
 water.   It is  sparingly soluble in water, but
 more abundantly in alcohol and  the volatile oils.
 It exhibits an alkaline action, and forms neutral
 and crystallizable  salts with  the acids.  Dr.
 Christison killed a dog in two minutes with
 one sixth part of a grain injected in the form of
 an alcoholic solution into  the  chest.   He has
 seen a wild boar killed in the same manner
 with a third of a grain  in ten minutes.  There
 is little doubt that half  a grain  introduced into
 a  wound  might kill  a man in  a few  minutes.
 It acts most rapidly and energetically when a
 solution of it is injected into a  vein.
   365. A. The symptoms produced by strychnia
 are uniform and  striking, when this substance
 is applied in a large, poisonous  dose.  The ani-
 mal is at first  agitated,  and is  soon afterward
 seized with startings and stiffness of the limbs,
 which increase until it is attacked with a  fit of
 violent general  spasm, in which the head is
 bent back, the spine stiffened, the limbs extend-
 ed and rigid, and the respiration checked by
 spasm of the respiratory muscles.  An interval
 of calm succeeds, during which the sensibility
 is generally more than  usually acute,  and the
senses unimpaired; but  another paroxysm  soon
follows, each successive attack beingrnore se-
 vere, and the invervals shorter,  or less marked,
until at length  the severity of  the fit,  and the
duration of the spasm of the respiratory muscles,
terminate in suffocation.  Dr. Christison has
observed the first symptoms of this poison in
 from 60 to 90 seconds after the application of
 it  to a wound;  and 45 seconds after its injec-
 tion into  the   pleura.   MM.  Pelletier  and
 Caventou  have  seen  them appear  after 15
 seconds,  when  injected  into this  cavity.   M.
 Bouillaud says that it  has no effect when ap-
 plied directly to a nerve.
   366. B. As to the quantity of  strychnia likely
 to destroy life, much will depend upon the mode
 of application, and its administration  in a dis-
 solved or undissolved state.  There is  no doubt
 that one half,  or even  one third  of  a grain,
 when dissolved and injected into a vein, would
 be sufficient to  destroy a man.   Three eighths
 of a grain given  medicinally produced violent
 tetanic convulsions, spasms of the extremities,
 trismus, opisthotonos, spasmodic contraction
 of the respiratory muscles, &c.  Dr.  Pereira
 has given the particulars of a case which favours
 the idea that strychnia,  like digitalis,  accumu-
 lates in  the system, and suddenly occasions
 violent symptoms after  the  exhibition of  it in
 small and frequently repeated doses, and which
 demonstrates the poisonous operation of this
 substance in man.   A Swede, between  fifty
 and sixty years of age,  suffering from  general
 paralysis,  one  side being more affected than
 the other, took one eighth of a grain of strychnia
 three times a  day  for  some weeks,  without
 effect. The dose was increased to one quarter
 of a grain thrice daily, also without effect.  It
 was farther increased to half a  grain, twice or
 thrice a day ; and this dose was  taken for some 
412         POISONS—Exciting and Constringing—Nux Vomica—Strychnia.
 days before the effects of this substance were
 manifested.  The  patient was found in a fit.
 The whole body  was in a  state  of  tetanic
 spasm ; the trunk  and limbs  were  extended ;
 the shoulders thrown back;  the muscles- rigid
 and hard ;  the face and chest were of a purple
 colour; respiration had ceased, and the pulsation
 of the heart was very weak.   Artificial respi-
 ration  was imperfectly kept up by compressing
 the thorax ; and the circulation was somewhat
 restored.   The deep  purple colour of the face
 went off.  The man sighed, and the respiration
 returned ;  but the  spasms very soon appeared
 with increased violence, and attacked the  res-
 piratory muscles.   Respiration entirely ceased,
 the surface again became purple, but the  cir-
 culation  still went on.   Artificial respiration
 was continued imperfectly, when the relaxation
 of the  muscles would allow of it, but was  this
 time ineffectual.   The heart  soon  ceased to
 beat, and the purple colour of the surface was
 instantly replaced by the  pallor of death.
  367.  A young man  swallowed forty grains of
 strychnia.   The symptoms  commenced in a
 quarter of an hour.   Trismus and spasm of
 all the muscles speedily appeared, and the whole
 body became as stiff as a board.   The lower
 extremities were  extended and  stiff, and  the
 soles of the feet concave.  The skin became
 livid, the eyeballs prominent, the pupils  dilated
 and insensible, and the  patient lay in a state
 of universal tetanus.  A  remission occurred,
 but the symptoms soon  became aggravated,
 and the  patient died asphyxiated  owing  to
spasm  of the muscles of respiration, in about
an hour and a half after taking the poison.  On
inspection, twenty  hours after death, the body
was very rigid.   There  was  affusion  in  the
 spinal sheath [probably only the spinal fluid],
and the upper part of the  spinal marrow was
 softened ;  the brain  was congested, but  the
 alimentarv canal was in its normal state.   (Lan-
cet, Jan. 2*7, p. 647, 1838.)
  368.  Mr. French informed Mr. Taylor that
 a person took a grain of strychnia at a dose.
 Vomiting occurred, and no ill effects were pro-
 duced ; but half this  quantity may give  rise to
dangerous symptoms, when taken for the first
time.   When commenced with in small doses
 and gradually increased,  the system may  be-
 come gradually habituated to its influence, until
 a large dose is reached, when its effects may
 be suddenly and fatally manifested, as in  the
 case mentioned above (y 366).
  369.  The operation of strychnia, or of its salts,
 or of any of the substances which contain this
 poison, should  not be mistaken  for tetanus.
This disease is developed much more slowly,
and death  takes place after  a  much  longer
time, than in cases of acute poisoning with any
of these poisons.  But if the dose be small and
frequently repeated, a much less acute form of
poisoning may  be  produced,  and one  which
may, with great difficulty, be distinguished from
tetanus.  An attempt was made to defraud in-
surance offices in London, by insuring the  life
of a young woman very largely, and destroying
her bv  administering  strychnia in porter.
  [Dr.  W. C. Warner, of Bristol, Vt., died
 suddenly at Montpelier, October 11,  1846, aged
 39, while attending the Legislature, from tak-
 ing about one fourth of a grain of strychnia.  In
 less than five minutes he felt a constriction of
 the throat and tightness of the chest, with rigid-
 ity of the muscles, on attempting to move.  Ho
 complained of want of air, and requested the
 window to  be raised.   He  was  immediately
 seized with a tetanic convulsion, in which his
 head was drawn back, his countenance became
 livid, fluid matters issued from  his mouth, with
 frequent moans;  the palpebrae constantly in
 motion.  The first paroxysm lasted some  five
 minutes, which was  succeeded by an interval
 of partial calm, during which it  was difficult for
 him to articulate with distinctness.   He made
 several efforts to vomit,  by exciting the fauces
 with his finger: there was  such  constriction
 about the  throat  as to  prevent  swallowing.
 This interval lasted about five minutes, when
 another paroxysm succeeded, by a little start-
 ing and stiffening  of the extremities, and  im-
 mediately the whole  body was thrown into a
 tetanic spasm, which lasted two or three min-
 utes, when life was extinct, in about 14 minutes
 from the time of swallowing the poison.  The
 intellect remained  clear to  the last.—(Bost.
 Med. and Surg. Journ.)
  In one case, where  we  recommended strych-
 nia endermically, one third of a grain, applied
 to a blistered surface, nearly  proved fatal;  the
 patient, a stout man, being thrown into violent
 tetanic  spasms, which lasted,  with intervals,
 for more than two hours.]
  370. C. Nux Vomica, the Bean of St.  Ignatius,
 the  Upas Tieute, the Wourali poison, and  the
 other substances enumerated  above  (Y 364),
 owe their  poisonous  properties to strychnia.
 St.  Ignatius's bean is said  to  contain  nearly
 three times the quantity of this alkaloid found
 in nux vomica.  But this last substance is most
 frequently employed as a poison.  The  symp-
 toms produced by it are similar to those caused
 by strychnia, but are less  severe. Nux vomica
 is usually taken in the form of powder.  It has
 an intensely and persistent bitter  taste ;  and
 generally tetanic spasms  appear in from  five to
 twenty minutes after  it has been taken.  The
 symptoms are altogether the same as have been
described, and death is  produced  by the  as-
 phyxia consequent upon the spastic contraction
of the thoracic muscles.
  371. Mr. Baker states that nuxvomica is taken
 by many of the nations of Hindostan habitually,
generally night and morning, beginning with an
eighth part of a nut, and gradually increasing
the dose to an entire nut, or about twenty grains.
 If it  be taken immediately before  or after a
meal, it never occasions any ill  effects ;  but if
this precaution be neglected, spasms are apt to
ensue.  As this substance is taken in a state
of coarse powder, and not in greater  quantity
than one nut, and frequently after having been
half roasted, it is probable that it is only slowly
acted upon by the juices  of the stomach ;  and
that the modifying influence of habit as regards
 it is not considerable.   Mr. Baker adds  that is
 is thus used as a preservative from lepra and
some other chronic disorders;  but it  is more
 likely that it is taken on account of  its tonic
 and aphrodisiac properties.  The habitual use
of this substance proves  that the  cumulative
 influence imputed to  it above does not exist.
 (Trans, of Med. and Phys. Soc. of Calcutta, vol i
 p. 140.)                                  " '*
  372. D. As nux vomica, in powder, in extract
 and in tincture, is an excellent remedy in several 
POISONS—Exciting and Constringing—Nux Vomica—Strychnia.         413
disorders, and  is frequently used medicinally,
the symptoms indicating its injurious operation
should be more fully described.  When  large
doses are given, the stomach  often becomes
disordered, the  appetite impaired, and the bow-
els constipated.  The muscular system and the
sensibility are next affected.  All the senses
are more than  usually acute.  The sensibility
of the surface  to  cold, or to  slight touch,  is
remarkably acute ;  and depression of spirits,
anxieiy, and a feeling of weakness and weight
in the limbs are complained of.  Mr. Pereira
remarks that the limbs tremble, and slight rigid-
ity or stiffness is felt upon motion. The patient
staggers, and, when he stands, a slight tap on
the ham brings  on  a convulsive motion, which
nearly throws him down.   If the medicine be
persevered in, these effects increase, and the
voluntary muscles are thrown into a convulsed
state by very  slight causes.  The sudden con-
tact of external bodies acts like an electric shock
upon him, and produces a convulsive paroxysm.
A deep inspiration, turning suddenly in bed,
startling sounds, &c, have a similar effect.
The farther  use of nux  vomica renders  the
symptoms still more intense; the fits of spasm
now occurring spontaneously, and without any
of these provocations.  It acts upon the bladder
and genital organs, and exerts an aphrodisiac
effect on both sexes.  The pulse, however, is
but little increased in frequency, and is some-
times calm even when muscular rigidity has
appeared.  Preceding and accompanying these
effects, great  sensibility of the surface, painful
formications,  and acuteness of the senses are
experienced.  The intellectual  powers are un-
impaired.  If the use of this substance be con-
tinued,  especially  in an  increased  dose, the
symptoms are still more violent, and tetanus,
tetanic asphyxia, and death succeed each other
with great rapidity, as they follow large doses
Of strychnia (Y 365).
   373. a. Dr.  Christison states the smallest
quantity of nux  vomica likely to produce death
to be three  grains of the  alcoholic extract;
which is not  so small a dose as fifteen grains
of the powder,  which was  fatal  in a case ad-
duced by Dr. Trail.  Thirty grains, taken  in
two doses, caused death ; and fifty grains (equal
to a quarter of a grain of strychnia) were fatal
in an hour.
  374. b. The period after the ingestion of the
poison at which death usually occurs is gener-
ally from one  to two hours,  but Dr. Christison
mentions a case that terminated in fifteen min-
utes.  When  this poison destroys life within a
few  hours, or in still shorter  time, vomiting
rarely occurs, and the patient  dies  from the
tetanic asphyxia.  But when death does not
take place thus  suddenly in a fit  of spasm, the
person continues to be affected for twelve, or
eighteen, or twenty-four hours with similar or
milder paroxysms,  and may expire from ex-
haustion, or  entirely recover.   A fatal termi-
nation by exhaustion  is not, however,  so fre-
quent as that  by asphyxia.  M.  J. Cloquet met
with a case  of fatal exhaustion  consequent
upon the violent and repeated spasms produced
by this substance.  The tetanic fits returned
for more than twenty-four hours, the sensibility
being very acute.   Death  did not  take place
until the fourth morning.  (Nouv. Journ. de Med.,
t. x., p.  157.)
   375. c. There  are several  instances of re-
 covery on record.  Sobernheim states that a
 young man took half an  ounce of this  powder,
 and experienced the usual symptoms.  After
 the  administration  of emetics he  recovered.
 Dr.  Bassedow has recorded a similatcase, re-
 covery following the operation of emetics.  Mr.
 Baynham states that a girl swallowed  half an
 ounce of the powder ; the usual symptoms ap-
 peared, but the treatment having been  prompt,
 they subsided jn about four hours  from their
 first appearance, and the next day she was only
 feeble and exhausted.   He says that  he has
 often prescribed a scruple of nux vomica three
 times  a  day without any ill effects  !  In this,
 as well as in other  cases, there was  neither
 vomiting nor purging until they were produced
 by the treatment.  A strong dose of sulphate
 of zinc caused free vomiting in a.few minutes.
 (Lond. Med. Gaz., vol. iii., p. 445.)
  376. E. Appearances after Death.—These vary
 with the rapidity with which death takes place,
 and the period after death at  which the body
 is examined.  In a case recorded by Mr. Ollier,
 death took place  in an hour, and the changes
 were slight. The stomach was almost natural,
 although between two and three drachms of
 the powder of nux vomica had been taken. The
 vessels of the brain were somewhat congested;
 the heart flaccid, empty,  and pale.   In a case
 which was rapidly fatal,  detailed by M. Olli-
 vier, and examined  by him and Orfila, the
 body was found remarkably rigid, although not
less  than forty hours had  elapsed since death.
The  more depending parts of the external  sur-
faces were  purplish.  Much  serous effusion
was  found on the surface of  the cerebellum,
and softening  of the whole cortical substance
of the brain, but especially of the cerebellum ;
this case confirming  the opinion of Flourens,
that  nux vomica acts especially on the cerebel-
lum.   The lungs  were congested  with black
 fluid blood.  (Archives  Gener. de Med.,  t. viii.,
 p. 18.)  In a case mentioned  by Mr. Taylor,
 a  quantity of the powder was found  in the
stomach, to the  internal  surface of which it
 adhered tenaciously.   The vessels of the brain
 were congested.   No other changes were no-
 ticed.  The spastic contraction of the muscles
 seems to pass into  the  state of cadaverous
 rigidity after death, without intermediate flac-
 cid ity.
  377. F.  Treatment. — The most  efficacious
 treatment of poisoning by the  substances con-
 taining strychnia is an immediate recourse to
 the stomach-pump, and, if this apparatus is not
 at hand, to the more  powerful emetics.  Dr.
 Christison remarks, that, when nux  vomica
 in powder has been taken, it adheres tenaciously
 to the inner surface  of the stomach, and that
 the means used to evacuate the stomach should
 therefore be assiduously  continued.   Emetics
 may not act, as in Mr. Ollier's case, therefore
 they ought not to be  solely confided  in.   If the
 patient be not attacked  with  spasms  in  two
 hours, he may be considered likely to recover.
 In cases ofpoisoning with strythnia, the efficacy
 of any treatment is very doubtful, for the quan-
 tity  which is poisonous  is so small, and  its
 absorption so  rapid,  that  means must  be  in-
 stantly resorted to in order to be efficacious.
 Dr. Christison quotes M. Donne, who states
 that he has found iodine, bromine, and chlorine 
414         POISONS—Exciting and Constringing—Strychnia—Brucia,  etc
to be antidotes for poisoning with this, as well
as  the  other  vegetable alkaloids ; these sub-
stances, he  says, forming, with  the alkaloids,
compounds  which  are not  deleterious,  and
which, being in chemical union, are not readily
decomposed.  Animals, he states, which  had
taken one grain of strychnia, or  two grains of
veratria, did not sustain any harm, when tinc-
ture of iodine was administered immediately
afterward; but the  delay of  ten  minutes in
the administration of the antid«te rendered it
useless.  Farther evidence  is required as to
these antidotes.    Dr.  Pereira  remarks, that
probably astringents, as infusions of galls, green
tea, &c, would be serviceable.  To relieve the
spasms, riarcotics may be  employed.  Sachs
and  others  have ' recommended opium.    .\s
conia is the counterpart  of strychnia, it de-
serves a trial.  Dr. Pereira applied  it to a
wound in a  rabbit affected with  tetanus from
the use of strychnia ; the convulsions ceased,
but the  animal died.  In the absence of conia
the extract  of hemlock may be tried.  To  re-
lieve the symptoms  consequent  upon the en-
dermic application of strychnia, acetate of mor-
phia applied  to the same part has given relief.
