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LIBRARY
OF
PRACTICAL MEDICINE.
PUBLISHED BY ORDER OF THE
Massachusetts Medical Society
FOR THE USE OF ITS FELLOWS.
VOLUME II.
CONTAINING-PRINCIPLES OF SURGERY, BY JOHN PEARSON, F. R. S.
AND SURGICAL OBSERVATIONS ON THE CONSTITUTIONAL ORI-
GIN AND TREATMENT OF LOCAL DISEASES AND ON
ANEURISMS, BY JOHN ABERNETHY, F. R. S.
The Property of
The Medical Society
City at County of Denver
BOSTON:
STIMPSON & CLAPP.
J. E. HINCKLEY AND co. 14 WATER-STREET.
1832.

PRINCIPLES
Colo. Mad. Lib'y Asso'n.
OF
S U R G E RY.
BY JOHN PEARSON, F. R. S.
SENIOR SURGEON OF THE LOCK HOSPITAL AND ASYLUM, SURGEON OF THE PUBLIC DIS-
PENSARY, AND READER ON THE PRINCIPLES AND PRACTICE OF SURGERY.
Rationalem quidem puto Chirurgiam esse debere, instrui vero ab evidentibus causis ;
obscuris omnibus, non à cogitatione artificis, sed ab ipsa arte rejectis.
Aur. Corn. Celsus in Praefat.
The Property of
The Medical Society
Gity & County of Denyer
Füst ed. pub. 1788
BOSTON:
STIMPSON & CLAPP.
J. E. HINCKLEY AND CO. 14 WATER-STREET.
1832.
002.
P3 .
C, M, L, А.
+7
Ранр
972.2.
25 - - - -
CHA
617
PREFACE.
SURGERY hath commonly been defined the art of curing dis-
eases by external remedies, or manual operation; and hence
many people have imagined, that when a man has learned
the art of dressing sores, of applying bandages, and perform-
ing operations with a little dexterity, he must necessarily
be an accomplished surgeon. If a conclusion so gross and
fallacious had been confined to the vulgar and illiterate, the-
progress of scientific Surgery would have suffered little inter-
ruption; but if young minds are directed to these objects, as
the only important inatters upon which their faculties are to
be exercised; if the gross informations of sense constitute the
sum of their knowledge, little more can be expected from such
a mode of study, than servile imitation, or daring empiricism.
Indeed some people have affected to oppose surgery as an
art, to Medicine as a science; and if their pretensions were
justly founded, the former would certainly be degraded to a
mere mechanical occupation. But it is not very easy to com-
prehend the grounds of such a distinction. The internal and
external parts of the body are governed by the same general
laws during a state of health ; and if an internal part be at
tacked with inflammation, the appearances and effects will
bear a great similarity to the same disease situated externally;
nor are the indications of cure, in general, materially different.
If by science, therefore, be meant, “a knowledge of the laws
of nature," he who knows what is known of the order and
method of nature in the production, progress, and termination
of surgical diseases, merits as justly the title of a scientifical
practitioner, as the well-educated physician. The practical
parts of Physick and Surgery are very frequently disunited,
but their theory and principles are indivisible, since they truly
constitute one and the same science. But although the sci-

CMLA344
PREFACE.

ence of Physic and Surgery cannot properly be separated, yet,
in the application of rules and principles to the knowledge
and cure of chirurgical diseases, an extensive acquaintance
with the theory of medicine will by no means be sufficient for
practical purposes : lax and general notions floating in the un-
derstanding can be of little advantage, until they are reduced
to something limited and specific; and except knowledge be
in the detail, the application of it in particular instances will
be attended with almost insurmountable difficulties. He
therefore, who desires to practise Surgery with probity and
success, must study it both as a science and as an art; for a
man destitute of principles, is little better than a surgical au-
tomaton, while the man of mere erudition can only be con-
sidered as a learned spectator.
It is not a little extraordinary, that in those practical sci-
ences, where the principles of action chiefly consist of probable
truths, men should often fancy themselves qualified to judge
and to act without any previous study: and yet, if a young
man performs but a mere routine in lecture-rooms and hospi-
tals, he will probably make no doubt of his professional qualifi-
cations. He knows, indeed, that study and diligence would
be nécessary to enable him to exercise any of the liberal arts
with reputation and success ; but it would seem as if Surgery
were purely an intuitive business, the mere exercise of common
sense, and might be acquired without the fatigue of observing
and thinking. The progress of scientific Surgery, indeed, is
not to be compared with the improvements that have been
made in the operative part. A successful cultivation of anat-
omy hath drawn aside the veil from nature in so many in-
stances, that the performance of almost any operation in Sur-
gery is become safe and easy, so as to give some reason to
fear, lest a fondness for operating degenerate into excess.
This however is certain, that he who reduces the province of
a Surgeon to the performance of operations, and consequently
directs his attention in a transient and careless manner to the
less splendid parts of his profession, may learn the art of mu-
tilating his fellow creatures with ease and dexterity, but will
never deserve to be treated as a good Surgeon. The celebrity
which an expert and successful operator readily acquires
among all ranks of people, has somewhat in it so brilliant and
seducing, that young minds are too apt to fix their attention
upon this part of his character alone ; and they overlook quali-

PREFACE,
vii
fications more solid and substantial : hence it is, that they
press with anxious solicitude to see a multiplicity of operations.
and perhaps remain ignorant of the diseases for which they
were performed, and the subsequent mode of treating the
wound. This is an error that hath at different times been
lamented and censured by the most eminent nen in the pro-
fession, but it is to be feared that the evil will not be easily
eradicated. “The study of chirurgical diseases which may,
and which ought to be cured without having recourse to ope-
rations, should at all times be considered as the principal sub-
ject of a surgeon's attention. Painful methods are always
the last remedies in the hands of a man that is truly able in
his profession ; and they are the first, or rather they are the
only resources of him whose knowledge is confined to the art
of operating. If a surgeon wishes to obtain that knowledge
which is capable of a happy application to practice, he must
pass through a novitiate in hospitals, and under able masters,
and learn from thence successfully to unite theory with prac-
tice. Surgery is not to be learnt by desultory fits of atten-
tion; it would demand the study of a whole life; and is only
the fruit, of intelligent observation, profound reflection, and
learned experience. When a man is once properly instructed
in the principles of his profession, the time that is required to
learn the mode of operating is exceedingly short : there is
something so obvious and gross in the route which the hand
has to take, that we daily see the most ignorant and vulgar of
mankind perform very delicate operations upon brute animals,
without the trouble of purchasing dexterity by a course of
study and experiments.” *
This inattention to the scientific part of Surgery, of which
we now complain, does not always originate from involuntary
mistake; it may often proceed from indolence or dissipation,
* Histoire de l'Acad. Royale de Chirurgie. Tom. IV. p. 27.
" A competent knowledge of Anatomy (says a sensible writer), a steady
hand, and a calm temper, are qualifications which may enable any man,
even of no great experience, to perform several of the more capital opera-
tions with success, and accordingly, in almost every hospital in Europe,
we continually meet with expert operators ; yet we do not find (which is
much to be lamented) surgeons possesed of such knowledge in prognosti-
cating the events of surgical diseases as might be expected. The reason of
this defect is evident: In the present mode of education, the student be-
stows little attention on the subject, and suffers himself to be wholly occu-
pied in the various methods of operating, or in minute anatomical and phy-
siological investigations, which are more curious than useful."
Monthly Review, Vol. LXXVII
viii
PREFACE.

and not uncommonly it arises from some lofty conceit of supe-
rior talents. As nothing is more flattering to youthful vanity,
so nothing is more dangerous and inimical to his progress in
knowledge, than for a young man to fancy himself to be a
genius. He will immediately claim emancipation from the
laws of patient observation and careful induction, which are
imposed upon common-sized understandings, and with a fas-
tidious impetuosity will attempt to rend the veil from nature,
by the mere powers of his own intellect. If she cannot thus
be taken by storm, he will not condescend to interrogate her,
for, by the vastness of his mental powers, he finds it much ea-
sier to create a world, than to give a natural history of that
which he inhabits. The science of healing, like every other
branch of natural knowledge, is not the production of a vigor-
ous imagination, nor a lively invention, but it is the offspring
of long and diligent experience; and if a man attempts to
learn it in any other way than by going from his study to the
bed-side of his patient, and returning from thence to his study
again, he will find himself mistaken. The human mind may
be dazzled by the boldness of her flights, or wounded by the
keenness of her speculations ; but the subtilty of nature can
only be penetrated by those who submit to become her patient
and vigilant servants.
Sphynx (says the illustrious Verulam) was overcome by a
man that was lame in his feet; for when men hasten with too
much violence and rapidity to solve her enigmas, instead of
acquiring dominion over the works of nature, they wound and
distract their own minds by the subtilty of their reasonings.*
Some people, indeed, have treated theory and principles in
medicine as useless, or absurd, pretending that good-sense and
some experience are sufficient for every practical purpose. This
kind of language has something imposing in it, at first sight;
and is well calculated to entrap the assent of the vulgar; but
I would beg leave to ask those gentlemen, what good-sense and
illiterate experience have been doing for two thousand years,
that they have suffered the art of healing to remain in so cir-
cumscribed and imperfect a state? There is no opinion, how-
ever absurd, which may not be defended by some person's
experience; and the observations of our forefathers, like the
oracles of old, speak so equivocally, that a man may very com-
monly interpret them according to his own convenience. Ex-
* De Sapientia Veterum.
PREFACE.