(Pereira, Op. cit.,  p.  1306.)   In a  case in
which I pushed strychnia so far as to occasion
severe spasms, spirits of turpentine  were ap-
plied with tincture of opium in the form of an
embrocation along the spine, and were admin-
istered  in enemata  with  asafcetida,  and  the
spasms very soon disappeared.
  378. iii. Brucia—Brucia Antidysenterica,  or
false Anguslura Bark.—This vegetable alkaloid
causes symptoms of the same  kind as strych-
nia.  According to Andkal, brucia is twenty-
four times less powerful than strychnia ;  but
the bark itself appears to be nearly as strong
as nux vomica.   Professor Marc took an  in-
fusion of this bark in mistake for true Angus-
tura ; and, although the dose was only three
fourths  of a wineglassful, yet he was seized
with nausea, pain in the stomach, giddiness,
sense of fulness  in  the head, ringing in  the
ears, stiffness  of  the limbs, pain on every  at-
tempt at motion, locked jaw, difficult articula-
tion,  &c.    These  symptoms continued two
hours, and abated under the use of ether and
laudanum.   Dr.  Emmert  states, that a boy
who died from taking this poison experienced
so distressing  a state of sensibility in  the  in-
tervals between  the spasms, that he begged
not to be touched, as he was  thereby thrown
into a paroxysm.   This physician has investi-
gated the operation of this poison, and he be-
lieves that it acts directly on the spinal cord,
and not through  the  intervention of the brain.
In his experiments division of the medulla ob-
longata, artificial  respiration being kept up, or
division of  the spinal  cord,  did not  prevent
the effects of the poison from being manifest-
ed in the parts supplied  with nerves below the
division. The symptoms and treatment of this
poison are the same as those of strychnia, and of
the substances which contain it.  JThere are
few other substances which  are productive of |
death by operating  in  such  a manner as to j
bring them under the present category ; but the
Cocculus Indicus and the Coriaria myrtifolia ap-
pear to possess  properties in manv respects
similar to the foregoing.  [The Rhus toxicoden- j
dron, and some of the  other species, possess '
tetanic  properties similar to those of strychnia
and brucia.]
  379. iv. Cocculus Indicus.—The Berries or
Fruit of the Anamirta Cocculus.—Cocculus Indi-
cus is poisonous to all animals.  It acts on the
cerebro-spinal nervous and muscular systems,
causing tremblings, staggering, tetanic convul-
sions, and death.  It does not appear to increase
the sensibility ; and the coma observed is rather
the result of the  exhaustion  of vital influence
by it, than of any narcotic property, which is
only produced when the dose is large, and at
an advanced period of its operation.  Orfila
says, that this poison acts like camphor on the
nervous system,  and principally on the  brain.
M.  Goupil  states, that it communicates its
poisonous properties to fish,  which  have been
killed by it, and more especially to barbel.   It
is frequently added to malt liquors for the purpose
of increasing their intoxicating powers. Its ac-
tive principle has been called Picrotoxine.  Dr.
Pereira observes that, from accounts he receiv-
ed from an excise officer, the action of this poi-
son is exerted more upon the voluntary muscles
than upon  the  intellectual powers ; and that,
notwithstanding the severe prohibitory statutes
against the employment of Cocculus Indicus in
brewing, there  is every reason to  believe that
it is extensively  used ; but a solution of the
extract being employed, the detection of it is
rendered very difficult.  Morrice, a writer on
brewing, directs three pounds of Cocculus Indi-
cus to be added to every ten  quarters of malt.
" It gives," he says, " an inebriating quality,
which passes for strength of liquor, and pre-
vents second fermentation in bottled beer, and
consequently the  bursting of bottles in warm
climates :"  pleasant information this for those
who  indulge  in these liquors; and satisfacto-
rily accounting for  the injurious operation of
them  on the human  frame.  According to
Wepfer and Orfila, this substance in poison-
ous doses exhausts the irritability of the heart.
  380. The  treatment of poisoning by Cocculus
Indicus, or by picrotoxine, consists in the prompt
removal of the poison  from the stomach, and
in having recourse to  the means  advised  for
the effects of nux vomica (y 377).
  381. v. Coriaria Myrtifolia possesses prop-
erties similar to the foregoing.  It is frequently
found as an adulteration of senna.   According
to Professor Mayer, it produces violent fits of
tetanus, followed by apoplectic coma. A  grain
injected into the jugular vein of a rabbit occa-
sioned in about five hours a single convulsive
paroxysm,  which  proved  immediately  fatal.
Sauvages has  recorded two  cases of  death
caused  by the berries.  M.  Fee  has adduced
five cases of poisoning, owing to the adultera-
tion of senna with this  substance ; and one of
them  proved fatal.   The symptoms were vio-
lent convulsions,  locked jaw, and  colic.   M.
Rocx also published, in an interesting memoir]
three  cases which came under his own obser-
vation, one  of which proved  fatal  ; the symp-
toms  being  sparkling and rolling  of the  eyes,
locked jaw, loss of voice, convulsions recurring
in paroxysms of the duration  of  eight or ten
minutes, and death after sixteen  hours.  Of
those fatal  cases the membranes of the brain
on dissection, were found congested in one  no
other change being observed ;  the internal sur-
face  of the  stomach and bowels was injected 
POISONS—^Irritating and Depressing—Aconite.                  415
in another ; and in the third no alteration could
be detected.  The treatment for poisoning with
this substance does not differ from that recom-
mended for the substances containing strych-
nia (v 377).
  382. Class  V.—Irritating and  Depressing
Poisons.—Irritating and Paralyzing—Acro-Sed-
atives.—Although  this class of poisons is more
or less allied  to the third and  fourth classes,
and not  less so the sixth and eighth, still it is
distinct  from  all of them: 1st, in the altera-
tions of function  and structures produced by
it; and,  2d, as respects the treatment  required
to remove these alterations.  The  substances
ranged under  this, class  not  only affect the
nerves of the part to which they are applied,
but  irritate them,  and excite  more or less of
morbid action  of the capillaries.   In conjunc-
tion with this local action, they are more or less
imbibed  by the membranes, and absorbed into
the  circulation, thereby affecting,  each  with
modifying influence, the  vital  manifestations
of the systems and organs  of the body.   Their
general  operation,  when administered in very
large or poisonous doses, is to irritate the tis-
sues with which they come in contact, and to
depress  vital  power throughout the frame, or
to paralyze the functions of certain organs or
parts.  The irritating  action they exert local-
ly is extended, especially as respects some  of
them, to adjoining viscera; and this action is
also exerted in those excreting organs which
eliminate them from the blood,  although  often
very slightly or inappreciably.  But it is rare
to observe after death evidence of irritation
and its consequences to such an extent as to ac-
count for the fatal  issue ; and therefore we are
induced to infer that,  although  these changes
may have aided in producing this result, the
depressing influence exerted upon the  nervous
systems, and  upon the vitality of the frame in
general, by this class of  poisons, is that to
which their fatal operation is mainly due.   Even
in those cases in which evidence of irritation,
and the changes consequent  upon  this condi-
tion, are the most remarkable, although death
may, according to the views  of some, be as-
cribed chiefly or altogether to those changes,
still they are insufficient of themselves  to ac-
count for the  rapidity of this  issue, especially
when they are compared  with the extensive
disorganizations observed  after the more cor-
rosive poisons, whose action is strictly  local,
and which often do not cause death until after
prolonged periods  of suffering.
  383. i. Aconite—Monk's-hood—Aconitum na-
pellus. —Aconita—Aconiline —Aconitina. — Ac-
cording  to the observations of Dr. Fleming, the
species napellus, and its varieties, are the most
poisonous of the genus.  The  amount of numb-
ness and tingling felt on chewing  the root in-
dicates  the respective activity of  the various
species ; the  power of exciting these  sensa-
tions residing in the aconitina,  which the plant
contains.   The most active  officinal  prepara-
tions are  the tincture and alcoholic  extract;
but all parts  of the plant are  poisonous, this
property residing  in the aconitina,  the alkaloid
discovered in Aconitum napellus by Geiger and
Hesse.   Cases of poisoning  by this plant  are
not frequent.  1 have seen only one instance ;
but  injurious effects have followed,  although
rarely, from  a too large dose of the  tincture.
 The expressed juice and the officinal prepara
 tions are most rapidly fatal when injected into a
 vein, or into a  recent wound.   They are also
 injurious in  smaller quantity, and with greater
 rapidity, when introduced into the serous cavi-
 ties, or in the cellular tissue, than when taken
 into the stomach; and they are poisonous, also,
 when introduced into the mucous canals.
   384. A. A^pplied locally, aconite produces very
 slight irritation  of the tissues ;  but it often ex-
 cites a sense of heat.   It hardly occasions any
 visible change of the part.    On the nerves it
 acts as a local sedative, especially to the nerves
 of sensation, occasioning numbness and ting-
 ling.  The loss of sensibility is followed by im-
 pairment of muscular contractability and irri-
 tability.   It  does not  appear, according to  Dr.
 Fleming's experiments, to  produce dilatation
 of the pupil;  and he states that the topical appli-
 cation of the poison is unaccompanied by pain,
 redness, or swelling, even when the physiolo-
 gical and  remote effects are produced  to  the
 greatest extent; the peculiar sensations caused
 by chewing the root being unattended by any
 inflammatory irritation.
   385. B.  The remote or constitutional opera-
 tion of aconite depends upon the absorption of
 it, as shown, 1st, by the rapidity and intensi-
 ty of the remote action being in proportion to
 the absorbing powers of the part to which it is
 applied, and to the facility with which the prep-
 aration employed is capable of being absorb-
 ed ;  2d,  by the circumstance  of no remote
 effects, or but slight  effects, being  produced
 when it is applied to the sound skin, although
 the  topical action  indicates  that the  nerves
 were affected by it, in the manner above stated.
 Being imbibed and absorbed into the circulation,
 it acts upon the nervous system, and more es-
 pecially on the cerebro-spinal  nervous system ;
 impairing the sensibility and the  functions of
 sense, and diminishing the power of muscular
 action.   It seems also to impair organic ner-
 vous influence and irritability, proving a seda-
 tive of the cardiac and vascular actions, and re-
 ducing, as shown by Dr. Fleming, the strength,
 volume, and frequency  of the  pulse more or
 less, according to the dose.  This antiphlogis-
 tic or  sedative  operation of aconite has been
 fully evinced in  various  diseases for which I
 have prescribed it.   It is of importance to  de-
 termine whether or  no the  frequent  or con-
 tinued exhibition of this  substance produces a
 cumulative action.  Although I have often pre-
 scribed aconite, yet I have  not had  reason to
 believe that this action has ever occurred.   Dr.
 Fleming, however, states that two individuals
 were affected with general tremours, severe pain
 in the head  and eyeballs, constant lachryma-
, tion, intense photophobia, heat of skin, quick
 pulse, and great restlessness, symptoms which
 were distinctly attributable to the continued
 use of this substance.
   386.  C. The  symptoms produced  by poison-
 ous doses of the aconite are,  a sense of warmth
 in the stomach, with  a numbness and tingling,
 and feeling of distention of the tongue and lips,
 sometimes with slight nausea, followed by vom-
 itings or retchings.  The countenance becomes
 pale and sunken, and muscular power prostra-
 ted.   The senses are impaired, but conscious-
 ness remains, or slight wandering delirium ap-
 pears.  Some persons feel as if they were dying 
416
POISONS—Irritating and Depressing—Aconite.
or sinking   The voice is whispering or lost;
the respiration weak and superficial ; the pulse
weak or slow, small or irregular.   The surface
is cold, and covered with a clammy sweat.  At
a more advanced  period the patient  becomes
speechless, deaf, and  blind.   The pupils  are
at first contracted ; but afterward, sometimes
general muscular tremours orslightconvulsions
supervene ;  the pulse, at first slow,  becomes
imperceptible, the coldness of the surface and
extremities increases, and the patient dies from
syncope.   In a case in which 1 was consulted,
petechial ecchymoses  appeared on  the surface
of the body and on the face, and marked con-
gestion of the brain occurred with hemiplegia,
yet the patient recovered, the palsy  having
nearly disappeared when I saw him some years
afterward.   In most  cases, especially when
any part of the plant has been  ate by mistake,
heat, sense of constriction, numbness and  tin-
gling in the mouth and throat are the first symp-
toms complained of.   Vomiting or diarrhcea is
generally present,  with swelling'of the abdo-
men. A lady was poisoned by eating the root
in mistake for horseradish with  roast beef.
She  could not thus have taken  much of it; but
shortly afterward slight vomiting, with abdom-
inal pains, came on, and although emetics, &c,
were used, she died in three hours.
   387. The symptoms may appear immediately
after taking the poison or not for one or  two
hours, the delay being owing  to the part  and
state of the plant taken, and to the presence of
food in the stomach.  Five grains of the fresh
extract of aconite were given to each of three
patients  in  the hospital at Bourdeaux.   In a
quarter of an hour after taking the poison, they
had  tremours of the  muscles, a  pricking sen-
sation over the body, and severe vomiting fol-
lowed.  They became  unconscious  ; and on re-
covering their senses they complained of con-
fusion of sight and  intense  headache.   The
pulse was slow and irregular, the respiration
short and hurried ; the skin was cold and clam-
my.  Two of the patients  recovered.   Dr.
Geoghegan adduces two cases,  one of which
died in an hour and a quarter  after eating the
root, and the other in two hours.  One drachm
of the root has proved fatal, but it is probable
that less than this would  kill an adult.  Dr.
Male  died from the effects of not more than
 eighty drops of the tincture taken in ten doses,
 over a period of four days, the largest quantity
 taken at once having been ten drops.
   388. D. The alkaloid, acomtine, is the most
 virulent poison known, exceeding even prussic
 acid.  One fiftieth part of a grain  of aconitina
 proved nearly fatal.  Its operation and effects
 are altogether the same as those of aconite,
 only much more intense.
   [A case of poisoning by aconitina has recently
 been reported by Dr. Golding  Bird, of London
 (Med. Gazette), which, from its interesting na-
 ture, we present to the reader.  It is the first
 case of the kind, we believe, ever  published,
 although there are several on record where the
 roots and leaves of the aconite have accident-
 ally produced death.  There are few agents,
 Dr. Bird thinks, more likely to be employed by
 the secret poisoner,  with greater certainty  of
 escaping detection, than aconitina.
   A gentleman of high intellectual attainments,
  and holding an important  position in society,
swallowed  intentionally about two and a half
grains of aconitina.  From collateral evidence,
it appeared probable that  almost immediately
after having taken it, he must have fallen and
struck  his head a severe  blow  against some
furniture in the room.  The poison, or the blow,
or both, produced violent vomiting, as the room
was  flooded with vomited matter.   Dr. Bird
saw the patient about eight hours after taking
the poison.  The patient was then fearfully col-
lapsed ;  the surface cold and sweating; quite
pale ; the  heart's action scarcely perceptible;
pupils sensible to light; no paralysis either of
sensation or motion; intellect unimpaired. The
most prominent symptom  was incessant  and
severe vomiting  of a brownish fluid.   This
vomiting was, however, peculiar, and perhaps
hardly  deserved  that title,  the  patient being
really seized with a kind of general spasm, dur-
ing which he convulsively turned on his abdo-
men, and with an intense contraction of the ab-
dominal muscles  he jerked out, as it were, the
contents of the stomach, with a loud shout, de-
pending, apparently, on the sudden contraction
of the diaphragm.  These exhausting and dis-
tressing symptoms  occurred every minute or
two.  On attempting to make him swallow any
fluid, a fearful spasm  of the throat took place,
producing the distressing effects so well known
in hydrophobia;  this  was not produced by the
sight of water, but  the  convulsive movements
of the body, and emptying  of the stomach, were
excited by abruptly touching him.   He  was
placed in  a hot bath, and afterward removed
to bed, covered with blankets, and a large mus-
tard poultice to the sorbiculus cordis, and an
enema of turpentine administered. He remain-
ed in much the same state, the sedative effects
of the aconitina on  the heart gradually lessen-
ing, so that in the  course of seven hours  the
pulse became perceptible, though very weak;
the hydrophobic symptoms were, however, then
produced by every  attempt to swallow, so that
none of the medicines suggested could be made
use of.  Enemata of  beef tea, and yolk of egg,
with ten drops of laudanum, were administered,
with the view of affording support and quieting
the patient.  He passed a dreadful night of ex-
haustion and spasm ;  intellect perfect, and even
vivid,  so as  to astonish the by-standers.  By
two o'clock the  following day the poison  had
so far ceased to operate,  that the patient was
regarded as convalescent.
   The aconitina must in this case probably have
 nearly all been discharged by vomiting, and yet
most violent effects followed. Dr. Bird seems
 inclined to believe that the  convulsive vomit-
 ing and imperfect  hydrophobia are character-
 istic of the effects of this poison, differing, how-
 ever, from the effects of aconite root, with the
 exception of the sedative influence on the heart.
 This, however, is in accordance with a fact well
 known, viz., that a pure  alkaloid often differs
 materially in its  physiological action from that
 of the plant from w hich it is obtained, as in the
 case of"the alkaloid conia]
   389. E.  Death is produced by aconite owing
 to the sedative  influence caused by it on the
 nervous system, or to its paralyzing effect upon
 the muscles of respiration, or to the impaired
 irregularity of the heart, fatal syncope super-
 vening. The death of the human subject takes
 place generally by syncope,  which sometimes 
POISONS—Irritating and Depressing—Arsenic.