periments made by those who are not duly furnished with
preliminary knowledge, may prove useful by accident, but can
never be trusted till a mind properly qualified has verified
them. A mere experimentalist is like a blind man who feels
his way by means of a staff; such an one indeed may stumble
upon a truth, which may afford illumination to a man whose
senses are perfect ; but it is an equal chance whether the dis-
coverer himself reaps any advantage. These men despise
reasoning, because they can neither combine ideas, nor deduce
consequences : they contemn theories because they cannot
comprehend them.
Let us hear one of these gentlemen speak in the name of
his fraternity: 6 We are blind men, who have been long ac-
customed to travel in the same roads, and by dint of habit have
acquired so perfect a knowledge of every path, that we are in
much less danger of going astray, than your clear-sighted peo-
ple, who have travelled the same roads less frequently than
ourselves.”____ It is of little consequence, indeed, whether a
man be actually blind, or whether he never opens the eyes of
bis understanding, but gropes his way for twenty or thirty
years in the same routine of experience, as he is pleased to call
it; for he is, perhaps, only so many years older in obstinacy
and prejudice. Before we can derive advantage from what we
see, it is necessary to learn the art of observation ; the same
images may be painted upon the retina of a philosopher and a
peasant; but the mental process that follows the impression, is
dissimilar in a degree which none but a philosopher can com-
prehend. But while I would advise the student to make him-
self acquainted with the theory and principles of his profession,
let me not be suspected of recommending him to indulge in
simple speculation, and philosophical abstractions; the fancy
can construct, at will, seducing schemes of structure and de-
rangement, which no more represent the reality of nature, than
the wild illusions of a delirium resemble the orderly operations
of a sober mind. From a single history, or a solitary fact.
men will sometimes rashly pretend to establish general princi-
ples; which, being destitute of basis and support, are unable to
withstand the severe scrutiny of a just interpreter of nature.*
* Monsieur Quesnay's observations upon this subject cannot be too high-
ly commended. See Men. de L'Acad. Royale de Chirurgie. Essai Pły.
sique sur l'Economie Animale, Discours Preliminaire.
PREFACE.

By theory I mean, an application of the laws of nature to
the solution of particular phenomena."--A theory formed by
learned experience and legitimate induction, must not only be
fruitful but luminous; and it will serve as a lamp to guide the
cautious Student through the dark and hidden labyrinth of
nature. It is however to be lamented, that the theory of med-
icine is still in a lirnited and imperfect state. Even studious
and thinking men, seem to bestow more pains to become rich
in the knowledge of particular instances, than to generalize
their facts, and reduce them to scientific principles. But, in-
deed, until we have “ A true and active natural philosophy
upon which the science of medicine can be built,»* there is
little solid ground to hope for a theory that would deserve to
outlive its inventer.
We are not to expect to see these deficiencies supplied, and
the fabric of true chirurgical science erected, by the particular
labours of separate individuals, much less by the powers of a
single arm; there must be a combination of learned men, who
will act in concert under prescribed laws; and by the conjunc-
tion of their labours, it is probable, that such discoveries and
improvements might be effected, as we have scarcely yet learnt
how to wish for.f.
Before I close this Preface, it may not be improper to give
some account of the book to which it is prefixed. The follow-
ing Work is primarily designed as a text-book, for the use of
the gentlemen who honour the author with their attendance
on his Chirurgical Lectures. In conformity with this design,
it is drawn up in a concise and aphoristical form: the reader
is therefore requested to remember for whom it was written,
and not hastily to reject the naked facts and unsupported con-
clusions he may meet with, as many parts of the work are
little more than a sketch of what is delivered in the Lectures.
Nor is the order in which the different morbid affections are
treated, to be considered as an attempt at a scientifical arrange-
ment. I am by no means satisfied with the manner in which
_* Restet unicum, quod pluris est, quam illa omnia. Desideratur nimirum
Philosophia naturalis vera et activa, cui medicina scientia inædificetur.
Bacon, De Augmentis Scientiarum.---Lib. iv. Cap. ii.
† It is not a little extraordinary, that England, amidst all her learned
societies, cannot boast of a society established for the exclusive purpose of
promoting chirurgical knowledge.
PREFACE.

surgery is divided at present, but it will scarcely become me to
The doctrine of inflammation, and its modes of termination,
of Gangrene, Erysipelas, and Cancer, constitute a considerable
part of the outlines of scientifick Surgery. In delivering the
history of these diseases, I have neither servilely imitated, nor
fastidiously rejected the labours of my predecessors; while I
have endeavoured to avail myself of their assistance, I have
also assumed the liberty of thinking for myself. Where it
hath appeared necessary to deviate from the opinions of others,
I have generally assigned some reasons for my conduct; if
Lorhistical, 1 skaible that it in
scheme of id as muc
sophistical, I shall have a pleasure in seeing them subverted.
I am very sensible that it is an easy matter to adduce plausible
objections against almost any scheme of human invention; it
it has been my wish, therefore, to avoid as much as possible
that fondness for novelty, which delights in petty reformations ;
to encourage such a taste is the indubitable character of a
minute mind, which, by endeavouring to appear the more
learned, only becomes the more troublesome. If there be any
particular part of the work for which an apology is more im-
mediately requisite, it is in those chapters where I speak upon
the effects of heat and cold, on living animals. This is a
subject that hath not been greatly cultivated, and luminous
facts are in so scanty a number, that if little be performed, but
little was to be expected. Perhaps it may appear paradoxical
to some, when they see it affirmed, that heat by its proper
effects stimulates and invigorates the body, while cold, on the
contrary, relaxes it. This view of the subject is by no means
novel, and if it be admitted with proper limitations, there will
not be the least opposition between these assertions, and the
seemingly contrary effects which occur co the mind on a super-
ficial survey of the subject. A proper use of the cold-bath
certainly braces and strengthens the system; the warm-bath
will generally produce relaxation and debility. These are use-
ful facts, but they are utterly insufficient to form the basis of a
theory of the effects of heat and cold on living bodies. The
proper qualities of natural substances are fixed and immutable.
but their effects upon us are subjected to considerable variation ;
we are sure, however, that the same power cannot exert itself
in opposite modes, so that if contrary phenomena present
xii
PREFACE,

themselves, we are to seek for the cause in the state of the
object, and not in the properties of the agent. .
If the publication of this first part of the Principles of
Surgery, shall excite a spirit of industry, and assist the chi-
rurgical student in acquiring a knowledge of his profession,
I shall think my time and labour well bestowed ; and it will
probably encourage me to prosecute the plan to a greater
extent.

ADVERTISEMENT.
WHEN I published the first edition of this little work, in the
year 1788, it was my intention to add one or two volumes
more, so as to comprehend a large proportion of the subjects
usually treated upon in a course of Chirurgical Lectures. The
state of my health did not allow me to accomplish my pur-
pose at that time; and increasing engagements in business,
afterwards, obliged me to defer, from one season to another,
the further prosecution of my design. Various reasons, of
little moment to the public, have at length determined me to
conclude the work, by relinquishing altogether the labour of
adding another volume to the PRINCIPLES of SURGERY.
In revising the work, for the edition now presented to the
surgical student, I made some alterations, and interspersed sev-
eral additions, especially on the subject of Scirrhus and Can-
cer. The chapter on the Edema appears now for the first
time.
Although many important additions have been made, in
the course of a few years, to the Principles of Surgery, and
several valuable improvements have been introduced into the
operative part—yet a number of diseases still exists, for which
we have no adequate remedies, and many operations continue
to disappoint the hopes of the surgeon and the patient.
If the prospect of that which remains to be done, after the
labours of so many ages, tends to abate hope and to discourage
endeavour-yet it should be remembered, that no man can
determine the measure of success which may be connected
with industrious research and zealous exertion, and that
whatever may be the degree of advancement of which surgery
is capable, he who endeavours to perfect it, has the satisfaction,
at least, of knowing, that he is fulfilling his duty, when his
efforts are directed to alleviate the sorrows and diminish the
sufferings of mankind.
Golden Square, August 20, 1808.



CONTENTS.
CHAP. I.
Of Inflammation in General .
mnon 11 General . .
.
. . .
Sect. I. Of the Phenomena of Inflammation
Sect. II. Of the Remote Cause of Inflammation . .
Sect. III. Of the Proximate Cause of Inflammation
Sect. IV. Of the Distinctions between Inflammation and
Erethismus .
Sect. V. Of the Progress and Terminations of Inflammation.
Sect. VI. Of the Treatment of Inflammation

.
CHAP. II.
Sect. I. Of the Furunculus, or Bile
Sect. II. The Mode of Treatment
CHAP. III.
Sect. I. Of the Abscess of the Breast
Sect. II. Of the Treatment of the Mammary Abscess .
CHAP. IV.
Sect. I. Of the Paronychia, or Whitlow
Sect. II. The Mode of Treatment .
CHAP. V.
Sect. I. Of the Empyema Psoadicum
Sect. II. The Mode of Treatment
CHAP. VI.
Sect. I. Of the Gangrene and Sphacelus
Sect. il. The Symptoms of Gangrene, &c.
Sect. III. The Treatment of Gangrene
Sect. IV. The Local Treatment
.
Sect. V. The Treatinent of Sphacelus
Sect. VI. The Local Treatment of Sphacelus
CHAP. VII.
Sect. I. Of the Anthrax, or Carbuncle
Sect. II. The Treatment of Anthrax
CHAP. VIII.
Sect. I. Of the Pernio, or Chilblain .
Sect. II. The Treatment of Chilblains .
xvi
CONTENTS.
Page
Peras
86
87 1
88
91
97
100
100
CHAP. IX.
Sect. I. Of Burns and Scalds ... ..
Sect. II. The Treatment of Burns and Scalds
CHAP. X.
Sect. I. Of the Erysipelas
Of the Zona .
Sect. II. The Mode of treating Acute Erysipelas .
Sect. III. The Treatment of Edematous Erysipelas
Sect. IV. The Local Applications to be used in Erysipelas .
Sect. V. The Treatment of Zona . . .
N CHAP. XI.
Sect. I. Of Scirrhus and Canceri
Sect. II. Of the Cancer
Sect. III. Of the Locality of a Cancer
Sect. IV. Desiderata
Sect. V. The Treatment of Scirrhus and Cancer
CHAP. XII.
Sect. I. Of the Ozaena
Sect. II. Of the Treatment of the Ozaena . . . .
CHAP. XIII.
Sect. I. Of the Canker of the Mouth
Sect. II. The Mode of Treatment
: : : :
CHAP. XIV.
Sect. I. Of the Edema
Sect. II. Of the Edema Simplex Flaccidum
Sect. (II. . Of the Treatment of the Edema Simplex Flaccidum
Sect. IV. Of the Edema Simplex Durius i
Sect. V. Of the Treatment of the Edema Simplex Durius.
Sect. Vl. Of the Edema Symptomaticum
Sect. VII. Of the Edema Deuteropathicum seu Puerperarum
Sect. VIII. Of the Treatment of the Edema Puerperarum .
Sect. IX. Of the Edema cum Erythemate
Sect. X. Of the Mode of Treatment
Sect. XI. Of the Edema Purulentum .
Sect. XII. The Mode of Treatment
ABERNETHY'S Surgical Observations on the Constitutional
Origin and Treatment of Local Diseases
ABERNETHY on Aneurisms . . . . . . .
105
107

108
109
110
112
113
114
115
115
117
118
119
120
121
122

123
235
PRINCIPLES OF SURGERY.
CHAPTER I.
OF INFLAMMATION IN GENERAL.