417
occurs suddenly, unexpectedly, and immediate-
ly : the fatal sedative and paralyzing influence
of the poison on the nervous system appearing
chiefly in experiments  on the lower animals,
when the dose of the  poison has  been  very
 arge.
   390. F. The appearances  on dissection have
been very imperfectly observed.  Venous con-
gestion, to a greater or  less extent, has gener-
ally been found.  In some instances, engorge-
ment  of the brain and  membranes,  with  con-
siderable sub-arachnoid  effusion, has been met
with.   In the cases recorded by Pallas, Deg-
land, and Geoghegan,  inflammatory  appear-
ances were  present in  the alimentary canal.
The lungs were generally congested, and the
blood very dark.
   391. G. The  more diagnostic or characteris-
tic phenomena produced  by this  poison are
numbness and tingling of the mouth and throat,
or parts  to which  it is  applied;  vomiting or
retching, with  tumefaction  of the abdomen,
numbness, tinglings or tremours of the extremi-
ties, contraction of the pupils, slowness or fail-
ure of the pulse and of  the heart's action, and
death from this last change.
   392. H. Treatment.—If retchings only have
occurred without free  vomitings,  an emetic,
consisting of sulphate of zinc with capsicum,
or of mustard  mixed in water, should  be ad-
ministered.  If the poison have passed into the
intestines, or sufficient time have  elapsed for
this to have  taken place, warm purgatives and
enemata should be resorted to.  Stimulants, as
warm brandy and water ;  camphor or ammo-
nia, with capsicum, and  small doses of opium ;
sinapisms or terebinthinated embrocations over
the epigastrium, or along the  spine ;  strong
coffee, and frictions of the surface, are  the
means chiefly to be confided  in.
   393. ii. Arsenic—Arsenious Acid—Arsenic
and its Compounds.—Of all the varieties of death
by poison, none  is  more  important,  as  Dr.
Christison remarks, than poisoning by arsenic.
The facility  with which it as well as all oth-
er poisons may be procured in this country, and
the ease with which it may be secretly admin-
istered, lead to  its adoption for the purpose of
murder.  It  is fortunate, therefore, that there
are few substances, and hardly any other  poi-
son,  which can be detected in such  minute
quantities, and with so great certainty, accord-
ing to the full and minute directions which will
be found in the  works of Orfila, Paris, Beck,
Christison, Devergie, Pereira, Taylor, Guy,
and others.  The compounds of arsenic met with
and employed  in the arts,  and by which life
may be destroyed either accidentally or inten-
tionally, are,  1. The protoxide of Berzclius, or
fly-powder ; 2. Arsenious Acid, or white arsenic ;
3. The Arsenite of Copper, or mineral green ; 4.
The Arsenite  of Potass, or Fowler's solution ; 5.
The Arsemate of Potass;  and, 6. The various sul-
phurels, pure  and impure, as Realgar, Orpiment,
and King's yellow.   Of these, arsenious acid, or
white  arsenic, is that most frequently adminis-
tered as a poison.   Mr. Taylor states,  that in
1837 and 1838 there were  185 cases of poison-
ing by this substance in England, the greater
number of which were cases of suicide and
murder.
  394. White arsenic possesses a very feeble
acid reaction, although  it combines with alka-
    III               27
 lies.   It has, in small quantity, hardly any taste,
 and hence the frequency and risk of its employ-
 ment.  It is sparingly soluble.  Cold water dis-
 solves from half to one grain to one fluid ounce
 of water;  and  boiling water  allowed to cool
 upon the powder dissolves  a little more than
 one grain to the ounce of water.   Mr. Taylor
 states that the presence of organic matter in a
 liquid diminishes  the soluble power of the li-
 quid.  Viscid or mucilaginous fluids, of course,
 suspend the finer parts of the powder of this
 substance.  The solubility and action of arse-
 nious  acid are said to be increased by admix-
 ture with nitre.   This writer states that a tea-
 spoonful of powdered arsenic weighs about 150
 grains, a table-spoonful 530 grains, and a pinch
 about seventeen grains.
  395. A. Symptoms.—Arsenic,  taken into the
 stomach, produces different forms of poisoning,
 according to the quantity and 6tate of the^poi-
 son, as respects admixture, &c., and to  the
 stale of the  stomach and constitution of the in-
 dividual, according to the various modifying
 circumstances already mentioned (v 51, et seq.).
 The forms of poisoning  thus  resulting are, 1st.
 Acute; 2d. Chronic; and the acute assumes two
 varieties, which have been distinguished and de-
 scribed by Dr. Christison.
  396. a. The acute form of poisoning with this
 substance is differently characterized according
 as the  arsenic affects more  especially the ali-
 mentary canal, or the nervous system, and vital
 powers.—(a) When the  digestive canal is more
particularly attacked, signs of violent irritation
are manifested along its  whole  course, with
faintness, sickness, burning  pain, and tender-
ness in the region of the stomach.  When the
poison  has been taken  in  a  state of solution,
these symptoms  are felt very soon after its in-
gestion—generally from ten to fifteen minutes ;
 but, in other circumstances, it usually does not
 begin to act until half an hour after it  is swal-
 lowed ; and its operation is seldom delayed be-
 yond  an hour.  Several cases are, however,
 recorded in which the action  of the poison was
 not manifested for several hours—for three,
 four, five, or even  seven hours.   Dr.  Christi-
 son thinks that it is delayed for a longer or
 shorter time by sleep.   The  sickness and pain
 are soon followed by retchings and vomiting,
 especially when drink is taken.  There are also
 heat, dryness, and tightness  in the throat and
 pharynx, creating an incessant desire for drink,
 attending and occasionally preceding the vom-
 itings.   Sometimes this affection of the throat
 is very slight.  When it is severe, it  is often
 attended by fits of suffocation  and convulsive
 vomiting, and by hoarseness and difficulty of
 talking.  The matters vomited after alimentary
 matters have been thrown off are yellowish or
 greenish, and in the more protracted cases they
 are streaked or mixed with blood.  Soon after
 the appearance of the gastric symptoms, diar-
 rhoea generally  supervenes ; but  in some in-
 stances, instead  of diarrhoea,  the patient is har-
 assed by ineffectual calls, or  tenesmus.  About
 this time the pain at the pit  of the stomach is
 excruciating, and  is likened to  a fire within
 him.  It often extends over the abdomen, which
 becomes tense, tender, and sometimes swollen •
 but occasionally drawn inward at the navel!
 If diarrhoea be considerable,  or has continued
 for a short time, pain, heat, and excoriation of 
418
POISONS—Irritating and Depressing—Arsenic.
the anus are complained of.  In some instances,
the burning pain and irritation with vascular
injection  appears to extend from the mouth to
the anus ; and there are frequently, also, observ-
ed signs  of  irritation  of the air-passages and
lungs, with shortness of breath, tightness across
thelower part of the chest, and occasionally
darting pains.   Sometimes symptoms of pneu-
monia are more fully developed.   The urinary
organs are often affected, the patient being dis-
tressed by frequent,  painful, and difficult mictu-
rition, by pain in the bladder, or swelling of the
penis.  Females frequently experience burning
pain, swelling, or excoriation of the labia  pu-
dendae.  Occasionally the irritation is so great
as to cause  suppression of urine ; but the dis-
order of the urinary organs rarely occurs unless
the lower bowels are also severely irritated, and
the case has been protracted for two or three
days*   Soon after the appearance of the first
symptoms, the pulse becomes feeble,  small, and
rapid, and subsequently irregular, and hardly per-
ceptible.  The surface of the body and extremi-
ties are cold, and often covered  with clammy
cold sweats. The feet and hands are often livid.
The features are collapsed, and expressive of
extreme suffering and anxiety.   The conjunc-
tiva is often very much injected ; and the eyes
are red and sparkling.  The tongue and mouth
are parched ;  and aphthous appearances  are
sometimes observed in the throat. Convulsive
motions,  especially of a slight form, and con-
sisting of tremours  or twitchings, often com-
mence in the trunk and become more general.
When the diarrhcea is severe, or has continued
for a short time, cramps in  the legs and arms
are severe and frequent.  Delirium sometimes
appears towards the close, and is occasionally
attended  by stupor.   Death takes place  calm-
ly, but is sometimes preceded  by convulsions.
In some instances, a remission of the  symptoms
has been observed,  particularly when life has
been prolonged till the close of the  second or
third day.   In  cases  such  as  now  described,
constituting the most frequent variety of the
acute form, death occurs  about twenty-four
hours after the ingestion of the  poison, and gen-
erally before the close of the third day ; but, in '
rare instances,  life may be prolonged until'the
fifth or sixth day.
  397. (b) In the second variety  of acute poison-
ing by arsenic, the  signs of irritation and in-
flammation  of  the digestive canal  are either
slight or  altogether absent ; death ensuing in
five, six, or seven hours, or at a period too early
for the full development of inflammatory action,
owing  to the impression of the  poison on the
organic nervous system, and on the general vi-
tality of  the frame.  When Sir  B. Brodie in-
jected a solution of the oxide into the stomach
of a dog, the pulse was rendered slow and in-
termitting,  and the animal became  palsied in
the hinder legs, lethargic, and died  in convul-
sions,  in  some cases of this variety, one or
two attacks of vomiting occur at the usual in-
terval after taking the poison, but it seldom con-
tinues ; extreme faintness, amounting almost
to syncope, being the most uniform symptom.
Pain  is usually felt at the  epigastrium, but  it
is sometimes very slight, and unattended by
the other signs of inflammation.  Occasionally
there are oppression, stupor from depression, or
 slight convulsions ; but the faintness and gen-
eral sinking of the vital powers are the promi-
nent phenomena, death commonly taking place
in a few hours.   Even in the more protracted
cases, and where life continues till the second
day, extreme vital depression is the most stri-
king feature.  Dr. Christison remarks that this
acute variety has been observed, 1st,  when the
dose of the poison  was very large ;  2d, when
it was in small masses ;  and, 3d, when it was in
a state of solution.   The first and last of these
circumstances account for the rapidity and char-
acter of the symptoms, as furnishing the condi-
tions favourable to  a general or extended im-
pression  of the substance on the villous coat of
the stomach, and a rapid absorption of it into
the circulation ; but the second circumstance
just named admits not of sp ready an explana-
tion.   Cases of this variety of poisoning by ar-
senic are not frequent; but Dr. Christison has
referred  to twelve instances in illustration of
it;  and which  sufficiently show that  the most
rapid cases of poisoning by arsenic are  not al-
ways attended  by either violent or well-marked
symptoms.  It should, however, be recollected
that the  present variety passes insensibly into
the former ; that many cases will present phe-
nomena approaching more or less either of the
varieties now  described, or intermediate be-
tween  them. '
  398. All the above symptoms are not present
in every case of the acute  form, for pain may
be entirely absent, although the quantity of the
poison has been very great; the greatness of
the quantity, as just stated, having been suppo-
sed to have been the cause of its absence.  But
Mr.  Taylor  states,  that a case  occurred  in
Guy's  Hospital, where only forty grains had
been taken, and the patient  died without com-
plaining of pain.  The symptoms of intestinal
irritation are seldom wanting, or there is vom-
iting if there be no  purging.  But Mr. Taylor
refers  to  a case in  which there  was neither
vomiting nor purging.  Thirst, although a most
common symptom, may also be absent.
  399. b.  The chronic form of poisoning by ar-
senic may also  present two varieties or states.—
(a)  In  one the symptoms may at first be acute
and inflammatory ; but these may subside, w ith
or without treatment, and signs  of nervous
irritation  and vital  depression become most
prominent; or  the  inflammatory  and the ner-
vous symptoms may appear together, and pro-
ceed pari passu.  The nervous affection varies
in different persons.   It chiefly consists of par-
tial  or incomplete palsy in  some cases, or of
more or less complete epilepsy in  others, or of
partial or  irregular convulsion ; or  they  may
even resemble  those of hysteria, of tetanus, or
of delirium, passing into stupor.  Five individ-
uals partook of a dish poisoned with arsenic,
and were seized  with the usual symptoms of
inflammatory irritation of the alimentary canal.
One of these had an epileptic fit  on the first
day, which returned  on the  second,  with fre-
quent  twitches of  the  muscles of the trunk,
numbness in one side, and heat and tingling of
the  feet and hands,   .\nother had tremours of
the right arm and leg, followed by epileptic fits
in  the night, which returned  the  next fifteen
days at the same hour in the evening, and after-
ward recurred  at intervals for several months.
  400. Of the  secondary effects of this  variety
of arsenical poisoning, palsy and spasm, or con- 
POISONS—Irritating and  Depressing.—Arsenic.
419
 tractions of the extremities, are the most fre-
 quent.   The palsy is generally partial, and oft-
 en'commences at the fingers or toes, and pro-
 ceeds gradually upward.  Dr. Murray (Edin.
 Med. and Surg. Journ., vol.  xviii., p. 167) has
 given an instructive account of this effect of
 arsenic.  Four persons were affected about an
 hour after  breakfast with the  primary symp-
 toms of poisoning by arsenic.  But, in addition
 to these, the muscular debility was  extreme;
 and in two amounted to true partial palsy.  One
 of them lost altogether the  power of the left
 arm.  The other had great general debility, and
 long-continued  numbness and pains of the leg.
 In a case of an over-dose of the arseniate of po-
 lassa. the paralytic  affection consisted in the
 loss of sensation  and of motion  of the hands,
 and the loss of motion in the  feet, with  con-
 traction of the knee-joints.
   401.  (b) In some instances,  especially when
 the dose of the poison has been small and frequent-
 ly repeated, instead of the acute or inflammatory
 symptoms at the commencement,  indications
 of slow or chronic  poisoning approach insidious-
 ly, and may be mistaken for chronic disease of
 the digestive organs  or of the nervous system.
 Hahnemann  has briefly defined slow  poisoning
 by arsenic as "a  gradual sinking of  the pow-
 ers of  life,  without  any  violent symptom—a
 nameless feeling of illness, failure of strength,
 an aversion to food  and drink, and  all the  oth-
 er enjoyments of life."  This is, however, not
 a correct view of such cases, although it may
 represent a few of the  most slow  or chronic
 states produced by  this poison ; as  with  the
 gradual sinking of vital and of muscular power,
 there are generally more or less of the symp-
 toms about to be enumerated  also  present:
 Protracted indigestion with flatulence, pain in
 the stomach or bowels, sometimes in the course
 of the colon ; slight diarrhcea, or tenesmus, or
 both ; furred tongue, with dryness, constriction
 of the throat, and thirst; severe attacks of flat-
 ulence,  sometimes with hiccough  when  sub-
 stances are taken  into the stomach  ; occasion-
 ally salivation or exfoliation of the epithelium
 of the lips, cheeks,  and throat;  inflammation
 of the conjunctiva, with suffusion of  the eyes,
 intolerance of light, and frequently with a dark
 circle surrounding the eyes ; irritation of the
 skin, often with an  eruption—the  Eczema ar-
 tcnicale—and exfoliation of the cuticle, and fall-
 ing out of the  hair;  extreme muscular weak-
 ness, tremours, paralysis, spasms,  or contrac-
 tions of the limbs;  sometimes convulsions,
 anxiety,  faintness, or syncope ;  shortness of
 breathing, dry cough'; palpitations on  slight ex-
 ertion, or upon being startled,  remarkable weak-
 ness, smallness, and  irregularity of the pulse ;
 emaciation, swelling  or  oedema of the extrem-
 ities ;  nervous  headache, mental  depression,
 sometimes low delirium, stupor, or  even death,
 have  supervened  upon  excessive or too  long
 continued doses of arsenical preparations   I
 once suffered severely from dyspepsia and ex-
cessive flatulence, caused by an accidental over-
dose of Fowler's solution ; and I have met with
several cases where the above symptoms-some
in one case, others in another, &c—have fol-
lowed the use of these preparations.   There is
also some reason to  believe  that endocard.tis
and lesions of the valves of the heart have  been
excited by the  too  liberal employment of the
 arsenical solution.  I have at present a patient
 with  disease  of the cardiac valves, who has
 taken the solution in very large doses, and du-
 ring several protracted courses, for lepra.
   402. B.  The application of arsenic to sores, ul-
 cers, or eruptions; or to wounds, or to blistered or
 other  surfaces deprived,  of its cuticle, often has
 produced fatal  poisoning.    When  arsenic  is
 thus applied, both local inflammation is excited
 or increased, and constitutional effects are pro-
 duced by its  absorption.  Wepfer states that
 a girl, affected with  psoriasis of the scalp, had
 it rubbed with a liniment of butter and arsenic ;
 and was  soon seized with acute pain and swell-
 ing  of the whole  head, fainting  fits, restless-
 ness, fever, delirium, &c.  She died in six days.
 Similar cases  are recorded by Amatus  Lusita-
 nus, Zitmann, Belloo,  Roux, Blackadder, and
 others ; the arsenic having been applied to sores
 or ulcers.  Harles remarks, respecting the pro-
 priety of the  outward application of this sub-
 stance, that it may  be  applied  with safety to
 abraded surfaces, to  common ulcers, or to ma-
 lignant sores, even when highly irritable, pro-
 vided the  part be not recently wounded, so as
 to pour out blood.  This distinction is not, how-
 ever, to  be confided in under every circum-
 stance ; for the poison  may be absorbed with-
 out being imbibed  by the venous capillaries of
 the part.
  403. When  arsenic is thus applied, inflamma-
tion  of the part, extending more or less, is gen-
 erally  produced.   In some instances the local
irritation  is but slight, or altogether absent;
but it  is  in others very severe.  The lesions
consequent upon the absorption of the poison,
when thus employed, are irritation of the stom-
ach  and  bowels,  especially  of the rectum;
 various affections of the nervous system, as
 spasms, convulsions, palsy, &c. ; faintness, and
 vital  depression.   In several  instances  palsy
 has appeared  in  parts adjoining that to which
 the poison was applied.   An  arsenical prepara-
 tion  was  long employed to  destroy  a  tumour
 on the right side of the  neck, and was followed
 by complete palsy of the muscles of the neck
 and arm of that side.*
  * [We have known three cases of death, caused  by the
absorption of arsenic, from cancer plasters applied by quacks
for the cure of this disease.  The patients died from peri-
tonitis and enteritis, the poison being determined to the se-
rous surfaces, there producing the ordinary symptoms of in-
flammation of these organs.  A case is reported by Dr Ho-
sack, in the American Medical and Philosophical Register,
vol. iii., p. 389, where palsy of the right arm and neck was
occasioned by the external application  of arsenic, for the
purpose of removing an encysted tumour on the side of the
neck.  Dr. Moore Hoit, of New York, has reported a fatal
case from the absorption of arsenic applied to  a tumour at
the angle of the jaw.  (New York Med.  and Phys. Journal,
vol. iii., p. 375.  In France, the pate arsenicale  is used, con-
sisting of cinnabar, 70 parts ; Sanguis draxonis, 22 ; arseni-
ous acid, 8 ; made  into a paste at the time of applying it.
In England, PLUNKETT's Ointment is used, consisting of arse-
nious acid, sulphur, and the powdered leaves of the Ranun-
culus inflammata and Cotula fetida ; also, D*ViD.soN'sRem-
edy for Cancer, arsenious acid and powdered hemlock,  la
the United States, we have, among others, Davidson's Can-
cer Plaster, the active ingredient of which is arsenic; the
poke-root is also used, in form of an extrari, but arsenic is
mixed with it in all cases by the cancer quacks.
  A medical gentleman, during the past year, being greatly
annoyed by a carious tooth, was induced, by the urgent so-
licitation of several of his friends, to apply to  the affected
part a paste, in which it was ascertained the  white oxide
of arsenic was one of the ingredients.  Within a period of
two hours, local inflammation took place so rapidly as to in-
volve Ihe whole of the jaw of one side.   Before many honrs
had elapsed, though active antiphlogistic means were prompt-
ly adopted, the inflammation soon involved the fauces, throat, 
420
POISONS—Irritating and  Depressing.—Arsenic
  404.  C.  The  Poison may be  administered  in
Enemata.—Fodere adduces the following case :
A lady was under treatment for some slight dis-
order, but died unexpectedly after symptoms of
poisoning.   It was  afterward  discovered  that
her servant, after unsuccessful attempts to poi-
son her by dissolving arsenic in her soup, had
succeeded by administering it in injections.  In
this  way, doubtless, all the effects of arsenic
may be  produced, and the poison  be  the  less
likely to be detected after death, this mode  of
poisoning requiring all the vigilance which the
physician can exert.
  405.  D.  This  Poison  may be  introduced into
the  Vagina. — Among other instances of this
mode of poisoning  adduced  by Ansiaulx and
Christison,  the following is recorded by Dr.
Mangor : A farmer  near  Copenhagen lost his
wife  under suspicious circumstances, and six
weeks afterward married his maid-servant.  In
a few years he attempted, aided by another ser-
vant, to poison his  second wife.  Having fail-
ed, he introduced a mixture of arsenic and flour
into  the vagina after coition in the morning.
The  symptoms  appeared  about midday, and
death took place next morning.  The murderer
married, soon after, his guilty paramour, and
after  a  few  years got rid of her in a similar
manner.  About three in the afternoon she was
seized with shivering, and with heat and  pain
in the vagina;  the poison having  been intro-
duced in the morning.  The remembrance  of
her former crime excited  her  suspicions, and
she wrung from her husband a  confession.  On
the local symptoms, acute pain in the stomach,
incessant vomiting, and delirium supervened :
death took place after twenty-one  hours.   On
dissection, grains of arsenic were found  in the
vagina,  although frequent lotions had been used
larynx, and trachea, and he died in extreme distress, with
what was recorded as laryngitis, before twenty-four hours
had expired from the commencement of the fatal application.
  " This powerful agent" (arsenic),  says Dr. Francis,
"whether given internally or applied externally, is capable
of destroying life with equal certainty. A valuable mem-
ber of our community, the late Mr. O., fell a victim to the
empirical practice of arsenic, in the form of unguent, appli-
ed to a  small tumour situated between his shoulders.  In
this case," adds Dr. F., " I had an opportunity of testing
the accuracy of Air. Brooie's idea of the aotion of the arse- i
nious acid on the human constitution. Mr. Brodie considers
this mineral poison in its operation to produce its effects pri-
marily on the nervous system, and  that death is the result
of the suspension of the functions of the heart and brain.  In
Mr. O.'s case this theory was verified.  There was paraly-
sis of almost every limb of the body, and every joint seemed
to be greatly enlarged and tumid ; the intellectual functions
were nearly destroyed ; he died suddenly and unexpectedly,
in a manner characteristic of death by arsenical poison."—
Facts on Medical Jurisprudence, New York Med. and Phys.
Journal, vol. ii.
  We have facts confirmatory of this pathology in the issue
of cases in which arsenic is preposterously employed for the
cure of tinea capitis.
  Gilman Davis, of Portland, Maine, reports a case (Bos-
ton Med. and Surg. Journal, vol. xrviii., p. 214) of poisoning
by arsenic in a woman, who took half an ounce of arsenic, at-
tended with severe vomiting, but no pain or thirst. She
took the carb. ferri in large doses, but died the next day.
  Dr. Storer, of Boston, reports several cases of poisoning,
in the Boston Medical and Surgical Joumal,vo\. xxiii., p. 34&-
8. In one case, that of Mr. Kinney, who  was supposed to
have been poisoned, there was found extensive ecchymosis
of the mucous membrane of the stomach, which Dr. S. con-
siders characteristic of poisoning  by this substance, and
which, with the bloody tinge of the fluid fn the cavity of
the peritoneum and pericardium, would serve to distinguish
the case from one of cholera.  In one of the other cases
there was no vomiting, although  emetics  were given,  nor
any pain of any kind complained of, nor swelling of abdo-
men. Death ensued five hours after the poison had been
.-.vallowed, perfectly rational, and without a struggle.]
in the treatment.   The labia were swollen and
red, the vagina flaccid, the os uteri gangrenous;
the duodenum was inflamed, the stomach nat-
ural.
  406. E. Poisoning by Arsenic may take place
through the Respiratory Organs.—This usually
occurs in consequence of the accidental inhala-
tion of arsenical vapours.   Otto Tachenii s, a
chemist of the sixteenth century, quoted  by Dr.
Christison,  states, that he once  incautiously
happened to breathe the fumes of arsenic, and
was surprised to find his palate impressed with
a sweet, mild, grateful taste, such as he  never
experienced  before.  But  in  half an hour he
was attacked by pain and  constriction of the
stomach ; then  with difficult breathing, general
convulsions,  an unspeakable  sense  of heat,
bloody and painful micturition, and, finally, with
such  an  acute  colic  as contracted  his  whole
body for half an hour.   He recovered from these
alarming symptoms by taking oleaginous drinks;
but during all the succeeding winter he had low
hectic fever.  There can be no doubt of arsen-
ical vapour or fumes being rapidly poisonous,
when inhaled in a concentrated state, or even
when very diluted,  if longer breathed; and then
they may produce slow or chronic poisoning.
The vapour may even be employed in this way
with criminal intentions.   Dr. Christison has
quoted several writers and cases illustrative of
this mode of poisoning.   The following is a
most  instructive   instance of the kind:  An
apothecary inhaled the fumes  while  subliming
arsenic,  and  was  soon after seized with  fre-
quent faintness, constriction at the praecordia,
difficult  breathing, constant  thirst,  parched
tongue and throat, great restlessness, watch-
ings, and pains  in the feet.  He had  afterward
profuse daily perspirations and palsy of the
legs,  and  several  months  elapsed before  he
quite  recovered.   (See B. Time's, Cas.  Mdl.,
L. vii., c. 11 ; and  Christison, Op. cit., p. 302,
for similar cases.)   Paracelsus, being one oay
enraged  with an acquaintance, held him over
an  alembic in  which arsenic  was subliming ;
but the object of his temper nearly lost his life.
  407. F.  Applied to the sound skin, arsenic has
either no effect, or merely a slow and slight ef-
fect, unless  under certain circumstances.  If
the poison be simply placed in contact with the
skin it seldom  acts;  but if it  be  rubbed  upon
the skin, especially when mixed with fatty mat-
ters, it acts chiefly locally, producing a pustu-
lar  eruption or  eschars; but according to Re-
nault it produces no  constitutional  disorder.
This  statement, however,  should not be de-
pended upon; for  there are several  facts re-
corded that prove  arsenic sometimes to have
been productive of very serious local and con-
stitutional effects when applied to the human
skin, either in the state of fine powder, or in
the form  of ointment, liniment,  or paste.   In
these cases, several of which are adduced by
Dr. Christison, the symptoms were  faintinga,
giddiness, pain  in  the stomach, vomitings, te-
nesmus,  ardor urin», tremblings of the limbs,
low delirium, hectic fever,  debility, prolonged
recovery, and falling out of the hair.
  408. G. Diagnosis. — Poisoning  by arsenic
may be mistaken for the severer states of chol-
era, or even  for a  case of pestilential cholera.
The propriety of deciding  the question  from
the symptoms alone, as to whether or no poi- 
POISONS—Irritating  and Depressing—.\rsenic
421
poisoning has been produced by arsenic, belongs
more especially to the writer "on Medical Juris-
prudence.  This question has been ably discuss-
ed by Dr. Christison and the other writers so
often referred to.   But the diagnosis between
poisoning by this substance and natural disease
falls more  especially within my province.  It
should be admitted that the diagnosis is often
difficult; but due attention to the history of the
case, especially in  respect of the accession  of
the attack ; the  prickings,  burning  sensations,
or heat, redness and constriction in the  throat,
and in the course of the oesophagus, especially
early in  the attack; the redness of the eyes;
the swelling, heat, pain, and excoriation of the
anus ; the tenesmus, and the burning or colicky
character of the abdominal pain ;  the ardor uri-
nae, dysuria, and heat of the urinary passages ;
the increased suffering on  speaking and swal-
lowing;  the consecutive eruption of pimples,
or excoriations of the lips, tongue, and throat;
the nature of the nervous symptoms, particular-
ly the epileptic form of convulsions, the incom-
plete or partial palsy, the nervous sinking, anx-
iety, and muscular tremours, and the low deliri-
um, are diagnostic of poisoning, especially  by
this substance, and are rarely present, even in-
dividually,  in  cholera, and  perhaps never  in
such states of association as are  observed after
the administration of arsenic.   But strict atten-
tion to the  phenomena and recollection  of the
symptoms, as described above, will show the na-
ture of the case with tolerable  certainty; al-
though much more  precise information, as re-
spects both the  moral circumstances and the
chemical investigation, will be required for the
administration of justice.
  409. H.  The Organic Lesions produced by the
Preparations of Arsenic.—These have been de-
scribed most ably by Dr. Christison, and illus-
trated by reference to numerous cases, to which
I must refer the reader.  The changes produced
by arsenic  are numerous, and varied in most
instances, according to the quantity administer-
ed, the state of  the stomach at the time, and
the period the patient lived after its ingestion.
Similar changes are usually observed after poi-
soning by the  external application of the sub-
stance to those produced by its internal admin-
istration.  The most remarkable alterations are
generally found when the quantity swallowed
has not been very large, and when the individu-
al has lived sufficiently long to admit of the de-
velopment of inflammatory action and its more
immediate consequences.  When death has ta-
ken place very rapidly—in a shorter period than
eight, or  ten, or even twelve hours, little or  no
change is often  observed.  In these  cases it
may  be presumed  that  the impression  of the
poison on the organic nervous system, and the
action consequent upon its absorption  on the
heart and nervous centres, cause death before
vascular  reaction could supervene.—a.  Much
more frequently, however, the internal surfaces
of the stomach and duodenum, often also of the
oesophagus and pharynx, on the one hand, and
of the intestines, more especially the rectum
and colon, on the other, evince signs of inflam-
matory irritation and certain of its more im-
mediate  results, especially capillary injection,
sometimes  with  small ecchymosis, or slight ex-
travasations of blood, or softening of the villous
coat, or effusion of lymph, or ulcerations.  Red-
 ness, with vascular injection, is seldom absent
 from the throat and gullet, when the patient
 has lived above a few hours.  In the  stomach
 the colour is often a dull or brownish red; or
 it is of a brighter hue, interspersed with dark
 striee of altered blood.   The ecchymoses and
 larger extravasation of blood are always of a
 dark hue.  Ulceration rarely occurs, and chiefly
 in cases where death has not taken place until
 after the second or third day. Although inflam-
 matory appearances may  be absent in  cases
 which have ended rapidly, yet  they have been
 found  in  the stomach  in several which  have
 terminated in five, six, seven, or eight hours af-
 ter the administration of the poison. Thicken-
 ing,  or tumefaction  of  the villous membrane,
 with more or less softening, a  friable  state of
 it, and even abrasions of minute portions, are
 occasionally observed.   Gangrene and  perfora-
 tions of the stomach or intestines are  never
 found.  Changes, which have  been mistaken
 for gangrene, have consisted chiefly of extrava-
 sations of dark blood.  The ulcerations said to
 have been found in some instances when death
 has taken place a few hours after the ingestion
 of the poison, are very probably minute abra-
 sions or excoriations of the villous surface.  A
 sanguinolent fluid is sometimes  found in the
 cavity of the stomach ;  and occasionally arse-
 nic, variously altered in its appearance,  is found
 closely adhering to the  internal  membrane.
 The  colon is often much contracted and its in-
 ner surface inflamed, especially the sigmoid flex-
 ure and the caecum.  The  rectum is generally
 much inflamed and excoriated, the latter change
extending around the anus, particularly when
life has continued one,  two, or three days.
  410. b.  The respiratory organs sometimes are
 found congested, and the bronchial membrane
 more or less reddened.   Occasionally the pleura
 is injected, and  slight effusions of serum exist
 in the pleural cavities.   The heart is generally
 flabby, and sometimes the inner surface, partic-
 ularly the columnae carneae and valves, is more
 or less reddened.  The  blood is  often fluid, and
 generally dark-coloured.   Slight effusions of
 serum and congestion are  occasionally  found
 within the cranium.   Inflammatory changes are
 frequently seen in the urinary passages, and oft-
 en extending to the female sexual organs.
  411. c. The antiseptic influence of arsenic, more
 especially upon those parts where this substance
 exerts its injurious action, or where it is brought
 in contact, has recently  attracted attention and
 been fully established.   It thus very frequently
 not only preserves these parts, more especial-
 ly the alimentary canal, from putrefaction, but
 also the alterations  which it had produced  in
 them.   It may be presumed that the amount of
 antiseptic effect will depend very much upon
 the quantity of the poison, and upon the reten-
 tion  of it in the body at the time of death.  If
 much of it remain in the stomach and bowels,
 or become absorbed and continue either in the
 blood or in the several  tissues  and organs, an
 antiseptic and mummifying effect may be ex-
 pected ;  but if the poison be discharged  by vom-
 iting and purging, and eliminated from the body
 before death takes place, then the putrefactive
 process  will proceed as  usual, or even with
 greater celerity.  This effect of arsenic in ar-
 resting the  progress of putrefaction seems to
 be the result of a chemical action exerted by 
422
POISONS—Irritating and Depressing—Arsenic
 this substance upon the fluids and soft solids of
 the body.
   412.  /. The quantity of arsenic likely to destroy
 life depends  upon a variety of circumstances,
 But four grains, or even three, may kill a child,
 if it be  taken in solution or when  the stomach
 is empty.  Dr. Christison adduces the case of
 a child  who died in six hours after taking four
 grains and a half in a state of solution ;  and a
 woman, 70 years of age, was  killed by four
 grains.   Mr. Taylor  states that a young lady
 died after eating a portion of cake which could
 not have contained more than four grains, and
 probably less than three grains.   He states
 that three of a party at dinner who  had par-
 taken of the port wine on the table were seized
 with symptoms of arsenical poisoning.   The
 wine was found to contain about one to two
 grains of the poison in each fluid ounce.   A lady
 took a quantity containing less than two grains
 of  arsenic.   In  about half an hour she  expe-
 rienced faintness, violent vomiting, but no pain.