SECTION 1..
OF THE PHENOMENA OF INFLAMMATION.
1. The term Inflammation, when applied to disease, is figura-
tive, and probably derives its origin, either from the presence
of heat as a symptom, or from an opinion which formerly
prevailed, that there is a preternatural accumulation of fire in
an inflamed part. With more propriety it may be considered
as a technical name, not at all designed to express the cause,
or form, of the morbid affection.*.
II. In every phlegmon, or true inflammation, there is a pre-
ternatural sensibility of the part affected ; the action of the
arteries in that part is increased, both in velocity and strength;
there is an unnatural sense of heat, and often a considerable
augmentation of temperature : these symptoms are attended
with redness, itching and pain; a sensation of throbbing in the
part, accompanied with tumefaction and tension; the functions
of the part affected are either abolished, or they are perform-
ed with difficulty and irregularity.

* To a particular series of appearances, uniformly connected, is given
the name of inflammation ; but we are unacquainted with that specific
morbid alteration in which the several phenomena necessarily exist, in a
combined state.
18
OF INFLAMMATION.
III. In every true inflammation, there subsists either an ab-
solute, or relative plethora : a plethoric state of the general
system will have a considerable effect in increasing the vio-
lence and extent, and influencing the termination of this dis-
ease; but the effects of a partial plethora will be very much
regulated by the state of arterial contractility.
IV.
inflamed part seems to contain more blood, ca-
teris paribus, than during its healthy state, and as the vessels
which contain this fluid, propel their contents with an increased
momentum and velocity, more or less of obstruction to its
transmission must be the consequence. But this obstruction
does not necessarily arise from any alteration in the qualities
of the blood; it may be explained, by reasons founded upon
the change produced by disease in this part of the arterial
system, and the effects of lateral pressure. The increased
quantity of interstitial fluid, a necessary consequence of arte-
rial irritation, must also contribute to augment the obstruction,
and to give bulk to the diseased part.
V. Blood taken away during the prevalence of inflammation,
is longer in coagulating than healthy blood, and frequently ex-
hibits a buffy, or sizy, coat upon its surface; but these circum-
stances do not indicate any material change in the qualities of
the blood, although there is commonly some alteration in the
relative proportion which the several constituent parts bear to
each other. *
VI. It is very probable, that a true inflammation is princi-
pally seated in those blood-vessels which are possessed of a
systole and diastole, and which are consequently not beyond
the sphere of the heart's immediate influence.
VII. When the immediate seat of inflammation is assigned to
the living solids, the humoral pathology is not thereby meant
to be rejected. Every considerable change in the properties
and relative quantity of the fluids, produces an alteration in
the motions, tension, and sensibility of the moving vital solids;
and every great derangement of vascular action, has a propor-
tionate influence upon the condition of the fluids. But to
make such a practical application of these facts, as to be able,
in every particular instance of the disease, rightly to separate



e Blood. ter on the fir. He
* Davies on the Analysis of the Blood. Hewson's Experimental In-
quiry. Fordyce's Practice of Physic. Hunter on the Blood, &c. Hey's
Observations on the Blood. Dr. Davies anticipated Mr. Hewson's Dis.
coveries on the state of the coagulating lymph in inflammation, and on
the nature of the buffy coat.
MiU

OF INFLAMMATION.
19
the cause from the effects, is a degree of knowledge highly to
be desired, but not hastily to be arrogated.
VIII. A legitimate inflammation is always accompanied with
a painful sensibility in the nerves, and an augmented velocity
and strength of contraction in the arteries of the part affect-
ed: where these are present, an inflammation is present ;
when any one of these characters is wanting, the disease is not
an inflammation.
IX. These phenomena are closely connected with the pre-
sence of tone, or such a state of the system, or of a particular
part, as may be described by the term diathesis phlogistica.
Heat, redness, and tumour, although accompanied with more
frequent contractions of the blood-vessels than are natural, by
no means characterize a disease to be truly inflammatory.
X. An inflammation is called local, or topical, when it is
confined to a particular part of the body : when the whole
system is affected, it is termed general, or universal inflamma-
tion. When the inflammatory symptoms run high, and the
disease hastens rapidly to a termination, it may be denomina-
ted an ACUTE inflammation. But where the symptoms are
less violent than ordinary, and the disease gradually increases
in extent and intensity, it may be called a CHRONIC inflam-
mation.
XI. The degree of tumour and distention which attends
upon a phlegmon, situated externally, will vary according to
the structure of the affected part. Where the cellular mem-
brane abounds, the effects and mode of termination will often
deviate from those which are consequent on the inflammation
of a tense membrane. But although a strict resemblance of
appearances may not always be exhibited by inflamed parts
of different structure, yet the analogy is sufficiently complete
to warrant the application of our proposition, by giving it as a
general rule, that the phenomena enumerated (at No. 8) are
never absent: when they are present, inflammation is present,
and e contrario.
XII. There is a considerable variety in the susceptibility of
different parts, to assume the form of inflammation; nor does
this disease always proceed with equal violence and activity :
but it is not necessary to assign as causes of these deviations,


* It may be doubted whether such a state as this be at all compatible
with life.
20
OF INFLAMMATION.
distinct or opposite modes of action in the morbid parts ; for
an attention to the previous state of the system, and to the seat
of the disease, will generally enable us to account for this
want of uniformity.
XIII. In applying the preceding doctrine of inflammation
to those diseases, that are more immediately the objects of
chirurgical treatment, we shall not make use of the common
divisions ; many of them being founded upon the mode in which
an inflammation terminates, rather than upon specific and es-
sential peculiarities in the form and character of the existing
disease. It is, therefore, proposed, to consider inflamma-
tion as an homogeneous disease, possessing one determinate
character; and to avoid all such distinctions, as tend to con-
found it with affections of a very different kind. When it is
also further considered, that the indications of cure, in every
true inflammation, are nearly similar, the propriety of mul-
tiplying species will be rendered extremely doubtful.
XIV. It has been already hinted (No. 10, 11) that there
is some variety in the phenomena exhibited by the inflamma-
tion of different parts; exempli gratia, when the substance
of the brain, or of the lungs, is inflamed, the pulse is much
softer, than when the investing membranes of these viscera la-
bour under the same disease. A remarkable depression of
strength very frequently attends an inflammation of the intes-
tines, accompanied with a small, hard pulse ; whereas, when
that disease is situated on the surface of the body, there is
often a temporary augmentation of tone, with a full, strong and
hard pulse. The peculiar symptoms which originate from the
different organization and functions of the parts affected, re-
quire a close attention in studying the history of particular in-
flammations.
XV. Inflammation ought to be carefully distinguished from
Fever, Erysipelas, Erethismus, or symptoms of Irritation,
Scrofula, and from the specific action of certain poisons.
XVI. As it would be esteemed absurd in physics to affirm,
that an atom could move in contrary directions at the same in-
stant of time, so it would be equally unreasonable to suppose,
that the human body, or any part of it, could exist in opposite
conditions at the same period. To assert, therefore, the sub-
sistence of an inflammation in any particular part, while the
same part labours under an affection which implies a state the
reverse of inflammation, would be inaccurate and unphilosoph-
ical.



Colo. Med. Libyan Asso'n.
CML 344
· OF INFLAMMATION.
XVII. Although the general truth of the foregoing proposi-
tion seems tolerably obvious, yet such is the involution of dis-
eases, that appearances seemingly inconsistent with its validity,
very often present themselves. It may not be possible to give
a perfectly satisfactory solution to every difficulty which can
be proposed; but without attempting so extensive a task, the
following considerations are offered, by way of elucidating the
general principle, and rendering its practical application less
difficult. There are many stimulating matters that possess the
power of increasing the action of the system, without increas-
ing its strength; as for example, a certain quantity of wine
will produce a temporary state of tone and vigorous action of
the blood-vessels, in a very feeble body; but this high state of
excitement is known to be artificial, and dependent upon the
continued action of its cause. If therefore in Fever, Erethis-
mus, Scrofula, &c. symptoms resembling true inflammation
shall appear, in consequence of pain, irregular determination
of the nervous energy, &c. it may not be improper to consid-
er those diseases as acting upon the general principle of stim-
uli. We ought also to remember, that the actual strength of
the system is not augmented by topical congestion taking place
in fever; and that such phenomena do not unequivocally
prove the conversion of one disease into another.
XVIII. The presence of scrofula generally implies the
presence of a state of the system very remote from a tonic
state ; and the supervention of an inflammatory disease will
commonly produce a temporary suspension of its progress and
appearance. If any appearances resembling inflammation,
shall therefore take place in a scrofulous patient, it will be very
improper to give them the name of SCROFULOUS inflamma-
tion, since scrofula is merely the remote cause of these phe-
nomena.
XIX. In Lues Venera, the acrimony of the poison .some-
times excites very severe inflammation in the contaminated parts;
but such an affection ought not to be denominated VENEREAL
inflammation : it is of importance carefully to discriminate be-
tween an accidental occurrence, and the proper and peculiar
effects of the venereal poison.


22
OF INFLAMMATION.
SECTION II.
OF THE REMOTE CAUSE OF INFLAMMATION.
XX. A Remote Cause is an agent, or a power, extrinsic to
the subject acted upon, which being applied, an alteration suc-
ceeds, which is termed the effect. These two facts, the an-
tecedent and the consequent, it is of importance to know, but
no one has yet explained, satisfactorily, the nature of the con-
nexion between them. It is however useful to inquire into the
nature of the alteration produced, and the several changes that
take place in succession, until the complete effect be formed.
XXI. In assigning to any known action the prerogative of a
cause, nothing more is intended to be implied than this, that
the application of certain substances, &c. is generally followed
by, and connected with, determinate, and similar phenomena.
XXII. Whatever hath a power of greatly accelerating the
motion of the heart, and increasing the force of contraction in
the arteries, may, in certain assignable circumstances, prove a
REMOTE cause of inflammation.
XXIII. Among other remote causes, the following may be
properly enumerated:
1. The application of chemical stimuli, as
à High degrees of actual heat.
b. Caustick substances.
C. Alcohol.
d. The partial application of cold.
e. Certain poisons, introduced artificially, or generated with-
in the body
f. Acrid vapours.
2. The application of mechanical stimuli.
a. External violence, as dividing, bruising, or suddenly
distending any part of the body.
b. Extraneus matters lodged in any part of the body,
whether introduced from without, or generated by disease; as,
calculous matters, bones, bullets, splinters, &c.
XXIV. In the preceding enumeration of remote causes,
the same effect has been ascribed to powerful agents, whose
mode of action must be apparently very diverse from each
other, as heat, cold, poisons, &c.-But it may be observed,


OF INFLAMMATION.
23
that when we call certain effects specific, the epithet is per-
haps more applicable to the limited state of our knowledge
than to the nature of the subject; for many phenomena that
have been occasionally thought to be peculiar, have afterwards
been resolved into a common principle.
XXV. The application of any of these remote causes,
(particular poisons excepted) is not in all cases necessarily fol-
lowed by a true inflammation : the power and certainty of their
action will be influenced by several circumstances, amongst
which it may be proper to enumerate the following:
1. The temperament of the patient.
2. The previous state of the system.
3. The age of the patient.
4. The climate.
5. The season of the year.
6. The general manner of life.
XXVI. The powerful effects of habit, in enabling a part to
resist the morbid action of the remote causes of disease, are
very remarkable ; and, on the contrary, the mildest substances
will on certain occasions be attended with all the consequences
of acrid stimuli ; for we know by experience, that the simple
admission of atmospheric air into cavities which are not na-
turally exposed to its influence, will be very often followed by
severe inflammation.
XXVII. There is considerable variety in the susceptibility
of different persons, to be affected by the application of nox-
ious powers, and of the same person at different periods ; so
that the same agent may in one instance produce phlegmon,
in another erysipelas, and in another erethismus, &c. The
laws by which these effects are regulated have not yet been
ascertained.




SECTION III.
OF THE PROXIMATE CAUSE OF INFLAMMATION.
XXVIII. In attempting to assign the Proximate Cause of
any morbid alteration in the human body, we ought carefully
to distinguish between a true physical cause, and those which
may be termed metaphysical. A knowledge of the former
24
OF INFLAMMATION.
constitutes real science, and conducts to useful practice : to
rest satisfied with the latter, is to be contented with empty
figments and barren speculation. If from a defective natural
history of man, in the states of health and disease, we are
unable to assign an adequate physical cause to explain the
phenomena, --instead of terminating inquiry by feigned or
nominal solutions, it becomes us to prosecute the subject still
further, with patience and sagacity.
XXIX. After the foregoing observations, it will scarcely be
expected that we should examine the merits of those causes,
which are proposed to us under the different terms of Archæus,
Anima, Vis Medicatrix Naturæ, Constitution, Living Principle,
Sympathy, &c. The existence of MORBIFICK and CURING
faculties, must be first demonstrated, before any interpretations
founded upon their agency can be admitted.
XXX. By Proximate Cause, is to be understood a real
physical cause, so inseparably connected with the disease, that
the presence of one implies the agency of the other : upon the
existence and duration of the proximate cause, depends the
existence and duration of the disease, and if the former be
changed, there is a correspondent change in the latter.
XXXI. The opinions of learned and ingenious men upon
this subject, have been extremely diverse ; but without enter-
ing into a particular enumeration of them, the principal causes
that have been assigned may be reduced under the following
heads, viz. that the proximate cause of inflammation is to
be sought for, either,
1. In a morbid change of quantity or quality in the fluids,
or,
2. In a spasmodic affection of the living solids.
XXXII. The sentiments that are included within these di-
visions, have been severally supported by appeals to facts, ex-
periments, and learned authorities; and they have been suc-
cessively opposed by the same sort of pretensions. Without
presuming to decide with whom truth and science will be found,
it is not improbable, that the different systematic writers have
been too hasty in forming their several conclusions. Their
inferences cannot yet be supported by the premises we possess,
since each seems to have assigned to a striking phenomenon
the dignity of a law of nature.
XXXIII. As the several phenomena that constitute an in-
flammation, are only learnt by the diligent study of nature,




OF INFLAMMATION.
25
there can be very little room for debate upon such appearances
as are the objects of sense; and when the symptoms that char-
acterize a disease are once duly ascertained and verified, we
ought next to endeavour to detect the laws by which they
are regulated. But, to exalt any single phenomenon to the
rank of a proximate cause, while it impedes further inquiry,
must prove a fertile source of fruitless contention. Let it be
granted that bile, acidity, lentor, plethora, or spasm, is the
proximate cause of inflammation, and then inquire how much
true science will gain by it. What is that general law of
the system by which the connexion between the remote and
proximate cause is regulated ? Any of the causes above
enumerated may exist in the body, without being necessarily
accompanied by the presence of phlegmon ; which is a strong
presumption that they are simple phenomena, and by no
means characteristic of the form or essence of the disease.
To expose, however, the fallacies by which different systema-
tic writers have been misguided, is no part of my present busi-
ness; but I shall endeavour to avoid the censure of temerity,
by declaring that I am unable to assign in a satisfactory man-
ner the proximate cause of inflammation.


SECTION IV.
OF THE DISTINCTIONS BETWEEN INFLAMMATION, AND ERE-
THISMUS.
XXXIV. 1. Inflammation is attended with an increased
force in the action of the arterial system : Erethismus is
characterized by a remarkable depression of strength.
2. The presence of Erethismus depends upon the contin-
ued application of the remote cause : Inflammation will con-
tinue and be progressive, after the remote cause has ceas-
ed to act.
3. In Inflammation the pulse is often full, but always hard
and frequent : Erethismus is marked by a small, quick, and
often an unequal pulse.
4. Inflammation may be an idiopathic disease: it is never
stationary, but always tends to increase, to resolution, or to a
a

26
OF INFLAMMATION.
termination in some other disease, as effusion, abscess,&c.
Erethismus is a symptomatic affection, where the action of
the system does not appear to be directed to any determinate
end : it regards no periods, it does not admit of cure by any re-
gular natural process, nor by the conversion of this into some
other disease.
XXXV. It is probable that the symptomatic fever which
often attends the infliction of large wounds, &c. is not a fever,
in the proper sense of the term, but would have a more pro-
per arrangement under the head of symptomatic inflamma-
tion or erethismus.

SECTION V.
OF THE PROGRESS AND TERMINATION OF INFLAMMATION.
XXXVI. When a particular part of the body is in a state
of high inflammation, and the general condition of the system
is favourable to the disease, there is reason to apprehend the
supervention of a great degree of symptomatic inflammation.
XXXVII. A local inflammation may be properly divided
into three distinct periods; the commencement, the acme, and
the termination. The circumstances that tend to accelerate or
retard its progress through these successive stages, and to de-
termine its mode of termination, may be referred to the pre-
vious state of the system ; to the action of the remote cause;
and to the organization, functions, &c. of the part affected.
XXXVIII. The progress of a phlegmon is marked by an
increase, more or less rapid and severe, of all the symptoms
enumerated at No. 2.
XXXIX. An inflammation is never stationary ; but when
it is once properly formed, is either in progression towards a
natural cure; or to the destruction of the part; or it proceeds
to a termination in some other disease.
XL. Inflammation may terminate by
Resolution :
Effusion :
Suppuration-Abscess :
Retrocession :