 She recovered after a few hours.  A gentleman
 took as  much as contained little more than two
 grains.   His symptoms were similar, but more
 severe.   If he  had  taken another glass of the
 wine, he might  have bpen killed.   Although the
 wine was saturated with arsenic, yet  no pecu-
 liar taste was perceived.  The escape of these
 persons was probably owing to the circumstan-
 ces of  the wine  having been  taken on  a full
 stomach, and of its having  been soon follow-
 ed  by violent vomiting.  It  is  probable  that
 from one to two grains would prove fatal to a
 child or to a debilitated person, and three grains
 to an adult.  On the  other  hand, cases of re-
 covery  from  the ingestion  of large quantities
 are not  infrequent.   a\  person recovered after
 taking half an  ounce, the poison having been
 carried  off by vomiting and purging;  hut in-
 stances of recovery from so large a  quantity
 are very rare, and are owing to the arsenic hav-
 ing been taken  on  a  full stomach, and to its
 speedy  evacuation.
  413.  K. The  period at which death takes place
 from arsenic varies  with the circumstances  so
 often alluded to.  Dr. Borland informed Mr.
 Taylor of a case in which two ounces of arse-
 nic were taken, and death  took  place in less
 than two hours from syncope.  There was nei-
 ther pain, vomiting, nor diarrhea.  Such rapid-
 ly fatal  cases  are  very rare.  But the  time
 at which death takes place  is not strictly de-
 pendent upon  the quantity  of  the poison ta-
 ken.  There are many cases reported in which
 death has occurred in from three to seven hours,
but much more frequently it does not super-
vene until  a period varying from twelve  or
 eighteen hours to three days, in the acute forms
 of poisoning by this substance.   In thirteen ca-
ses recorded by Dr. Beck, the smallest quantity
taken having been one drachm, and the largest
two drachms, the shortest period for death was
four hours, the longest  two days.  In  one in-
stance, two ounces of the poison destroyed life
in three hours and a half; but in another case
four or five grains killed a person in four hours ;
so little  does the rapidity of the effect depend
upon the dose or quantity.  When the poison
has been administered  in small and repeated
doses, and in cases of slow or chronic poisoning,
and in some instances  of the external applica-
tion of it, and when a partial recovery from the
 first effects has occurred, a fatal issue may not
 take  place until many days or weeks after its
 administration.
   414.  L. The modus operandi of arsenic has not
 always been rightly estimated.   This substance
 has been generally considered as a tonic ; but,
 judging from my experience of its action in my
 own  person, and in the treatment of many dis-
 eases,  I cannot believe that  it possesses any
 tonic properties, but, on the contrary, that it
 exerts an irritating and depressing influence ; its
 chief medicinal effects being anti-periodic and al-
 terative, effects which result from the employ-
 ment of it in very small and frequently repeat-
 ed doses; an irritating and depressing, or par-
 alyzing action, following the administration of
 larger doses.   Its local operation  is chiefly as
 an irritant, capillary  injection, inflammation,
 and its immediate consequences usually occur-
 ring.   But the primary impression produced by
 large quantities of this poison is probably seda-
 tive as respects the nervous system, both local-
 ly and  generally, inasmuch as death, preceded
 by signs of vital depression, often takes place
 before inflammatory appearances are develop-
 ed.   That arsenic is  absorbed into the circula-
 tion,  and affects this fluid, the  heart, and the
 nervous centres, are  facts which the detection
 of it in the liver, spleen, kidneys, [serosity of
 blisters],  lungs, and  urine, fully proves,  and
 which the changes in these organs farther serve
 to show.   Even when it is applied to an abra-
 ded surface, or to  parts which admit of its ab-
 sorption, it has been  found to affect more es-
 pecially the inner surface of the stomach, duo-
 denum, and large bowels, and it has been detect-
 ed  in these situations by chemical research.
 It appears to exert a specific influence upon the
 alimentary canal,  irritating and inflaming it,
 and, at the same time, depressing the organic
 nervous energy.  It exerts, also, a marked ac-
 tion on the emunctories by which it is carried
 out of the circulation, especially the urinary or-
 gans, the villous surface and glandular appara-
 tus of the large bowels, the  skin, and lungs;
 exciting, irritating, or inflaming these, accord-
 ing to the quantity existing in  the circulating
 fluids.
  415.  M. Treatment.—.\s  the  poisonous op-
 eration  of the preparations of arsenic is chiefly
 owing to the absorption of them, it  is obvious
 that, before they can be absorbed, they must be
 dissolved—either dissolved when administered,
 or subsequently by the juices of the stomach.
 Therefore, no  substance  ought to be  recom-
 mended as an  antidote unless it possesses the
 property of rendering the arsenic insoluble, or
of preventing its solubility; and no known com-
pound possesses this power to any considerable
extent.   The hydrated scsqui-oxide of iron pos-
sesses this property to a  certain extent.   Mr.
Taylor performed  many  experiments on this
antidote, and obtained the  following results:
1st When arsenious acid is dissolved in water,
and agitated with  twelve or fifteen times  its'
weight of the hydrated oxide, the poison is pre-
cipitated with it in a very insoluble form.   2d.
When the poison is mixed and agitated  in  a
state of powder  with the oxide, there  is little or
no effect, the  poison  being only mechanically
diffused through the oxide.   3d.  When the poi-
son in powder is mixed with oxide of iron, ren-
dered alkaline by ammonia, so much appears to 
POISONS—Irritating  and Depressing—Colchicum.
423
combine with the iron as the quantity of alkali
present will render soluble in cold water.  The
rest is diffused-in  granules through the oxide.
Most of the experiments, he adds, in favour of
this antidote have  been performed in solutions
of arsenic ; and therefore the results are irrel-
evant, since arsenic is most frequently taken in
powder, and often in  very coarse powder.  Re-
cently the acetate of  the sesquioxide of iron has
been recommended as an  antidote by M. Du-
flos ; but Mr. Taylor  found  that, in  respect
of arsenic in powder, it is as inefficacious as the
hydrated  oxide, even when an alkali is added,
to produce effectual precipitation ; and that,
with regard to the  solution, the poison  is more
readily precipitated by the hydrated oxide than
by the acetate of iron.  Other  antidotes have
been  mentioned, more especially large doses
of magnesia and charcoal;  but they deserve lit-
tle credit, and are  no farther serviceable than
by involving the poison more or less, and there-
by preventing its action upon, or its absorption
by, the surface of the stomach : an intention
which may be accomplished more completely
by albumen, milk, and various other substances.
The substances formerly  lauded as antidotes
have been shown, by the researches of Renault,
Orfila, and others, to be quite inefficacious ;
whatever of success may have followed their
exhibition having  been owing  to the  several
circumstances shown above (§ 51, et  seq.)  to
modify, counteract, or prevent the operation  of
poisons.
   416. So little advantage, therefore, being like-
ly to be derived from antidotes, our chief hopes
should be placed on the immediate evacuation
of the poison from the stomach, and upon the
removal of the injurious effects which may have
been produced.  If vomiting has not taken place,
or is  insufficient, it should be  promoted by  an
emetic of sulphate of zinc, or sulphate of cop-
per, or by mustard  taken at intervals in a wine-
glass of water, or by tickling the  throat with a
feather;  or the  contents of the stomach  may
be removed by the stomach-pump, avoiding  as
much as possible the introduction of fluids when
the poison has been taken in a state of powder
or of imperfect solution.  When vomiting takes
place, it may be promoted by taking albumen,
milk, thick mucilaginous fluids, linseed tea, &c.;
and, although the patient should not be allowed
to exhaust  his  strength  in retching,  without
some one of these fluids being  taken for the
stomach to act upon, still it should not be taken
in too large a quantity at one time, in order that
the stomach may contract frequently on itself,
and thus expel from  its surface the mucous  se-
cretion which often envelops the poison, and
protects the inner  surface of the organ from its
action   Mr. Taylor advises a saponaceous li-
quid, made of equal parts of oil and lime-water.
to be given ;  and Dr. Paris a free exhibition of
olive oil   Whan vomiting has commenced from
the action of the poison, an emetic or the stom-
ach-pump is then  necessary, as  this operation
will proceed, when aided by the fluids just men-

 10417 Having by these means discharged  the
poison from the stomach  there generally  re-
main two formidable morbid conditions produ-
cedby it to be removed.  These are inflamma-
tory  irritation and action of the alimentary  ca
nal  and nervous  or vital depression,  with  va-
rious concomitant phenomena.  This associa-
tion is of the most perplexing kind, inasmuch
as the means calculated to relieve the one ag-
gravates the other.   Nevertheless, if there is
sufficient reason to infer that  the poison is al-
together evacuated, and more  especially if the
first impression or shock produced  by the poi-
son has passed off, the pain and vomiting  hav-
ing developed more or less reaction, blood-let-
ting, general or local, or both,  will be practiced
with advantage ;  but if too early resorted to,
the absorption of the poison and the vital shock
may be both increased by it.   Terebinthinated
epithems,  sinapisms,  or blisters over the epi-
gastric region, or over the greater  part of the
abdomen, and a free exhibition of opium by the
mouth, and in starch or mucilaginous enemata,
are generally most beneficial;  but before opium
be given, the entire evacuation of  the  poison
should be ensured.   Subsequently, and when
the irritation of the bowels assumes a dysenter-
ic  character, or when tenesmus or dysuria is
urgent, the opium  may be conjoined with ipe-
cacuanha, camphor,  nitrate of potassa, traga-
canth,  &c. ;  and  these  may  be administered
also in enemata.   The medicated warm-bath;
fomentations to the  perinauim and anus, pre-
ceded  by  the application  of leeches  to those
parts, and a  farinaceous or mucilaginous  diet,
are important parts of the treatment.
  418. The nervous symptoms often accompany-
ing the vital depression produced by the poison
are most successfully treated  by opium taken
with small doses of camphor; by the application
of terebinthinated  embrocations; and  by  mild
tonics and  restoratives in small doses, and in
demulcent vehicles.   If palsy continue after the
removal of disorder of the digestive  organs, ex-
ercise in the open air, the preparations of nux
vomica, or strychnia cautiously prescribed, and
external irritants are the chief means of cure.
If the bowels become confined, either during
the more chronic cases, or during recovery or
convalescence, olive oil. taken in frequently re-
peated doses, and administered in enemata, is
the most appropriate  aperient.  During conva-
lescence, and for a long period afterward, dys-
pepsia, flatulence, and various states of disorder
of the digestive  organs  often continue for a
long time,  and are best relieved by change of
air, by travelling, and by strict attention to diet;
by the adoption of a bland, farinaceous  diet,
avoiding spirituous liquors, and the  substances
pointed out as injurious in the article on Indi-
gestion.
   419. iii.  Colchicum  Autumnale — Meadow
Saffron.—All the  parts of this plant  are poison-
ous at such periods of the year  as occasion their
development or perfection, but  they vary slight-
ly in their  effects.  The  several preparations
of the plant have  lately been much employed in
medicine, on account of their influence in para-
lyzing or diminishing morbid sensibility, in re-
moving pain, and in increasing the functions of
excreting organs, especially of the digestive ca-
nal, the liver, and kidneys ; its effects on these,
however, being by no means certain.  In large
doses, it acts as  an irritant of the  alimentary
canal; and as a sedative, often remarkably de-
pressing vascular action and vital power. Even
from small or medicinal doses, these  injurious
effects are  manifested in  some instances, and
not in a few of these  the vital  depression is ex- 
•
 424               POISONS—Irritating  ani

 treme, and consequent upon one third or one
 fourth of the usually prescribed medicinal dose.
 I have seen on several occasions poisonous  ef-
 fects produced by too great temerity in the use
 of this medicine; and these effects were not
 manifested so injuriously on the digestive canal
 as on the nervous system and vital  influence;
 extreme sinkings, failings of the pulse, and syn-
 cope, following its ingestion.   In two instances
 —in one a powerful man—a single dose of only
 ten minims of the tincture, which I  prescribed
 for gout,  produced alarming symptoms ;  and a
 drachm, taken by a medical man contrary to my
 advice, produced effects  from which he recov-
 ered with difficulty.   In some constitutions,
 owing to  idiosyncrasy, it acts with remarkable
 severity,  particularly  as  respects the vital de-
 pression produced by it. Geiger  and Hesse dis-
 covered a principle in this plant, or alkaloid,
 which has been called colchicina,  colchicia, or col-
 chicine, and which neutralizes acids, and  forms
 with them crystallizable salts.
   420. A. The symptoms arising from poison-
 ous doses of colchicum have been described  by
 Messrs. Fereday, Chevallier, Dillon, Haden,
 and Christison.  The  cormi,  the seeds, the
 flowers, and the  leaves of the  plant produce
 nearly similar symptoms  when  taken in large
 quantities.  An hour, or an hour and a half, af-
 ter the ingestion  of the poison, acute pain, fol-
 lowed by  retchings, vomiting, and tenesmus  or
 purging, or both, is nxperienced.   The  pulse
 soon becomes feeble, the countenance anxious,
 and afterward  the matters vomited  are  dark-
 coloured,  and the  purging profuse  and watery.
 The pulse is excessively slow  or feeble, the
 respiration  hardly perceptible  or feeble, the
 muscular  weakness extreme, and the urine sup-
 pressed, the watery portions of the blood  being
 discharged by the bowels and stomach.  The
 patient sinks after a period, varying with the
 dose and the constitutional powers, from a few
 hours to three or  four days ; but there are nei-
 ther convulsions, nor insensibility, nor deliri-
 um, unless in a  few  instances.   Mr. Taylor
 states  that a burning pain is felt in the throat
 and pesophagus;  but this  is not mentioned in
 the details of some cases, and  probably it de-
 pends much upon the state in which the poison
 is taken.   Mr. Mann  communicated  to him  a
 case in which three drachms  and a half of the
 wine of colchicum were taken in  divided doses,
 and caused death on  the fourth day.  There
 was no inflammation of the mucous membrane
 found on  dissection, but simply  extravasation
 of blood into the mucous follicles.  Mr. Taylor
 states, that a man took a decoction made with
 a table-spoonful of the seeds and a pint and  a
 half of water.   He was seized  with  vomiting
 and purging, which were incessant until death,
 which took place in about thirty-six hours.  The
 only appearance of note was, that the stomach
 had a violet or purple hue.  A gentleman swal-
 lowed, by  mistake, an  ounce and a half of the
 wine of colchicum: he was immediately seized
 with severe pain and the  other symptoms, and
 died in seven  hours.   In another  instance,
 where an  ounce was taken, death occurred in
 thirty-nine hours.   Most of the cases recorded
 of poisoning by this substanoe have been detail-
 ed imperfectly and loosely.  In Mr. Fereday's
 case, which has been given more fully than the
others, there was  no cerebral disturbance.
i  Depressing—Hellebore.

   421. B. The chief appearances observed on
 dissection, were a patch of redness in the inter-
 nal surface of the stomach, near the cardiac or-
 ifice, and a slight effusion of blood between the
 muscular and peritoneal coat of a portion of the
 jejunum.   The  omentum was turned up be-
 tween the stomach and convex surface of the
 liver behind, and the diaphragm in front.   The
 pleurae were somewhat reddened,  and the lungs
 much congested with black blood.  The  heart
 was flabby, and its structure easily broken down.
 The surfaces of the lungs, diaphragm, and heart
 were  covered with ecchymosed  spots.   The
 bladder was empty.  The face, neck,  front of
 the thorax, insides of the thighs, and the integ-
 uments of the scrotum and penis, were covered
 with patches of purple efflorescence.  (Lond.
 Med. Gaz., vol. x., p.  160.)  In the bodies of
 the children  mentioned by  Bernt  there was
 considerable redness of the stomach and small
 intestines.   In  Geiger's  case, inflammatory
 appearances were seen in  the stomach  and
 small intestines.  In a case related by M. Che-
 vallier, and  in another adduced  in the Edin-
 burgh  Medical  Journal, no alterations  were
 found.  (Christison, op. cit., p. 792.)
   422.  C. Treatment.—Retchings often continue
 for  some time,  and are ineffectual; therefore
 full vomiting  should not be expected  without
 the  aid of an emetic, which may consist of sul-
 phate of zinc or mustard mixed in water.  The
 stomach-pump may be employed if the patient
 be seen soon after the ingestion of the poison.
 After the evacuation of it from the stomach, it
 remains to counteract the injurious impression
 produced by it on the organic nervous system, and
 upon the heart and nervous centres by its absorp-
tion into the circulation ; and the only means we
can employ with these intentions with any hopes
of success, are opium, ammonia, camphor, cap-
sicum,  and creasote, variously combined, ac-
cording to circumstances.   I have had very fre-
quent recourse to the preparations of colchicum
in practice, but have seldom given them in full
doses  without  conjoining  them with  one or
more of these substances, which have always
prevented any unpleasant symptoms from fol-
lowing  their administration.  Where idiosyn-
crasy, also, has stood in the way of their exhibi-
tion, I found these medicines prevent any sink-
ing and distress, and to remove these effects
when they have  appeared.  There cap be no
doubt, therefore, that these remedies are most
appropriate in cases of poisoning by colchicum.
They may be aided by sinapisms, or terebinthi-
nate embrocations, or epithems over the abdo-
men, and by mucilaginous or oleaginous draughts
and injections, which may be made  the vehicles
of the remedies just advised.
  423. iv. Hellebore.—Black Hellebore, Hclle-
borus Niger—White Hellebore, Vcralrum Album
— Veratrum  Sabadilla—Veratrine — Veratria —
The operation of black hellebore and of vera-
trum is nearly similar ; and the alkaloid of  the
latter—veratria—produces the same action as
either of these, a much smaller quantity being
required to produce the same amount of effect.
—A. Black hellebore, in poisonous doses, causes
a burning  pain in the stomach and intestines
vomitings, purging, cramps  in  the lower ex-
tremities,  cold  sweats,  faintness, paralysis
sometimes  insensibility from exhaustion or vi-
tal depression, and extreme weakness of the 
POISONS—Irritating  and Depressing—Poisonous Fish.
425
pulse.  Death appears to result from  the  ex-
cessive vomitings and purging, and impaired ir-
ritability and action of the heart.
  424.  B. White hellebore— Veratrum album —
acts as a local irritant, exciting at the same time
the nerves of the part.   In excessive doses, it
irritates the digestive mucous surface,  and  de-
presses nervous and vital power.   The symp-
toms  are  violent vomiting and purging, some-
times of blood ; tenesmus, and griping pains in
the bowels.   These  are  preceded  or attended
by a burning sensation in  the mouth, throat,
and a-sophagus; constriction of the throat, with
a sense of strangulation ; and are soon follow-
ed by a small or almost imperceptible pulse ;
by faintness, cold sweats, tremblings, giddiness,
loss  of voice, blindness, and dilated pupils, in-
sensibility, syncope or convulsions terminating
life.  In some cases, noticed by Dr. Pereira as
having occurred to Dr. Rayner, these symp-
toms were present, with  the exception of pur-
ging.
  425. C. Veratria is  poisonous  in very small
doses.   Mr. Taylor states that a physician pre-
scribed for a lady one grain of veratria divided
into  fifty pills, and three were directed to be ta-
ken  for a dose.  Not long after the first dose
had  been swallowed she  was found insensible,
the surface cold, the pulse failing, and with oth-
er symptoms of approaching dissolution.  She
remained some hours in a doubtful  state,  but
ultimately recovered.  If the veratria was well
 mixed in the pills, the dose was here not large ;
 but this admits of doubt.
   426. D. The treatment  of poisoning by these
 substances is similar to that recommended  for
 other poisons belonging  to this class.  After
 the evacuation of the poison, the effects should
 be attempted to be removed by means of stim-
 ulants conjoined with opium.  In a case treated
 by Dr. Pereira, the infusion of nutgalls  seemed
 to give relief.   Coffee has been recommended
 both as a drink and as a clyster.  The external
 applications already advised in similar circum-
 stances should not be withheld.   Demulcents
 should be made the vehicles for stimulants, as-
 tringents, and opiates.
   427. v. Food Poisons—Poisonous Food—Poi-
sonous  Fish — Poisonous  Meats — Poisonous
 Cheese. — Various articles of food  not infre-
quently occasion injurious  effects,  and even
death  in a  few hours.   The slighter effects
have sometimes arisen from idiosyncrasy ;  but
not so frequently as supposed by some writers.
This cause may be admitted in respect of those
instances which have sometimes occurred of  a
single person only having been affected, of sev-
eral  who have partaken  of the same article or
dish.  Poisonous articles of food—fish, meats,
&c.—have hitherto been classed as acro-narcot-
ics.  As  they are more or less irritant, and as
acrid and irritant convey ideas nearly related,
the first  part of the appellation somewhat  ap-
proaches the truth ;  but  that they produce nar-
cotic or stupefyng effects cannot be so readily
conceded, inasmuch  as this particular effect no
farther appears than  as  it results in some in-
stances from the sinking of vital and cerebral
power and the diminution of sensibility owing
to this state.  These poisons, in truth, act as ir-
ritants of the alimentary canal, and as sedatives
or depressants, or paralyzers of organic nervous
or vital energy.  While they irritate the  mu-
cous surfaces, and glandular apparatus of that
surface, they rapidly depress vital power ; and
the irritation they occasion passes not into in-
flammatory action, but into excessive secretion
and exhalation ;  or, if inflammatory action be
developed, it is of  an asthenic and  spreading
form.  That these  poisons do  not act locally
only, may be inferred from the ultimate effects
being much more serious in  most  instances
than the amount of local lesion can  explain ;
from their contaminating nature, from the ready
imbibition  of  them  by  mucous surfaces, and
from their speedy absorption from these surfa-
ces.  The various articles which are sometimes
productive of poisonous effects  occasion modi-
fied or even different symptoms ; but they are
remedied by very nearly the same means.
  428.  A.  Poisonous Fish.—Several species of
fish, both in this climate and between the trop-
ics, are always poisonous ; and others are inju-
rious  only occasionally or rarely.  Some ac-
counts of the poisonous fishes of the tropics
have been given by  Drs. Thomas, Chisholm,
and Fergusson ; and various memoirs and no-
tices of the  poisonous  fish found in Europe
havebeen published by Dr. Burrows,Dr. Combe,
Dr. Edwards, Professor Orfila, and Professor
Christison.  I had  occasion many years ago,
within the tropics, to treat a case of poisoning
by fish, which nearly  proved fatal; and I have
seen two  or three  instances of poisoning by
mussels in this country ; but there was no dan-
ger in these cases, although the symptoms were
severe.  The fish which are the most frequently
injurious in this country are all the kinds of
edible shell-fish, especially mussels, cockles, per-
iwinkles, lobsters, crabs, and craw-fish.   .\nd
either of these, when kept too long after having
been boiled, or when only parboiled and reboiled
after various intervals, as sometimes practiced
by the lower dealers, will produce more or less
disorder.   Salmon and eels are also sometimes
poisonous,  but the  former is injurious chiefly
when out of season, or when insufficiently pre-
served.
  429.  a. The symptoms produced by poisonous
fish differ much in different persons ;  and cer-
tain  of the effects observed are more or less
owing  to  idiosyncrasy; but the most violent
and fatal operation is not so frequently, if at all,
owing to this cause—(a) Thirty persons were
poisoned by mussels  in Leith in 1827, and of
these two died.  The symptoms were carefully
observed and described by Dr. Combe.   No one
complained of anything peculiar in the smell or
taste of the mussels, and none  suffered imme-
diately alter eating  them.   An  hour or two or
more elapsed, and then the bad  effects consist-
ed rather in uneasy feelings and debility, than
in distress referable to the stomach.  After eat-
ing two or three, and various numbers above
this, the lowest number, slight tension at the
stomach,  with heat  and  constriction of the
mouth and throat, was complained of.  These
were  succeeded by a difficulty of swallowing-
and speaking  freely, by prickly feelings in the
hands;  by numbness about  the mouth, gradu-
ally extending to the arms, with great debility
of the limbs.  Two or three had  cardialgia, nau-
sea, and vomiting ; but these were not general
or lasting symptoms.   The muscular debility
was  present  in all the cases.   An unpleasant
taste was felt in the mouth.  There was slight 
426
POISONS—Irritating and Depressing—Poisonous Fish.
  pain in the abdomen, on pressure, especially in
  the region of the bladder.  The secretion of
  urine was suspended in some cases, in others it
  was free, but passed with pain or effort. The ac-
  tion of the heart was feeble, and the breathing
  unaffected.  The face was pale, and expressive
  of anxiety; the  surface somewhat  cold, the
  mental faculties unimpaired.   One of the two
  fatal cases died in three hours, the •ther in six
  or seven hours.  In one case only did the symp-
  toms of irritation pass into those of inflamma-
  tion of the digestive canal.  The instance which
  was treated by me within the tropics was char-
  acterized by constant  vomiting, by remarkable
 loss of muscular power,  by rapid  failure of the
 heart's action,  coldness and clamminess of the
 surface, and sinking, with intermissions of the
 pulse.  This form of fish poisoning may be call-
 ed the paralytic, or vitally depressing, this con-
 dition predominating over the irritant.
   [We have known vomiting, and all the symp-
 toms of acrid, irritant poisons, produced by eat-
 ing of halibut, crabs, lobsters, oysters (out of
 season), mussels, &c.  In one instance, a fam-
 ily of six were poisoned  by eating mussels, of
 which one died, with all the symptoms of ag-
 gravated  cholera morbus.  Dr. A. C. Post  has
 reported a case of poisoning, from eating a por-
 tion of the liver of the  halibut, in the New York
 Journal of Med., vol. i., p.  101.  The patient
 was attacked soon after eating with pains, nau-
 sea, vomiting,  and headache ;  and soon  after
 the skin began to exfoliate  from  his face, and
 successively from every part of the body.  The
 disease went off in a few days under  the use
 of diaphoretics  and the warm bath]
   430. (b) In the  other form of poisoning by
 fish, cutaneous  eruptions, with or without asth-
 ma,  or  asthmatic  symptoms  without external
 eruption, are generally  present, and signs of lo-
 cal or general  irritation predominate.  From
 one to two or three hours after eating the fish,
 especially  mussels, uneasiness, or sense  of
 weight at  the epigastrium ;  heat, and constric-
 tion of the mouth and throat, with thirst; numb-
 ness, prickings, and itchings of the surface, par-
 ticularly of the extremities ; difficulty of breath-
 ing, lachrymacation and swelling of the eyelids,
 and an eruption resembling urticaria are com-
 plained of; but sometimes the eruption is papu-
 lar, sometimes vesicular, and it is always  at-
 tended by heat  and itching.  These symptoms
 are sometimes  attended  by vomitings,  by  col-
 icky  pains  and  diarrhoea; but these are often
 absent, or of short continuance.  In the cases
 related by Mohring, the eruption was preceded
 by dyspnoea,  lividity of the face, insensibility,
 and convulsions.  In Dr. Burrows's cases, the
 symptoms began with dyspnoea, nettle-rash, and
 swelling of the face, conjoined with vomiting
 and colic ; delirium and convulsions superven-
ed, and death took place in  three  days.   In
Mohrings cases the  symptoms appeared in a
few minutes ; in those by Dr. Burrows  not un-
 il twenty-four hours after eating.
  431.  (e) Fish kept too long before or after
having been cooked, or otherwise spoiled, espe-
cially salmon and shell-fish, has,  in two or three
instances  which  I  have observed, produced
symptoms differing more  or less from the two
forms of fish poisoning now described.  The
poison  causing  the above effects exists in  the
fish when cooked, is present in the fresh or live
  state, and is not produced by changes that have
  taken place, either after death or after cooking.
  But the injurious effects occasioned by such
  changes as occur after the death, or the" cook-
  ing of the fish, are different from the foregoing;
  and are not attended by either the rapid sink-
  ing of vital power on the one hand, or the dysp-
  noea and eruption on the other.  The injurious
  operation in  the  circumstances now stated,
  very much resembles an attack of colic, with
  vomiting, or an attack of cholera ; there being
  generally severe  vomiting with  griping pains,
  occasionally purging with cramps of the extrem-
  ities, much debility,  and sinking of the  pulse ;
  but these latter symptoms are not so severe as
 in the first form, and death has not occurred in
 any of the cases which I  have seen
   432. b. The source of the poison, in these ca-
 ses and  forms offish poisoning which are pro-
 duced by fresh fish, has been a matter of spec-
 ulation.   In the numerous cases observed  by
 Dr. Combe the mussels were fresh, plump, and
 healthy-looking; and Dr. Christison analyzed
 some of those which were taken from the stom-
 ach of one of his patients without being able to
 detect a  trace of copper, to  which the poison-
 ous operation of fish has been attributed.  That
 idiosyncrasy has,  as  Dr. Edwards  contends,
 something to do with the injurious  effects of
 fish, is true in few or  rare instances.  Dr.
 Christison  remarks, that a relation of his could
 not partake of salmon, trout,  herring, turbot,
 or lobster, without being attacked with violent
 vomiting;  and several instances of the  kind
 have been mentioned to  me  by  persons who
 have possessed this peculiarity; to which, how-
 ever, fish poisoning cannot be  imputed  in the
 great majority of  cases.  In the nearly fatal
 case seen and treated by me in a most intimate
 friend now living, who was never disordered by
 any kind offish on any other occasion, and has
 always been in the habit of partaking freely of
 every kind of fish, no such idiosyncrasy existed.
 The mussels, which proved to be  poisonous to
 thirty persons in Leith, were minutely examin-
 ed by Drs. Christison, Combe, and Coldstream ;
 and it would appear that nothing particular was
 detected  in  their appearance;  excepting that
 the liver  appeared much larger, darker, and
 more brittle than in the wholesome fish.   The
 poisonous mussels  were all taken from one spot,
 and every person  who partook of them was
 more or less severely affected, according to the
 number who ate of them.   Animals suffered as
 severely  as  man, a cat and dog  having been
 killed by  them.   It is very probable that, as re-
 spects these mussels, and perhaps also  as re-
 gards some other shell-fish, the poisonous prin-
 ciple exists  in  the liver, as suggested by the
 statement of Dr. Christison, but what that prin-
 ciple is has not been ascertained.  In the cases
of poisoning of two women by mussels, M. Bou-
chardat states, that he detected sufficient cop-
per to account for the effects ;  but it is not de-
tected in most  cases, and even when present
the quantity found  is too small  to account for
the poisonous effects on the human  subject
There can be no doubt, as I have suggested
above, that much of the injurious effects of va-
rious kinds of shell-fish, eels, &c,  arise from a
sickly, state, produced by  the  means  used to
bring them alive to market, and that the  chol-
eric and colicky symptoms described ($ 43i) as 
POISONS—Irritating and Depressing—Poisonous Meats.             427
being often produced by salmon and other kinds
offish, aris echiefly from changes subsequent to
the death and cooking or preserving of the fish.
  433.  c. The treatment of fish poisoning should
depend much upon  the  time that has elapsed
from the eating of the fish until the commence-
ment of the symptoms ; and this may vary from
a few minutes  to twenty-four hours, or even
more.  If the  period has been short, and the
fish  still  remains in  the  stomach, an  active
emetic, as  mustard, or the sulphate  of zinc,
should be given with a large dose of capsicum,
and the vomiting encouraged by means of dilu-
ents, conjoined with stimulants, aromatics, spi-
ces,  &c.  The elapse even of a long period be-
tween the ingestion of the fish and the appear-
ance of disorder, should not prevent a recourse
to emetics, for  the  fish may, in  its poisonous
state, remain long unchanged  in the stomach.
If vomiting has taken place without the  aid of
an emetic, it should  not be considered sufficient
unless there has been an abundant discharge
of undigested or other matters, the treatment
now advised being  required nevertheless.  If
the irritability  of the stomach become exces-
sive, it will be of no  avail to attempt to remove
it by means of opium and effervescing draughts,
unless they be conjoined with powerful stimuli
and warm spices ; for this state of the stomach
is always in fish poisoning attended by sinking
of the vital powers, especially of the heart's ac-
tion, and by colicky pains and  flatulent disten-
tion of the bowels.  Powerful stimulants, aided
by warm embrocations, rubefacient epithems,
or sinapisms, over the epigastrium and extrem-
ities, are then  required.  I believe that  capsi-
cum—the true  cayenne—or small  bird-pepper
—is an antidote to fish poison, when taken free-
ly.  In the nfiarly fatal case,  which I treated
within the tropics (Y 429), after other means
had  failed to allay the vomitings and rally the
powers of life, and after brandy and water had
been thrown off the stomach, a teaspoonful of
powdered cayenne was mixed  in a tumblerful
of brandy and water (equal parts of each), and
taken at a draught.  All  the  symptoms wer*
instantly mitigated, and the next day nothing
more than  debility  was complained of.   That
the constant vomitings attending this and some
other states of poisoning is owing to more than
irritation—is owing in some degree to exhaus-
tion  of vital power,  is shown by the instant ar-
rest of both the nausea and the vomitings by
so powerful an excitant  as that now mention-
ed, and which I have prescribed in somewhat
similar conditions with equal advantage.  I have
employed this  spice, especially in an early part
of my practice, and in  malignant  diseases, in
very large doses, believing that it is not so irrita-
ting  to the stomach as its  impression on  the
nerves of the mouth and palate would indicate,
but that, on the contrary, it imparts a salutary
stimulus to the digestive canal, and counteracts
the  influence  of many depressing agents.   If
the poisonous fish have passed into the bowels,
causing colicky pains, flatulent distention of the
abdomen, and sinking of the vital powers, ene-
mata, containing spirits of turpentine, with cas-
tor  oil •  and,  in extreme cases, asatcetida or
capsicum, or both,  should be administered  and
repeated, according to circumstances, and the
warm turpentine embrocation  or epithem ought
to be applied over the abdomen.