OF INFLAMMATION.
27
Induration :
Gangrene and Sphacelus.
OF RESOLUTION AS A TERMINATION OF INFLAMMATION.
XLI. The Resolution of an inflammation may take place
in different ways; the most simple mode is that in which the
increased action of the blood vessels, &c. (No. 7) gradually
diminishes; the other symptoms subside; no evacuation takes
place; and the part assumes by degrees its natural state, with-
out suffering any derangement of its organization or functions.
This may, in strict propriety, be called a perfect cure of in-
flammation.
XLII. Resolution may also take place by an effusion
from the exhalant arteries, &c. into some cavity of the body,
or into the cellular membrane.
XLIII. A spontaneous hemorrhage from the diseased part,
or from some neighbouring blood-vessels may produce a re-
solution. And it is worthy of observation, that the quantity
of blood which is evacuated in this way, is sometimes so small
as to bear no apparent proportion to the beneficial effects that
follow.
XLIV. It may be doubted whether Metastasis ever takes
place in true inflammation.
XLV. The fluid that is poured out by the exhalant arteries,
(42) always contains more or less of the coagulable matter of
the blood : in consequence of this, the cells of the connecting
membrane, &c. are often obliterated to a considerable extent ;
the part is larger than in its natural state; and the integuments
become preternaturally firm, and lose much of their mobility.
Where effusion takes place within a natural cavity, that has
no external opening, another disease is consequently produced.
XLVI. If an inflammation be excited in two surfaces that are
naturally destitute of cuticular covering, and when the violence
of the disease is subsiding they are detained in contact for a
certain length of time, an adhesion will be the consequence.
There is an analogy between this process and the union of
wounds by the first intention, &c.
XLVII. It does not appear on the strictest examination, that,
the essential characters of that inflammation which is followed
by an adhesion of contiguous surfaces, are at all diverse from



28
OF INFLAMMATION.
that which terminates in a very different manner. Hence it
appears very improper to make an accidental mode of termi-
nation the foundation for establishing a distinct species of the
disease.
OF SUPPURATION, AS A TERMINATION OF INFLAMMATION.
XLVIII. When an inflammation has subsisted in a very vas-
cular and sensible part, during a few days, it may be expected
to terminate by Suppuration. The period assigned for the
commencement of this process has been the fourth, or the
sixth day ; but absolute precision upon this point is neither at-
tainable nor important; for the formation of purulent matter
will always be influenced by the general state of the patient's
health, the violence of the disease, and the structure of the
part, &c.
XLIX. Suppuration is immediately preceded by an ex-
acerbation of the inflammatory symptoms ;-it is generally (not
constantly) attended with rigors, shooting pains, and a sense of
throbbing in the part. As it proceeds, there is a gradual remis-
sion of pain and tension, the redness upon the surface is less
vivid, there is a gentle subsidence of the tumefaction, and, at
length, it is known to be completed, by the evident fluctuation
of a fluid, and the conical figure of the part affected. To the
assemblage of these phenomena we give the name of ABSCESS.
L. An Abscess is a circumscribed cavity, formed by disease,
and containing pus; its internal surface may be considered, as
being somewhat similar to that of an ulcerated part.
LĪ. The cellular membrane is most commonly the seat of
suppuration and principally forms the parietes of an abscess;
in the natural and healthy state, pus, or any other fluid would
be readily diffused through its cells; but the previous inflamma-
tion produces an union of its laminė sufficient to render it im-
permeable.
LII. Purulent matter is generally first formed about the cen-
tre of the phlegmon; and in proportion as the quantity in-
creases, the cavity of the abscess is enlarged, and becomes
most prominent on that side where there is the weakest resist-
ance. Hence, an abscess sometimes bursts into a natural
cavity; or when the matter is confined by an aponeurosis, or
is seated very deeply among parts that resist its pressure, one
or more sinusses may be formed of considerable extent, the




OF INFLAMMATION.
29
aperture of which may be at a considerable distance from the
original seat of the disease ; and if the matter exist in a very
large quantity, the gravitating force of the fluid will give it a
tendency to a depending part. Hence, it may be understood,
why an abscess most commonly bursts upon the surface of
the body.--Med. Observ. Vol. 2.
LIII. The nature of Pus, and the mode of its formation,
hath given occasion to great diversity of sentiment: it is not
our intention to examine all the opinions that have been pro-
posed upon this subject, but only to hint at some of the princi-
pal ones.
LIV. It hath been imagined,
1. That pus consists of the serum of the blood, deprived of
its more watery part, and converted into a new substance by
fermentation. ---Ġaber. Sir J. Pringle.
2. That blood, or the coagulating lymph, or a mixture of
blood and solid parts in a state of dissolution, chiefly contri-
bute to the formation of this fluid.—Boerhaave. Heister. Plat-
ner. De Haen. Sauvages. Grashuis. Eschenbach. Portal.
3. That the solid parts are often actually melted down into
pus. Faudacq, &c.
4. That pus is a secretion from an ulcerated surface.
Simpson. Morgan. Hewson. Hunter. Brugmans. Home, &c.
LV. It is very certain that pus is not the produce of the
putrefactive fermentation ; its sensible qualities being very re-
mote from those that are exhibited by a putrid fluid.
LVI. Nor is the blood, nor the inflammatory crust, nor any
of the solid parts ever converted into true pus. When blood is
once extravasated, the system has no power to produce a
change in its properties; it either coagulates, or degenerates
into an offensive sanious matter.
LVII. As in the formation of an abscess, there is necessari-
ly some dilaceration of vessels and rupture of the cellular
membrane, it is probable that the matter is not always entirely
free from these substances; but the quantity of solid parts that
is injured, or wasted, bears no proportion to the quantity of
pus that is evacuated from an ulcerated surface.
LVIII. Dead animal matter certainly does not furnish the
pus album læve et æquale ; for in cases of sphacelus purulent
matter is not evacuated, until a separation between the dead
and the living parts has begun to take place.
LIX, Purulent matter does not exist formally in the blood ;
30
OF INFLAMMATION.
it is furnished by living vessels, in consequence of previous in-
flammation, and probably undergoes some change after it is
poured upon an ulcerated surface, or is evacuated into the
cavity of an Abscess.*-Vide Fizes & M. Quesnay, Sur la
ration.
LX. There is a kind of matter very much resembling pus,
that is discharged from the surfaces of inflamed membranes,
and which may with some propriety be considered as a secre-
ted fluid. No experiments that have been yet made public
have proved sufficient to establish certain criteria for distin-
guishing purulent matter, at all times, from what has been
called inflammatory exudation.t-Med. Observ. Vol. II.
Pott's Works, Vol. I.
LXI. The fluid that is excreted from a suppurating surface
does not always possess the properties of good healthy pus: the
varieties that are met with will depend either upon the previ-
ous state of the fluids from which the purulent matter is furnish-
ed ; upon the action of the vessels by which it is formed; or it
will be influenced by the condition of the fluid and solid parts
taken conjointly. This subject may be illustrated by applying
the preceding observations to contagious matter ;-to the dis-
charge from scrofulous ulcers ;—and to the matter of critical
abscesses, &c.
• LXII. The fluids that are evacuated from different ulcera-
ted surfaces may be arranged under the following heads, viz.
Pus.
Ichor.
Sanies.
Sordes.
Malignant Matter. Quesnay.
Contagious Matter.
LXIII. Pus is a smooth, white, uniform fluid, inodorous,
void of acrimony, lightly tenacious, and nearly of the consist-
ence of cream. When viewed in a microscope, in its pure
state, it is found to contain globules. I This fluid is discharg-
ed by a healthy granulating surface.



* The change which pus undergoes after its exit from the vessels which
form it, has been described by Mr. Home, in his Dissertation on Pus.
1 That a breach in the substance of a part was not necessary, in order
to the discharge of a matter resembling pus in all its sensible properties,
was known to Boerhaave, Sharp, Morgagni, and others.
# The globules in pus were first observed by Dr, Morgan and Mr.
Hewson, and have been since noticed by Mr. Home.

OF INFLAMMATION.
1
LXIV. Ichor, is a thin, watery, acrimonious discharge : it
is frequently attendant on cutaneous diseases, superficial ul-
cerations, and painful, ill-conditioned sores.
It ought to be distinguished from serous effusions under the
cuticle ; from acrid fluids poured out by mucous membranes;
from lymphatic discharges, &c.
There is a species of ichor which was called Melicera by
the Greeks, that is discharged from sores which are seated on
ligaments, or about the articulations. This ought to be dis-
tinguished from Synovia, and from the fluid that is contained in
Bursa Mucosa. .
LXV. Sanies is a fetid ichor mingled with some of the
red globules of the blood. It is often discharged by varicose
ulcers; by extremely irritable sores; and such as are disposed
to form repeated sloughs, or to become gangrenous. It must
be distinguished from that discharge which follows a few hours
after the infliction of large wounds, &c.
LXVI. Sordes, is a matter of denser consistence than sa-
nies : it is grey, or of a leaden colour, and sometimes resem-
bles an imperfectly coagulated mass : when a subjacent bone
is affected, it emits a very offensive odour of a peculiar kind.
A silver probe imbued with this fluid, becomes of a dark col-
our.
LXVII. Malignant matter is a fluid that is often discharg-
ed from those imposthunies, which form in pestilential diseases :
the vapour ascending from this matter has a sudden and pow-
erfully injurious effect upon the nervous system, but does not
communicate any specific disease.
LXVIII. Contagious matter being received into the body,
is multiplied, and produces a disease according to its own spe-
cific nature.
Are there any sensible qualities by which contagious matter
can be distinguished from that which is void of infection ?
LXIX. The puriform fluid which is evacuated by mucous
membranes, from scrofulous glands, from cancerous sores, and
that which is also contained in various encysted tumours, shall
be described when we treat upon those particular diseases.
LXX. Chirurgical writers have divided Abscesses into the
SIMPLE, where the matter is contained within one circumscri-
bed cavity; the COMPOUND, when the pus is dispersed into
several sinusses; and the COMPLICATED, in which a subjacent
bone is carious, or the abscess is connected with some particu-
32
OF INFLAMMATION.
lar virus. It would, perhaps, be more convenient to consider
them as, Phlegmonous, Indolent, Gangrenous, and Scrofulous,
&c.
LXXI. An abscess may be denominated IDIOPATHIC,
when it does not appear to be connected with any preceding
disease.
LXXII. If during the presence of a local disease, an ab-
scess shall supervene in a distant part, without removing, or
alleviating the original affection, it may be termed DEUTER-
OPATHIC : exempli gratia. A suppuration of the liver some-
times occurs in cases of inflammation and suppuration of the
meninges, or substance of the brain, &c.
LXXIII. If a connexion can be traced between an abscess,
and a preceding morbid appearance, so that the latter is evi-
dently the cause of the former, it may with propriety be called
a SYMPTOMATIC ABSCESS: exempli gratia, The wound of
an absorbent vessel in the finger or toe, is sometimes succeed-
ed by the suppuration of an absorbent gland in the groin, or
in the axilla.
LXXIV. If an ague, continued fever, &c. shall terminate
and disappear immediately upon the apostemation of an ex-
ternal part, it may be termed a CRITICAL ABSCESS.
How far may such a suppuration be esteemed the cause,
the effect, or the sign of a crisis ?
LXXV. It is not necessary to consider a critical abscess
as a cavity into which the Materies Morbi is deposited; for it
may be doubted whether the pus contained within it ought to
be regarded as contagious matter (No. 68). If any specific
virus be supposed to be present, it certainly exists in a diluted
state.
LXXVI. Those parts of the body which are naturally pos-
sessed of an inferior degree of sensibility, and are scantily sup-
plied with vessels that carry red blood, as tendons, fasciæ,
ligaments, &c. do not exhibit the same phenomena when dis-
eased, which appear in fleshy and muscular parts.
LXXVII. It has been commonly observed that the pro-
cess of suppuration is completed more speedily, when the ab-
scess is situated near the centre of the body, than when it is
seated in an extreme part.



OF INFLAMMATION.
33
SECTION VI.
OF THE TREATMENT OF INFLAMMATION.
UIT
LXXVIII. There are few diseases that fall within the pro-
vince of the surgeon, in which the well-directed efforts of art
appear to greater advantage, and wherein a judicious practice
meets with more distinguished success, than in the treatment
of inflarnmation: it is a common and highly interesting disease,
but is happily very much within the power of remedies.
LXXIX. An inflammation sometimes admits of a natural
cure, and terminates in the manner described at No. 41.
LXXX. Before any artificial means are used to cure an in-
flammation, it will be requisite to ascertain :
1. Whether the present affection seems to be the cure of
another and more important disease.
2. Whether it be the consequence of extraneous matters
lodged in some part of the body.
3. If the means to be employed will do more harm to the
general system, than the disease will, if it be suffered to pro-
ceed and terminate spontaneously.
LXXXI. During the first four or five days of the disease,
we are to make attempts to obtain a resolution of the inflam-
mation.
This rule is a general one, and perhaps admits of no excep-
tion in cases of internal inflammation : but it is not an invaria-
ble one, when the inflammation is situated externally.
LXXXII. INDICATION the first.
To remove the remote cause of the disease, if possible,
It is proper however to be observed, that the
remote cause, is not necessarily attended with the cure of the
disease ; for an inflammation may act as a remote cause of
its own continuance.
LXXXIII. The effects of external stimuli may be obvi-
ated, as
1. Cold, by air of a moderate temperature.
2. Motion, by a supine posture.
3. Distention, by warm vapours, warm oil, tepid baths,
mild cataplasms, &c.
4. Acute pain, by opium.



34
OF INFLAMMATION.
The effects of stimulating matters formed, or existing with-
in the body, may be corrected,
1. By destroying the poison with specific remedies.
2. Diluting the acrid matters.
3. Defending the parts affected from their influence.
4. Diminishing sensibility partially, or generally.
The application of these principles will be more fully eluci-
dated when they are applied to the treatment of particular in-
flammations.
LXXXIV. INDICATION the second.
To take off that state of the blood vessels, in which inflam-
mation consists (No. 8).
1. This is to be attempted by diminishing the quantity of
blood that is contained in the body, by bleeding from a large
vein, or opening an artery.
2. The velocity and momentum of the blood in the vessels
of a particular part, may be lessened by the application of cup-
ping-glasses, by scarification, leeches, arteriotomy.
LXXXV. The quantity of blood that ought to be evacu-
ated, is to be determined by the temperament of the patient,
the severity of the inflammation, and the importance of the dis-
eased part to the purposes of life.
LXXXVI. Twelve ounces of blood, taken away suddenly
from a large orifice, will have a more powerful influence in di-
minishing inflammation, than twenty-four ounces extracted at
three successive bleedings; especially, if several hours be suf-
fered to elapse between each evacuation.
LXXXVII. It is probable, that those reasonings upon the
effects of local and general blood-letting, which are merely
founded upon the circulation of the blood; by discouraging
topical evacuations, have proved detrimental to the practice of
surgery.
LXXXVIII. 3. To evacuate the system, and promote
derivation, by purgatives, especially such as operate with the
least irritation, as
Manna, neutral salts, castor oil, large doses of cream of
tartar, enemata, &c.
LXXXIX. The good effects of cathartics are more evi-
dently marked in topical, than in general inflammation ; more
especially in those cases where some part of the intestinal
canal is inflamed, or where there is an affection of the brain
or its investing membranes.




OF INFLAMMATION.
35
TO
XC. To subdue an inflammation by making large evacua-
tions, is not a very scientifical mode of curing the disease; it
were highly to be desired, that we were in possession of a me-
thod of treatment which would cure an inflammation, without
debilitating the system, and thus laying the foundation of other
diseases.
XCI. INDICATION the third.
To diminish the increased action of the blood vessels, by
such remedies as do not considerably weaken the actual force
of the system, e. g. by sedatives, as
1. Neutral salts in large doses, but sufficiently diluted, so
as to obviate their effects as direct stimuli.
To which may be added,
2. Abstinence from all solid food.
3. The plentiful use of diluents, in a tepid state.
4. Where pain acts as a remote cause of inflammation,
opium must be given, after due evacuation of the system : but
on such occasions, it ought to be exhibited in very large quanti-
ties; for if it be not administered in doses sufficiently powerful
to produce the proposed effect, it will augment the disease.
XCII. The remedies that may be employed externally, in
cases of topical inflammation, are
1. Cold air, cold water, ice, or snow.
2. Preparations of lead, vitriol, alum, solutions of differ-
ent neutral salts, as sal ammoniac, &c.
3. Relaxants, as warm water, warm vapour, oil, mild
emollient cataplasms, &c.
XCIII. In the use of substances that are intensely cold, or
highly repellent, great caution is required, as they have, when
imprudently applied, been followed by gangrene. There is also
an important distinction between applications which are actual-
ly cold, and diminish the action of a part, by reducing its heat
considerably below the natural temperature; and those sub-
stances, that are only potentially cold, and lessen the heat by
restraining the immoderate action of the blood-vessels.
XCIV. Some writers have recommended the excitement of
another inflammation in the vicinity of the diseased part : but
this is a mode of practice that ought very seldom to be adopt-
ed early, in cases of acute inflammation, unless where the dis-
ease is situated internally.
XCV. If a resolution of the inflammation does not follow,


CL

OF INFLAMMATION.
after properly using the remedies enumerated above, a sup-
puration may be expected to take place.
XCVI. A resolution of every phlegmon ought not to be
attempted, for there are several circumstances which frequent-
ly render it proper to promote the suppurative process, from
the beginning of the disease. .
1. When experience has proved, that a dangerous disease,
situated in a part that is contiguous to the inflammation, will
probably be alleviated, or cured by the formation of an ab-
scess; e. g. curvature of the spine, &c.
2. Where we have reason to expect the evacuation of ex-

3. Where à previous disease has existed in some viscus,
and there is reason to hope for an evacuation of matter, &c.
upon the surface of the body : e. g. abscess of the liver,
&c.
4. When there is reason to suspect that the phlegmon is a
critical inflammation (No. 74).
Resolution is not always to be avoided because the inflam-
mation is critical; but very often because the means that ought
to be employed, are contra-indicated by that state of the sys-

5. When a symptomatic phlegmon (No. 73) appears, in
consequence of the wound of a nerve, absorbent vessel, &c.
suppuration is generally to be promoted; more especially if
any poisonous matter were introduced into the wound. This
rule, however, is not always applicable, when we possess a
specific remedy, that is capable of destroying the activity of
the morbid matter.
6. When the structure of the inflamed part renders it pro-
bable, that by undergoing a suppuration, it will be sooner and
more completely restored to its functions in the animal econo-
my.
7. If the inflammation has so considerably deranged the
organization of the affected part, that its healthy functions can
never be restored.
XCVII. There is a certain degree of action requisite in the
vessels of an inflamed part, in order to the production of a
good suppuration; it ought to be somewhat below inflamma-
tory action, but the precise point can only be ascertained by
experience, and does not admit of the establishment of a gen-
eral rule.