  434. B.  Poisoncjs Meats.—Certain kinds of
meat are sometimes poisonous even in a fresh
state, independently of any disease.  Others are
poisonous owing to some disease of the animal
at the time of death.  Others, again, are injuri-
ous in consequence of changes which  have oc-
curred after the animal has been killed—these
changes arising either from the deposit of the
ova;  or exuviae  of insects—from fly-blowing,
or from decomposition, or the more  slowly de-
veloped combinations of  the elementary ^parti-
cles which take place in imperfectly preserved or
salted provisions, especially in sausages, dried
meats, bacon, &c.   The secretions of certain an-
imals are poisonous during their lives, especial-
ly those possessed by them for the purposes of
self-preservation ;  and the fluids and secretions
of others are sometimes poisonous, both during
life and after death, owing to the nature of the
disease of which these animals are the subject.
These latter infect the healthy, contaminating
the fluids and soft  solids.   They are fully con-
sidered in the articles Blood, Disease, and In
fection,  and in those devoted  to the  specific
forms of disease to which  they give rise.  Some
notice is also taken of certain of them when
treating of Septic Poisons.
  435. a.   Fresh pork is  often injurious,  and
gives rise to various symptoms, according to the
idiosyncrasy of the individual and to the man-
ner in which the animal had been fed.  In the
East, especially in warm climates, pork is often
injurious, and productive of diarrhoea and dysen-
tery ; effects which I have seen caused by  it in
several instances  in this country.  The Mosaic
law forbade the use of it; and there can be no
doubt  of the wisdom of  this law as  respects
warm countries, and I believe as regards all
countries.   The poisonous effects of  fresh pork
vary.  In the most severe cases it has produced
a dry and burning sensation in the throat, with
heat and pain in the stomach, retchings and vom-
iting ; a sense of sinking  at the epigastrium ; a
weak, small, and  irregular pulse; coldness of
the extremities, a cold and clammy perspiration,
and  colicky pains  in the  abdomen and around
the umbilicus. In other cases the pain has been
confined  to the stomach  alone, or it has  been
situated  in some other part of the abdomen.
In addition to these symptoms, there have some-
times been remarkable swelling of the face ex-
tending over the scalp without any  vesication
or redness, swelling and  tenderness of the ab-
domen, an eruption resembling urticaria over
the breast, legs, and arms, and a quick, s^harp
pulse.  In rarer instances, there have been nei-
ther retchings nor vomitings, but severe colicky
pains, and sinking of the pulse and vital powers.
Such were the more acute cases of poisoning
with pork, and of which  Dr. M'Devitt has de-
tailed si.x cases, all of which were produced by
fresh or recently salted pork, and  especially by
roasted pork.   He believes that  the injurious
effects are produced chiefly by the fatty parts;
but  I have reason to believe  that the viscera
are still oftener injurious.  [In this country, a
preparation of pork called head-cheese  is more
frequently injurious than any  other variety of
this food, and this is probably owing  to incip-
ient decomposition in the centre, as  in the  cast
of the German sausages.]
  436. The symptoms may appear any timt
from three or four to thirty hours after the in 
428
POISONS—Irritating and Depressing—Poisonous Meats.
gestion of the meat.  When the symptoms are
delayed  until seven or eight  hours after the
pork has been eaten, they much resemble those
of either violent colic or  enteritis, and are at-
tended by a sense of sinking  or of impending
dissolution, and a weak, intermitting pulse, &c.
In other cases, especially when a longer period
than this has elapsed from the ingestion of the
poisonous food—from  twelve to twenty-four
hours—diarrhoea, or an attack resembling chol-
era, or dysenteric symptoms of a severe char-
acter, have  taken  place.   In  many instances
the symptoms are slight, especially when the
offending article has been evacuated speedily
by vomiting or by copious evacuations from the
bowels ; and even when the symptoms assume
an alarming character, the discharge of it, when
fully accomplished, is followed by immediate
relief of all the symptoms.  When only one, of
several of those who have partaken of this food,
has been thus affected, then we may infer ei-
ther that the affection is owing to idiosyncrasy,
or that the part eaten by the individual has been
tainted or  otherwise changed ;  but I am ac-
quainted with occasions on which great num-
bers of persons, as a large portion of a regiment
of troops, have been affected after eating fresh
pork,  some very severely, with the symptoms
above described, or with  diarrhoea, or colic, or
dysentery.
  437. b. Bacon seldom produces symptoms of
acro-sedative poisoning unless  those parts of it
generally  on or  near  to the surface,  which
have undergone change  during the process of
preserving, or near the large vessels.   Mr. Tay-
lor states, that one fatal case from poisoning
by bacon occurred in  the metropolis  in  1836;
and I have seen very severe  effects produced
by a minute portion of a spoiled or rusty part of
ham or bacon  having  been  swallowed.  But
equally  severe and nearly similar symptoms
have  followed  the ingestion  of a very small
piece  of either mutton or veal, when fly-blown
or otherwise changed.  Mr. Taylor states, that
meat  of any kind, when  too recently killed or
decayed, may produce severe  effects, and even
death.  I believe, however, that decay,  unless
far advanced or connected with the deposition
of the ova  or exuviae of insects, or the genera-
tion of mouldiness, or the lowest forms of ani-
mal life in the preserved articles, will not pro-
duce of itself the severe symptoms constituting
acute or fatal poisoning.
   438. c. Animal substances of various kinds have
become poisonous, owing to changes  during
their  preservation, which Dr. Christison has
called a " modified putrefaction."  In Germany
and other countries, where animal substances
are preserved by drying  and  smoking chiefly,
and without much salt, some unknown  injuri-
ous principle appears to be developed in these
substances from the combinations of their ele-
mentary particles during  the process of preser-
vation.   The articles in which  these injurious
changes have been observed  are sausages, ba-
con, and hams, dried mutton  and beef, cheese,
smoked salmon, and various other dried  or pre-
served animal  substances.
   439. (a)  Sausages have proved most frequent-
ly poisonous ; but it is possible that they may,
at least in some instances, have possessed this
property independently of any changes  during
their preservation, and that it may have existed
in the flesh or viscera of the animal, especially
the pork, when quite fresh, of which the sausa-
ges were made.   This circumstance is render-
ed the more probable by the accounts of three
cases which terminated fatally from the effects
of sausages made with the liver of an apparent-
ly healthy pig slaughtered only a week before.
The inspection of the bodies threw no light on
the more immediate cause of death in these ca-
ses.  (Lond. Med  Gaz., November, 1842 )   But
the poisonous effects so frequently observed  in
Germany to be produced by sausages more ev-
idently are developed by a modified putrefaction
or by a combination of the elementary particles,
taking place during the process of preservation,
and different  from the usual states of putrefac-
tion.  The sausage poison  has been described
by Dr. Christison from the  materials furnished
by Keener, Dann, and Horn.  In a period of
little more than thirty years, 234 cases of  sau-
sage poisoning occurred in the state of W'urtem-
berg,  and of that number  110  proved fatal.
Those sausages which have been found poison-
ous have usually been of large size, and cured
by drying and smoking with wood.  They be-
come deleterious in the spring after they have
been long kept, and been alternately frozen and
thawed ; and are poisonous only at a particular
stage of decay, and cease to be so when putre-
faction  has  fully advanced.  Those that are
poisonous possess an acid  reaction, are  soft,
have a nauseous  putrid taste, and an  unpleas-
ant sweetish-sour smell.  The central parts are
chiefly deleterious, these parts being poisonous
even when the surface is wholesome.
  440.  (b) The  poison of cheese, as observed  in
several Continental countries, and rarely in this,
appears to be developed by  analogous  changes
in the curd to those observed in Sausages ;  and
is more properly developed  by a partial decom-
position having taken place  in the curd before
it was subjected to pressure, than by any change
subsequently to  this process.  Dr. Christison
thinks  that the cheese poison is occasionally
met with in Cheshire, where among the small
Dill-farms the limited extent of the dairies  obli-
ges much of the curd to be kept for several days
before the quantity required for large  cheeses
is accumulated.
  441. d. The symptoms produced by spoiled sau-
sages, cheese, bacon, hams, and salmon, which has
become partially decomposed before,  or  after
being cured, are probably very nearly the same
in respect of each of these articles;  but  they
have  been more frequently and  precisely ob-
served and described as regards the ingestion
of spoiled sausages.   Generally, the effects  of
these  are  not  manifested  until  twenty-four
hours,  or two,  three, or  even four days  after
they have been eaten.  This tardiness of opera-
tion is probably owing to the difficulty of digest-
ing them, and the slowness of their absorption.
The first symptoms are  pain in the stomach,
vomiting, purging,  dryness of the mouth and
nose, and hoarseness or loss of voice.  Deglu-
tition becomes  difficult and painful; the pulse
fails, swoonings ensue, and the skin is cold and
ultimately insensible.  The eyes,  eyelids, and
pupils are almost motionless.  The secretions
and excretions are at last suspended, but often
profuse diarrhcea continues  throughout.  Fever
is rarely present, and the mind continues unaf-
fected.  Fatal cases end with convulsions and 
        POISONS—Irritating and Depressii

oppressed  breathing  between  the third and
eighth day.'  In cases of recovery, convales-
cence in very long protracted.
  442. e. The appearances on dissection have been
described as observed in cases of sausage poi-
soning.  There are usually signs  of inflamma-
tory irritation in the internal surface of the di-
gestive canal.   The throat  is white and dry;
the oesophagus thickened ; the stomach and in-
testines reddened, and croupy exudations are
formed  on  the  surface of the trachea.  The
heart is flaccid, and the body is said to resist
putrefaction.  But it  is evident, from this- ac-
count, that the  structural changes consequent
upon poisoning  by these  articles  of food have
not been observed with due care and precision.
  443. /. The treatment of poisoning by pork, or
by sausages, preserved meats, and  other articles
too long kept or imperfectly preserved, should not
differ materially from that recommended for fish
poison.  The chief indication is to procure the
discharge of the offending substance as speed-
ily as possible, by means  of the emetics con-
joined with the warm spices  already mentioned
($ 433).  If it be inferred  that it has passed the
pylorus, the enemata advised  for fish  poison,
and the external applications also recommend-
ed,  should  be resorted  to.  In cases of poi-
soning by these substances,  creasote, conjoined
with warm spices, with small doses of opium,
and with ipecacuanha if diarrhoea or dysenteric
symptoms appear, will be found of great service,
especially when the stomach  becomes irritable.
In most cases, also, mustard poultices, or tur-
pentine epithems, over the epigastrium or ab-
domen, will be of service; and they ought nev-
er to be omitted in the more  acute and danger-
ous  cases.
  444. C.  Diseased a\nimal  Substances, Flu-
ids,  Secretions, &c.—a. The flesh  of over-driven
animals, especially if these animals have been
deprived of drink for some time before they
were killed, and  probably also their viscera,
produce injurious  effects, especially in cachec-
tic constitutions.  But, according  to the exper-
iments of M. Morand, the flesh of such animals
is perfectly wholesome when cooked and eaten,
although the application  of  the blood, or raw
flesh, to a  scratch  or wound, or  even to the
sound skin, is often followed by  dangerous or
fatal effects : sometimes consisting of an  erup-
tion  of gangrenous  boils, the pustules malignes
of the French, at other times appearing as dif-
fuse inflammation of the skin, or of the cellular
membrane, or of both.
  445. 6. The viscera  and offal of animals  occa-
sionally produce analogous effects to these just
mentioned, even on the unabraded surface  Sir
B. Brodie has shown  that the contact of these
with  abraded  or wounded  parts may cause
chronic states of erysipelas, &c.  I have seen
several instances  of the scratches or pricks of
the fingers of cooks by the  bones of hares or
of other animals, and even abrasions of the
skin, having been followed by inflammation of
the absorbents  or of  the veins, or by diffusive
inflammation of the cellular  tissue.
  446. c. The flesh or viscera of diseased animals,
and especially of  those which have died of en-
demic or epidemic distempers, are undoubtedly
injurious,  and even in some instances rapidly
fatal.  Mr. Taylor states, that four members
of a family in Oxfordshire, in the spring of 1841,
o—Diseased  Animal  Substances, etc     429

 dined in good health upon part of a sheep which
 had died of a disease then prevalent among cat-
 tle.   The  symptoms  which followed this  meal
 resembled those of irritant poisoning, accompa-
 nied  by others indicating an affection of the
 nervous system.   One of the patients, a child,
 died in  less than three hours;  the others recov-
 ered.   There was no poison discovered in the
 food, nor in  the body, nor was any poisonous
 vegetable used at the meal.  (Op. cit., p. 214.)
   447.  d. There are certain districts in North
 America, in which the milk and flesh of animals,
 especially  cattle, acquire poisonous properties
 from  the grass [or some vegetable] on which
 they feed.  The disease thus produced in per-
 sons  who  partake of this poisonous  food has
 been  named  in America the " milk-sickness,"
 or " trembles."  These districts lie to the west
 of the Alleghanies, and those who venture with-
 in them are  obliged to abstain  from  the  flesh
 of the cattle  within the same limits, as well as
 from  the milk and its  preparations.  It appears
 from the report of Drs. Hosack, Post, and Chil-
 ton, that the inhabitants of some of these dis-
 tricts, with a reckless disregard of human life,
 carry the butter and  cheese,  which they dare
 not themselves eat, to markets  at a distance;
 and that thus symptoms of poisoning, and even
 death, for which the medical attendant cannot
 account, are  frequently produced.  According
 to the same  report, the cattle from these dis-
 tricts are sent in great droves over the mount-
 ains,  but,  in  order to deceive the purchasers,
 they are sent to New York by a southern route.
 The flesh of these animals occasions aggravated
 symptoms  of cholera.  " The viscera of these
 cattle are often found  diseased; the livers most
 generally so."  Owing to the symptoms of poi-
 soning  which have followed the use  of  beef,
 butter,  and cheese from  these districts, the
 American government caused a medical inqui-
 ry to  be instituted into the matter, and the re-
 porters  recommended the sale of these articles
 to be prohibited.   In  the  event  of this recom-
 mendation being adopted, it  is not improbable
 that the poisonous food  may be exported to
 England.   (See Edin. Med. <£ Surg. Journ. for
 July, 1844.)
   [Cases of  poisoning by eating smoked  beef,
 cheese, head-cheese,  and ham,  are not of un-
 frequent occurrence in this city.   In December,
 1841, about forty cases of poisoning from eat-
 ing smoked beef occurred in a particular neigh-
 bourhood,  all of which could  be traced to the
 same source.  About nine hours after partaking
 of the food, pain and uneasiness were experi-
 enced at the precordial region, which, extend-
 ing to the  back and loins, were only tempora-
 rily relieved by the dejections which followed :
 vomiting now supervened, attended with great
 thirst and  a burning sensation at the pit of the
 stomach;  indeed, the irritability of this organ
 soon  became so great, that no substance, either
 as food or  medicine, could be retained by it for
 an instant.  These symptoms  soon  assumed
 the  njost  aggravated form; extreme prostra-
 tion  followed; the functions of the* nervous,
 muscular,  and digestive  systems were  much
 impaired, and the period of convalescence was
 very  protracted and tedious.   In one case only
 did the attack prove fatal.  There can be no
 doubt,  I think, that the  poison  was  generated
 by partial decomposition after the death of the 
430    POISONS—Irritating  and Depressing—Diseased Animal Substances, etc.
animal; or it is possible that the animal which
furnished  the beef was diseased.   Analysis
proved that the  beef contained no mineral or
vegetable  poison.  A decoction made from it,
when thrown into the circulation, caused death
in about three hours and a half; while a simi-
lar preparation, made from sound beef, produ-
ced no morbid signs in the animal experiment-
ed on.
  A  peculiar endemic prevails  in certain por-
tions of the Western States, called the milk-sick-
ness, or trembles.   The former name has its or-
igin in the circumstance that the disease is fre-
quently communicated  to  man  by  the  use of
the milk or butter of an infected animal, though
it will be as  readily produced by eating  the
flesh;  and the latter  name  arose from  the
symptoms of a trembling motion of the volunta-
ry muscles  manifested  in  cattle.  Horses  as
well as cattle die by the poison, and dogs, cats,
buzzards,  turkeys, chickens, and crows die by
eating the flesh of animals that have perished
by this disease.   Sometimes  the animals  are
affected to that degree that their flesh and milk
will  produce  the disease in man, and yet they
themselves manifest no unhealthy symptoms
whatever.   (American Med. Recorder, vol.  vi.,
p. 257).  Dr.  Graff, of Edgar county, Illinois,
says," Hundreds of persons throughout the West
and Southwest are annually perishing from its
attacks.  Butter and cheese manufactured from
the milk drawn from the infected cows are sup-
posed to be the most concentrated forms of this
poison.  They possess no distinguishing appear-
ance, colour, or taste from the healthy article.
A very minute quantity of either will suffice to
develop the disease in man.  The cream ordi-
narily to  be added to the coffee drank at a sin-
gle meal  is said to  have  induced an attack.