OF INFLAMMATION.
37
XCVIII. Suppuration is promoted,
1. By moderating the inflammation, when it is extremely
violent.
2. By diminishing the severity of pain.
Large doses of opium are of distinguished service, when
suppuration is disturbed by erethismus.
3. The vigour of the system is to be sustained by a proper
use of Peruvian bark, opium, wine, and other fermented
liquors.
XCIX. To the part affected, warm and relaxing applica-
tions are generally proper ; as fomentations, poultices of
bread and milk with oil, linseed meal, &c. They ought to
be applied warm, and be frequently renewed.
C. The general intentions of applying the remedies enu-
merated (No. 99) are chiefly by way of lessening the effects of
distention : to preserve an uniform and moderate heat in the
part, and thus to alleviate pain, &c. Stimulating applications
to a highly inflamed part are very seldom admissible, when we
desire to promote the formation of pus.
CI. Where an abscess is deeply seated in some important
part of the body, so that it is of consequence to the welfare of
the patient that it be conducted speedily to maturation, and
that the pus be evacuated at an external opening; heating and
stimulating applications may be used with propriety ; as sub-
tances containing turpentine, resins, the warm gums, can-
tharides, or acrid.vegetables.
CII. The complete maturation of Indolent and Glandular
tumours, which originate under circumstances extremely re-
mote from those which give rise to true phlegmonous ab-
scesses, may be assisted by,
1. Dry cupping, violent exercise, the applications men-
tioned at No. 101, strong rubefacients, electricity, repeated
blistering, a proper application of actual heat.
2. The internal remedies that were described at No. 98,
to which may be added mercury and steel.
CIII. When the abscess is completely formed, the cohe-
sion of the integuments at the most prominent part is gradual-
ly weakened ; erosion takes place in one or more points,
and the contents are evacuated spontaneously.
CIV.. Very frequently the spontaneous rupture of an ab-
scess may be permitted ; sometimes it inust be insisted upon ;
but it will also in many cases be prudent, or even absolutely

38
OF INFLAMMATION.
necessary, to discharge the matter contained it in by an arti-
ficial opening.
CV. There are certain cases, in which it is neither safe nor
expedient to wait for a natural erosion of the integuments ; as
in deep-seated abscesses, which are separated by a thin parie-
tes from an important natural cavity :-Paronychia ;-where
matter is confined by an aponeurosis, or the periostoum, &c.
and in general, where the parts in the vicinity of the disease
adınit of distention with great difficulty.
CVI. It has been said, that " matter is always ripe, and, as
matter merely, ought to be discharged as soon as possible ; but
as matter seated at some depth in the body, and confined by
inflamed flesh, it is proper that it should work its way gradual-
ly, and rise to the surface before it be let out.” In this propo-
sition, the beneficial effects of puš upon the hardness of the
surrounding parts: the gradual restoration of the inflamed
and obstructed vessels to their natural actions; and the favour-
able healing of the subsequent ulcer, seem to be wholly
overlooked. Besides, the attention of the surgeon will be di-
rected to the maturity of the abscess, and not to any supposed
ripeness of the contained fluid.
CVII. As it is sometimes the duty of a surgeon, to retard
the premature . rupture of the parietes of an abscess ; it is also
proper, when the quantity of pus is very considerable, and the
patient is weak, to prevent the matter from being too hastily
evacuated.
CVIII. Three different methods of opening abscesses are
employed, viz.-by
1. Simple Incision,
2. Erosion,
3. Seton.
Each of these modes possesses its peculiar advantage ; but it
is scarcely possible to lay down general rules, in so precise a
manner, that the practitioner will always be able to take a de-
cided part..
CIX. It will be sufficient for our present purpose to ob-
serve, that, where matter is deeply seated ;-when it is in the
vicinity of large blood-vessels and nerves ;-when the matter
is so widely diffused that a large opening is necessary ;-when
the skin that retains the pus is soft, thin, and little diseased ;
or when it will not be desirable to keep the ulcer open for




OF THE FURUNCULUS OR BOIL,
39
any particular purpose, &c.—the knife will be preferable to
caustic.
CX. The application of caustic is to be preferred before
the knife ;-when maturation has proceeded slowly, and the
suppuration is partial ;-when the integuments are considera-
bly vitiated; when it will be necessary to keep the ulcer
open on account of some disease at the lower surface of the
abscess ;-and generally in the suppuration of glandular parts,
and in abscesses situated near an articula
CXI. The seton may be advantageously employed where
maturation is complete, and the skin is in a healthy state ;-to
preserve important parts that are included within an abscess,
from much injury ;-to avoid the deformity of a large cicatrix;
-or where it will be useful to support an irritation for sorne
length of time, in the diseased part, &c.
CXII. If the spontaneous rupture of the abscess be antici-
pated by art, and the seton is not employed, it is generally
proper, by a free incision, &c. to lay open the whole internal
surface of the abscess. The treatment of the ulcerated cavi-
ty, and the doctrine of ulcers in general, will be discussed
in another place.

CHAPTER II.
SECTION 1.
OF THE FURUNCULUS OR BOIL.

CXIII. The Boil is a hard, circumscribed and exquisitely
painful phlegmonous tumor, seldom exceeding the magnitude
of a dove's egg; the seat of this disease is in the skin, it sel-
dom suppurates completely, and commonly arises from an in-
ternal cause.
CXIV. This tumor generally appears under the figure of
a cone, the base of which is considerably below the surface,
but its apex is rarely much elevated above the level of the skin;
upon the most prominent part of the boil, there is commonly a
whitish or livid pustule, exquisitely sensible to the touch ; and
40
OF THE FURUNCULUS OR BOIL.
immediately beneath this, is the seat of the abscess; the mat
ter is sometimes slow in forming, and is seldom found to exist
in a considerable quantity.
CXV. This little abscess is most generally suffered to
rupture spontaneously; and the discharge consists of purulent
matter, mixed with a portion of the red globules of the blood ;
the cavity from which the matter was evacuated, contains a
large quantity of slough, which must be discharged before the
ulcer can heal.
CXVI. There is no part of the body that abounds with
cellular membrane, which is wholly exempted from becoming
the seat of this disease. Most commonly the furunculus is
solitary, but sometimes it appears in considerable numbers,
especially when children are afflicted with it, or immediately
after the termination of some acute disease.
CXVII. The preceding history is descriptive of what
may properly be termed the acute boil; there is also a
chronic furuncle, which frequently occurs in subjects that
have suffered severely from the small pox, measles, lues
venerea, scrofula, and in constitutions that have been injured
by the use of mercury, &c.*
* CXVIII. The chronic boil, is commonly situated upon
the extremities; it is about the magnitude of the acute boil,
and has a hard circumscribed base; its progress is not attend-
ed with much pain; there is no considerable discolouration of
the skin, until suppuration be a good deal advanced; and ma-
turation is seldom completed in less than three, or four weeks.
This, like the former, sometimes appears in a considerable
number at a time.
CXIX. The matter that is evacuated from this abscess, is
an inodorous sanies, and is always of a thinner consistence than
good pus; when the boil has been large, and unusually slow
in suppurating, a considerable quantity of the tela cellulosa,
&c. will be cast off, from time to time, in the form of sloughs,
so as to leave a very deep cavity, before the ulcer assumes a
healthy appearance.
CXX. The furunculus is a disease which seldom occu-
pies the attention of the surgeon, unless it be of an unusual
magnitude, or accompanied with very distressing symptoms.


* Munnicks Praxis Chirurgica. Cap. iii. p. 19.
OF THE FURUNCULUS OR BOIL.
41
It may in general be regarded, rather as a troublesome com-
plaint, than as a dangerous one.
CXXI. The acute and chronic Furuncle, ought to be
distinguished, from Phyma, Phygethlon, Epinyctis, Anthrax,
&c.
SECTION II.
THE MODE OF TREATMENT.
CXXII. It is seldom desirable to obtain the resolution of
a boil; and if it were attempted, the efforts would most com-
monly be ineffectual.
CXXIII. Suppuration must be promoted by the means
enumerated at No. 99-101, &c. The maturation of the chro-
nic furuncle will be powerfully assisted, by frequent and long
continued exposure to the vapour of hot water...
CXXIV. The internal exhibition of Peruvian bark will be
sometimes advisable; and also a liberal use of opium.
CXXV. After the evacuation of the matter, a common mild
digestive ointment may be applied to the ulcer ; but where
the quantity of corrupted cellular membrane is considerable,
the hydrargyrus nitratus ruber may be employed with advan-
tage.
CXXVI. The general state of the system must be corrected
by remedies suited to its peculiar situation.
* CXXVII. It were highly desirable to remove, if possible,
that disposition of the body which is favourable to the produc-
tion of boils. We may sometimes succeed in this attempt, by
the use of Peruvian bark, sea bathing, acids, iron, &c.
• In some cases, those remedies which promote a flow of
urine, while they diminish vascular action, may be successfully
employed; as cream of tartar, nitre, Rochelle salt, vegeta-
ble or mineral alkali, in a diluted state.

OF THE ABSCESS OF THE BREAST.
T
CHAPTER III.
SECTION I.
OF THE ABSCESS OF THE BREAST.
ano
CXXVIII. As the inflammation and suppuration of the
Breast is a disease to which puerperal women, at certain peri-
ods, are peculiarly liable, our attention will be chiefly directed
to the history and treatment of what is commonly termed the
Milk Abscess.
CXXIX. The attack of this complaint is usually preceded
by rigors, which are soon succeeded by heat, thirst, restless-
ness, loss of appetite, and other symptomsof a general affec-
tion of the system. The skin of the breast is sometimes univer-
sally red; at other times, the redness appears in different parts
of the breast, in distinct and irregular patches. The breast
enlarges, becomes tense, heavy and painful : iſ the secretion of
milk continue, that fluid is more or less changed in its natural
qualities, and it cannot be extracted without pain and difficulty
* CXXX. The structure of the breast being partly glandular,
and partly cellular, an inflammation of this part may be seat-
ed, either in the conglomerated gland, which occupies the cen-
tre of the breast, or in the enveloping integuments. When it
is confined to the skin and cellular membrane, the inflained part
is uniformly distended; when the glandular part is also affected,
the enlargement is irregular, and seems to consist of one or
more large tumors, situated in the substance of the breast, and
the uneasiness is often communicated to the glands in the ax-
illa, and to the back, between the scapulæ. Not uncommonly,
the whole breast becomes enormously enlarged, and the gene-
ral system considerably disordered. The secretion of milk is
not always suppressed, when the inflammation is confined to
the integuments; and suppuration takes place there more
speedily than in affections of the glandular part.
* CXXXI. If the inflammatory symptoms regularly increase
during four or five days, a suppuration may be expected ; but
where the progress of inflammation has been slow, and its de-
gree has been very moderate, a resolution may frequently