The butter or cheese eaten at one repast has
frequently been known to prove effective.  The
property is not contained in any of the elements
of the milk exclusively, but distributed through-
out the whole of them, being  possessed by the
buttermilk as well as the whey."  The same
writer remarks (Am. Jour. Med. Sciences, 1841),
" That a  murderous practice is now carried on
in certain districts, in which  the  inhabitants
will  not  themselves consume the butter and
cheese manufactured, but, with little solicitude
for the lives or the health  of others, they send
it in large quantities to be sold in the cities of
the West, particularly Louisville, Kentucky, and
St. Louis, Missouri."  The committee who re-
ported upon  the  subject of poisoned beef, al-
ready referred to, Dr. Francis, chairman, ob-
serve, "From the inquiries  which  we have
made, we have ascertained that immense droves
come from the West  to supply our  markets ;
they are driven across the  mountains and reach
New York from the south ; hence they are call-
ed by the  dealers ' Southern cattle.'  Many of
these cattle become diseased on the route, and
are then  exchanged for the  pasturage of the
herd.  In  this condition  they are frequently
slaughtered by the farmers, the flesh  sjnt» to
the city find exposed for sale, producing in per-
sons who make  use of it  symptoms of aggra-
vated cholera morbus.   Physicians attest that
they have frequently met with such cases, which
it was impossible to account for in any other
way."  It is a well-known fact that the liver,
in southern and western cattle, is very liable to
be diseased;  so much so that it is always  cast
away, it being actually unknown as a^i article
of diet.   The late Dr. Forry observes (N. Y.
Journ. of Med., Nov., 1843), " Among the cattle
of our western country, and especially of Ohio,
there are frequently found in the liver the most
extraordinary heterolagous  formations.   This
viscus is often  discovered completely studded
with osseous sacs, containing a dark grumous
fluid, in which lives a species of entozoa,  hav-
ing physical  characters almost identical with
the native leech.   Of these leeches, as many
as fifty or sixty may be found in a single liver,
so that  not a cubic inch of normal liver re-
mains."  The cause of the milk-sickness is as
yet unknown, though it is generally attributed
to some poisonous vegetable.]
  448.  The  above interesting  and important
fact  is an ample illustration of  what has been
stated by some physiologists, namely, that cer-
tain  secretions may acquire poisonous proper-
ties from the  nature of the ingesta, without the
individual appearing to be materially disorder-
ed.  I have repeatedly had occasion to observe,
that the milk of a nurse  has produced all the
symptoms of slow poisoning, occasioning vomit-
ing, diarrhoea, and sinking of vital power, with
or without convulsions in the child which she
suckled ;  and that this state of the milk has not
been occasioned alone by the nature of the in-
gesta, but also by the more violent mental emo-
tions.  That  the  nature of the  food may  thus
affect the secretions without materially disor-
dering the animal, is farther shown by the poi-
sonous nature of the honey in some districts, as
that of Trebizond, which is said  to be collected
from poisonous  plants.   I believe that the del-
eterious effects of pork are chiefly owing to the
unwholesome nature of  the food upon which
the animals had lived for some time before they
were slaughtered.
  449. e. Poisonous honey, especially as met with
in Trebizond, causes, according to Mr. Abbot,
violent headache, vomiting, and a condition re-
sembling intoxication.  A large dose produces
deprivation of all sense and power for some
hours afterward.  These effects  agree  with
those mentioned  by Xenophon, in  his account
of the " Retreat of the Ten Thousand."  Pliny
also takes  notice  of this  poisonous  honey.
Tournefort  ascribes this property to the  bees
feeding on the Azalea pontica.   (Lond. Ac Edin.
Philos. Mag., vol. v., p. 314.)   The poisonous
effects of honey  have also  been  observed in
North America,  by Drs.  Barton and  Hosack,
who consider that the injurious  property is ow-
ing to the various  species of kalmia, the Androm-
eda mariana, the rhododendron, the Azalea undi-
flora, and the datura on  which  the bees have
fed.  The symptoms mentioned  by  Dr. Barton
are dimness of sight, or vertigo, succeeded by
a delirium, which is sometimes  mild and pleas-
ant, and sometimes ferocious; ebriety,  con-
vulsions, with foaming at the mouth; pain in
the stomach  and  intestines,  vomiting, purging,
and, in  a  few  instances, death.   Sometimes
vomiting is among the earliest symptoms, and
in that case  the patient is readily relieved, al-
though a temporary weakness of the limbs re-
mains.  (American Philosoph. Trans , vol. v., p.
65 )  In the cases recorded by Dr Hosack, the
chief symptoms were violent vomiting, cold ex-
tremities, 'a  livid appearance  of the  counto- 
• POISONS—Irritating  and Depressing—Mineral  .\cro-Sedatives.
431
nance ; the pulse having been  remarkably re-
duced.  In these instances the  honey was of a
dark-reddish colour, and of thicker consistence
than usual.  (Edin. Philosoph. Journ., vol. xiv.,
p. 01.)
  450. /. The treatment of poisoning by the
 flesh of diseased animals (v 444—448), judging
 from the effects or symptoms  as far as they
 have been described, should not materially dif-
 fer  from  that which  I have recommended  for
 poisonous fish (y 433).   Having  expelled the
 injurious substance by  emetics, and  by purga-
 tives and enemata, if it have passed the  pylo-
 us,  the powers of life should be developed by
 means of the tonics,  stimulants,  aromatics,
 spices, external applications, &c, there pre-
 scribed ;  and  especially quinine, camphor, cap-
 sicum, and opium.  In the cases of poisoning
 by honey, just  noticed, the efforts of nature sug-
 gested the best remedy, namely, the  early dis-
 cbarge  of the  injurious substance  from  the
 stomach and bowels by emetics and purgatives.
 I believe that, in  all cases  of poisoning by  in-
 jurious articles of food, the best purgative that
 can be employed is, a combination of spirits of
 turpentine, castor  oil, and capsicum, taken on
 the surface of coffee, or some aromatic water;
 enemata, containing the same medicines, being
 also  administered according to the circumstan-
 ces of the case.
   451.  vi. Mineral and  Saline Acro-Seda-
 tives—A. The Antimonial Compounds act as
 irritants of the surface  or  part to which  they
 are applied,  and, owing to their  absorption
 chiefly, and probably also to their more imme-
 diate  influence upon the nervous systems, they
 depress vital  power and vascular action.  The
 chloride of antimony,  the preparation which  is
 the most corrosive and irritant, has been no-
 ticed  above (Y 175, et  seq.), and shown to be in-
 jurious principally in consequence of its local ef-
 fects.  But the other officinal preparations of
 antimony exert a much more remote and exten-
 sive influence, more especially the potassio-tar-
 trate,  the sesquioxyde, the oxysulpRuret, or ker-
 mes mineral,  and the compound antimonial pow-
 der, which was intended to represent the em-
 pirical powder of  Dr.  James.   The  medicinal
 properties of  these preparations differ more or
 less;  but, tvhen given  in excessive  doses, the
 first,  or  the potassio-tartrate of antimony,  may
 be  considered as representing their injurious
 effects, both  local and constitutional.   When
 treating of it, therefore, my observations will
 apply  also to the other compounds of this metal.
  452 a. The antimony-tartrate  of potash, or po-
 tassio-tartrate of antimony, or emetic tartar, is a
 powerful irritant when  applied to any part, or
 even to the cutaneous surface, in a state of mi-
 nute division or strong solution ;  and generally
 causes an eruption of painful pustules resem-
 bling  those of ecthyma or small-pox, and vari-
 ous constitutional  changes, according to the
 dose  and the mode of employing it.  As  this
 preparation is the most prescribed, it is of im-
 portance that its local and remote effects should
 be  well  understood,  (a) When applied to the
 cutaneous surface,  emetic  tartar  gives rise to
 somewhat different results, according to  the
 mode of its  application.   In a 8tate of strong
 solution it occasions an eruption of small semi-
 globular painful  pustules ;  in  that  of powder
 sprinkled over a plaster, or mixed in an oint-
 ment, the pustules are larger, and, when fully
 developed, are flattened, with  a central dark
 point, contain  a  puriform  serum  and  an albu-
 minous deposit, and  are surrounded  by an in-
 flammatory border.   The  central dark  point
 soon extends, and forms a dark crust as desic-
 cation of the pustules advances,  that is after-
 ward thrown off.   The internal use of this sub-
 stance in large or poisonous  doses sometimes
 gives rise to a similar pustular eruption, or to
 aphthous spots, in the rnouth, fauces, pharynx,
 oesophagus, and intestines,  but more frequent-
 ly to redness, and other inflammatory changes
 in the gastro-intestinal villous surface ; attend-
 ed by pain in the region of the stomach extend-
 ing over the abdomen, and by  vomiting, follow-
 ed by purging.
  453. (b) The constitutional or remote effects of
 tartar emetic and other antimonial preparations
 vary with the dose.   In small doses emetic tar-
 tar increases  the secretions  of the liver and
 pancreas,  and the secretions and exhalations
of the gastro-intestinal villous surface ; and as
it passes into the circulation,  it increases sub-
sequently the perspiration and the mucous and
urinary excretions.  In larger doses it excites
nausea and vomiting, relaxes the skin, and aug-
ments the mucous secretions  and exhalations.
In still larger quantities it depresses the organ-
ic nervous energy, relaxes the muscular struc-
tures and all the tissues, and gives rise to gen-
eral exhaustion.  With its emetic operation it
occasions  distressing nausea  and sinking, and
is sometimes uncertain in the  amount of its ef-
fects, the emetic action being  slight, while the
depression and diarrhcea produced by it are ex-
treme.  Excessive doves of this substance have
acted as a violent irritating and depressing poi-
 son, and produced death, especially in children,
 and  infants when it has been  given frequently,
 and  in too large quantities for this class of pa-
 tients ; the  sinking of vital power and  death,
 which have in no rare instances ensued, having
 been mistaken for the progress and result of
 disease.  Orfila states that in one case a scru-
 ple,   in another,  twenty-seven grains  nearly
 proved fatal, and  that forty grains caused death.
 The  symptoms in these were vomitings, pain
 and tumefaction of the epigastrium extending
 over the abdomen,  hypercatharsis, delirium,
 convulsions, and, in the fatal case, death on the
 fourth day.
   454.  The  above should be  viewed as the ef-
 fects of this substance on the healthy body only,
 for it has been found that,  in states of inflam-
 matory excitement, in local inflammations, and
 fevers  attended  by  high vascular action,  the
 system will tolerate quantities of tartar emetic
 which have been productive  of the most dan-
 gerous effects in other conditions of the cecon-
 omy.  This salt  has been  given in  enormous
 doses by Rasori in these states of disease, and
 the statements of this physician have been par-
 tially confirmed by Laennec and others.  I have
 attempted, however, to give very large doses
 of it in pneumonia ; but, if  I advanced above
 five or six grains in  the twenty-four hours, dis-
  tressing diarrhoea and depression followed the
  emetic action of it, and I have been obliged to
  desist.  Some source of fallacy must exist as
  regards either the purity of the medicine, or the
  retention of it in the stomach and bowels, from
  either of which it may have  been more or  less 
432
POISONS—Irritating and Depressing—Mineral Acro-Sedatives.
completely rejected;  or then we must infer that
an excessive quantity of it acts less energetic-
ally than a very small dose :  an inference which
receives no support from the  external applica-
tion of it, or when it is administered or applied
so that its operation, especially as an irritant,
may be subjected to the senses of the observer.
It should, however,  be noticed, that in cases
of oppression of the brain, and of coma, large
doses of this salt  may be given without produ-
cing vomiting, and,  if fever  be also  present,
w ithout occasioning any very remarkable effect,
until dangerous sinking of the  powers of life, or
diarrhcea, or both appear.  This is the more apt
to occur in children and young subjects, and
requires more attention than it has received.
  455. The symptoms produced by antimonials
taken in poisonous  doses are, in the majority
of instances, such as have been just described;
but when taken in states which may affect the
mouth or palate, a strong metallic taste is per-
ceived in the mouth, both at the time of swal-
lowing and afterward ; and even during conva-
lescence from large  quantities, this taste some-
times continues, with an aphthous eruption in
the mouth and fauces.  There  are  generally
also syncope, small, weak pulse, great prostra-
tion of strength, cold, clammy perspirations,
vertigo or tremour; spasms of the extremities,
convulsions, in the more dangerous cases ; and
these symptoms generally precede death in fa-
tal cases.   Dr. Beck mentions  an  instance in
which fifteen grains of tartar emetic killed a
child.   I am confident of having seen fatal ef-
fects  follow the exhibition of  a smaller quanti-
ty) given in divided  doses, in cases of croup to
which I had been called.
  456. b. Tartar emetic, when injected into the
large bowels, or into other mucous  canals, pro-
duces nearly similar effects to  those already de-
scribed ; and is  also, in these  circumstances,
absorbed into the circulation, through the me-
dium of which, as well as when injected into
the veins or introduces"  into wounds, it acts
specifically upon the stomach, producing, as M.
Magendie has shown, a very decided action on
this organ, when thus employed.   When ap-
plied  to the skin,  in the form  of powder, or of
strong solution,  to  produce an artificial erup-
tion,  it rarely occasions any  constitutional  ef-
fects  of a severe character, or resembling those
occasioned by the ingestion of a poisonous dose.
Yet such effects have occurred, and have been
attended by nausea  and vomitings, and even by
diarrhcea.
   457.  c.  After death, the villous surface of the
stomach and duodenum has been found redden-
ed and covered by a slightly adhering layer of
mucus.  Mr. Taylor states, that in a man who
had taken forty grains of tartar emetic within
a period of five days, and who  then had died
apopletic, the stomach was found much redden-
ed and inflamed  in irregular  patches, the red-
ness  passing into a violet tint;  but there was
no ulceration of the internal membrane; the
duodenum was in a similar state, and the small
intestines were  but slightly inflamed.  In ani-
mals poisoned by this substance it is usual  to
find inflammation of the gastro-intestinal mu-
cous surface.*

    [We several years ago reported a case of poisjfiraby
 antimony, with the post-mortem appearances, ydfTi^&^may
 be found in Beck's Med. Jurisprudence.^      I Ui t
  458. d.  Treatment.—The evacuation  of the
poison from the stomach by the stomach-pump,
or by encouraging  vomiting by irritating  the
fauces, or by the free administration of warm
water, milk, or demulcents, should be enforced.
Any vegetable infusion containing tannin, or
an infusion of green  tea, oak bark, or  of  the
yellow cinchona bark, may be given freely ;  as
the tannin combines with oxide of antimony to
form an insoluble compound, thereby suspend-
ing the operation of the poison.  But Dr. Pe-
reira states,  that although cinchona decompo-
ses emetic tartar, it does not destroy the  ac-
tivity of this salt; for that, in many instances,
from one to two grains of the salt were given
with the yellow bark,  and  nevertheless nausea
or vomiting occurred.  In most instances of
poisoning by the preparations of antimony, opi-
um is most beneficial, especially when conjoin-
ed with small doses of camphor, and  even of
capsicum when the depression is urgent.  Mus-
tard epithems on the epigastrium, and the warm
bath, and several of the other measures advi-
sed for the removal  of the effects of other sub-
stances  already considered under this class,
will also be found of service.
  459. B.  Baryta and its Salts are poisons
of which but little is known as to their  opera-
tion on man.   Pure baryta is met with only in
the laboratory of the chemist;  but it is a caus-
tic poison.  The principal salts are the chloride,
nitrate, acetate, and carbonate, the last of which
is insoluble.   The sulphate is  said not to  be
poisonous, as it is insoluble ; but, as Mr. Tay-
lor remarks,  it would be well to establish this
by experiment, since  insolubility ought  not to
be received as evidence of the inertness  of any
substance, although it is erroneously assumed
to be so, and  is the  chief basis  of the doctrine
of chemical antidotes.  Arsenite of copper and
calomel are as soluble as the sulphate of bary-
ta, and yet they act  powerfully on the body.
The instances of poisoning which have occur-
ed from barvta have been caused by the chlo-
ride and the carbonate.
  460. a. The symptoms produced by the  chlo-
ride of baryta were  a  combination of irritation
of the alimentary canal, and severe affection of
the nervous system, especially  vertigo, convul-
sions, and paralysis.   In one case half an ounce
was fatal in two hours.  In another, one ounce
destroyed life in an hour.   It has been found
to affect the  system powerfully even in small
doses. Orfila has shown that the chloride of
barium is absorbed, especially  when  given in
small or moderate  doses.   He states  that he
has found it in the liver, spleen, and kidneys of
animals killed by it.
  461. The carbonate  of baryta  is said to have
been fatal in two cases, in each of which  one
drachm only was taken.  But, in a case record-
ed by Dr. Wilson, it  appears not to have been
nearly so virulent.   A young woman swallowed
half a tea-cupful of the powdered carbonate mix-
ed with water.  She had fasted for twenty-four
hours.  The  powder  had no  taste.   In  two
hours she had dimness of sight, double  vision,
ringing in the ears,  pain in the  head, throbbing
in the temples, with a sensation of distention
       ^^tat the epigastrium, and palpitation
of tfiO$£fcr>SAhe afterward complained of pain
inThlTIeirsKatHfkhees, and cramps in the  calves.
She vomited twice 8 fluid like chalk and water. 
 
 
 
NATIONAL LIBRARY OF MEDICINE
NLfl  OOTAA143A  fl
NLM009884388