1
OF THE ABSCESS OF THE BREAST.
43
be obtained at the distance of ten or fourteen days from the
first appearance of the disease.
CXXXII. The period about which a woman is commonly
attacked with the mammary abscess is within the first three
months after parturition; but it may intervene at any period
from thence to the time of ablactation.
CXXXIII. Of the remote causes which have been assigned
for the appearance of this disease, we shall only enumerate the

following, viz.
10
1. Sudden, or violent perturbation of mind.
2. Repressing the secretion of milk at an early period.
3. Exposure to cold.
4. Too free an use of the arms, when the breasts are dis-
tended with milk.
CXXXIV. The mammary abscess frequently occurs,
where no evident cause can be assigned for its appearance.
CXXXV. In the suppuration of the breast, the purulent
matter is not always contained within one cavity ; but several
distinct abscesses form in different parts, and are perhaps ma-
turated at different periods. When the abscess is permitted
to rupture spontaneously, the matter is often discharged from
an orifice that is situated near the nipple; or a gangrenous
slough is formed at the most projecting point of the tumour,
and when that loosens, the contents are evacuated. It is like-
wise not uncommon to see milk mixed with the pus which
flows from the mammary abscess.
CXXXVI. The glandular structure of the breast is some-
times so considerably altered, that after a future parturition, it
cannot secrete any milk : but the prognosis of the milk abscess
(as it is called) is almost always a favourable one, as there is
nothing in its nature at all analogous to Schirrhus, or Cancer.
CXXXVII. Where a scrofulous tumour has been present
in the breast during many months, or even several years, it will
often disappear soon after the termination of the abscess of
the breast.
CXXXVIII. The breasts of those women that have never
been pregnant, may be attacked with true inflammation, the
progress and termination of which does not materially differ
from the mammary abscess. Nor are men nor even children
wholly exempted from inflammation and suppuration of the
breast.
CXXXIX. The mammary abscess ought to be distinguish-
ed from scrofulous affections of this part, and from Schirrhus.

44
OF THE ABSCESS OF THE BREAST.
SECTION II.
OF THE TREATMENT OF THE MAMMARY ABSCESS.
CXL. If the surgeon be called at an early period to treat
this complaint, it will generally be proper to attempt a reso-
lution of the inflammation.
CXLI. To obtain this mode of termination, a very free use
of general blood-letting has been often recommended. This
however is a practice that can seldom be adopted with pru-
dence in large cities, or where the patient is of a delicate con-
stitution. I do not intend to say, that general blood-letting is
always inadmissible ; 'but I never once saw it necessary, either
in public or in private practice.
CXLII. 1. Topical blood-letting by leeches, properly con-
ducted, is a remedy that cannot be too highly recommended.
2. Saline laxatives, administered at due intervals.
3. Moderate abstinence.
4. A suspension of the inflamed breast.
5. Moderate bandage, by means of adhesive plaster, art-
fully applied.
6. Gentle friction of the breast with warm oil.
7. The vapour of hot water.
8. To obviate the effects of excessive distention by milk,
by gently extracting it at proper intervals.
9. Saturnine applications.
10. Solutions of neutral salts, as sal ammoniac, &c.
CXLII. If the inflammation tend to suppuration it may
be promoted by the means enumerated at No. 98-99.
CXLIV. The abscess ought in general to be permitted to rup-
ture spontaneously; and the use of the lancet, or knife,
ought by all means to be avoided, unless there be a plain and
absolute necessity.
CXLV. The application of a mild digestive ointment, cov-
ered by a poultice of linseed meal and boiling water, is gen-
erally sufficient for the cure of the ulcer.
CXLVI. If an unpleasant hardness remains in the breast,
after the termination of this disease, it will commonly yield to
saponaceous applications,-mercurial ointment-warm plasm
ters-assisted sometimes by the internal administration of cal-
omel, cicuta, bark with burnt sponge, &c.




OF THE PARONYCHIA, OR WHITLOW.
45
CHAPTER IV.
SECTION I.

OF THE PARONYCHIA-PANARISOR WHITLOW.
CXLVII. THE Paronychia is a phlegmonous tumour oc-
cupying the end of the finger; it is generally attended with ex-
cruciating pain.* The most usual mode of its termination is
by suppuration, but not unfrequently it is attended with a
mortification of the integuments and bone.
CXLVIII. As the nature and precise situation of this disease
admits of some variety, and the same mode of treatment does
not apply in every instance, it will be proper to divide it into
different species. I have adopted the following mode of divi-
sion as a convenient one:
1. The Cutaneous
2. The Benign
P aronychia.
3. The Malignant ?
4. The Venereal
CXLIX. The Cutaneous Paronychia is seated at the end
of the finger, immediately below the cuticle, and it sometimes
surrounds the finger and root of the nail. The skin is very
little discoloured; it speedily advances to suppuration; and
when this process is completed, the cuticle appears almost
transparent. After the contents of this little abscess are evac-
uated, the ulcer seldom demands any particular attention.
CL. The Benign Paronychia is situated in the cellular
membrane under the surface of the cutis :'its attack and pro-
gress are attended with a more acute and throbbing pain than
the cutaneous; suppuration proceeds more slowly, and matter
is frequently formed under the nail. The whole hand is more
or less affected with pain and tension, and uneasiness is often
felt along the course of the arm. The severity of the pain
frequently prevents sleep, and the whole system is thrown into
some disorder.
* It has been asserted by different writers, that this disease never at-
tacks the toes; but this is not correct. It occurs less frequently, indeed,
in the foot than in the hand.
46
OF THE PARONYCHIA, OR WHITLOW,

CLI. The Malignant Paronychia is accompanied with a
deeply-seated and intense pain at the end of the finger : the
tumefaction of the diseased part is not considerable ; but the
hand, and frequently the whole arm, is swollen, tense and pain-
ful. The uneasiness most commonly extends in the course of
the absorbent vessels along the internal condyle of the hume-
rus up to the axilla. The suppurative process advances very
slowly, and is attended in its progress with erethismus, lipo-
thymia, delirium, and other alarming symptoms; and there
have been instances where this species of paronychia has
proved fatal. The matter, which is small in quantity, is either
collected within the sheath of one of the tendons, or it is under
the periosteum, in contact with the bone, which is generally
found in a carious state; and sometimes the superincumbent
integuments suffer sphacelation.
CLII. As the Venereal Paronychia is a complaint that is
not universally understood, I shall deliver its history and treat-
ment upon the present occasion, although it might be referred
to another place. This disease generally appears in the form
of a smooth, soft, unresisting tumour, of a dark red colour, and
is situated in the cellular membrane about the root of the nail.
It is attended with an inconsiderable degree of pain in the in-
cipient state; but, as suppuration advances, the pain increases
in severity: its progress towards maturation is generally slow,
and is seldom completed.
CLIII. When the sordid matter it contains is evacuated, the
nail is generally found to be loose, and a very foul, but exquis-
itely sensible ulcer is exposed; considerable sloughs of cellular
membrane, &c. are frequently exfoliated, so that the cavity of
the sore is often v
CLIV. The discoloured and tumid state of the skin com-
monly extends along the finger, considerably beyond the mar-
gin of the ulcer : in such cases, the integuments that envelope
the finger become remarkably thickened, and the cellular
membrane is so firmly condensed as not to permit the skin to
glide over the subjacent parts. The bone is not usually found
in a carious state.
CLV. This species of paronychia is more frequently seen
among the lower class of people, when they labour under lues
venerea, than in the higher ranks of life. It does not ap-
pear to be connected with any particular state of the disease,
nor is it confined to one sex more than to the other. In the

OF THE PARONYCHIA, OR WHITLOW.
47

Lock Hospital, it occurs in the proportion of about one pa-
tient in five hundred.
CLVI. When 1 adopt the name of Venereal Paronychia,
it is not with the design of implying that this is a true vene-
real abscess, containing a fluid which is capable of communi-
cating syphilis to a sound person. Its progress and cure seem
to be unconnected with the increased or diminished action of
the venereal poison in the constitution, and to be also uninflu-
enced by the operation of mercury. I consider the venereal
disease as a remote cause, which gives occasion to the ap-
pearance of this, as well as of several other diseases, that are
widely different from its own specific nature.*
CLVII. The remote causes of paronychia in general,
have been divided into EXTERNAL and INTERNAL,
1. The external :
A puncture :-a bruise :—the application of acrid substan-
ces, &c.
The nature of the internal cause or causes I do not pre-
tend to explain.
CLVIII. PROGNOSIS.—The Cutaneous and Benign Pa-
ronychia have a favourable termination; the worst event to be
expected, is the loss of a part or the whole of a nail; but this
will frequently grow again.
CLIŇ. The Malignant Paronychia seldom terminates
without the loss of some part of the bone; the last phalanx
of the finger is most commonly separated. It is also attended
with considerable danger to the whole system.
CLX. The Venereal Paronychia generally terminates fa-
vourably, unless it be exasperated by improper treatment.
SECTION II.
THE MODE OF TREATMENT.
CLXI. The surgeon is seldom consulted about the cutane-
ous paronychia, until the abscess be actually formed. The
tumour in such a state must be opened by a lancet, the sepa-
* A chronic inflammation is sometimes seen at the extremity of the
finger, which never suppurates. This has been called Paronychia Sicca.
48
OF THE PARONYCHIA, OR WHITLOW.
rated cuticle removed by a pair of scissors, and the sore dressed
with a mild cerate.
CLXII. In the benign and malignant paronychia, resolu-
tion must be first attempted,
1. By a free incision, carried through the integuments to
the bottom of the diseased part, and where matter lies under
the periosteum, the knife must penetrate down to the bone, in
order to relieve the patient effectually. The blood may be suf-
fered to flow for some time, and the opening may then be
treated as a simple wound.
2. The use of boiling water, of ardent spirits, or strong
astringents, is of doubtful efficacy.
CLXIII. If pus be actually forming, we are not to wait un-
til the abscess be completely maturated ; an opening sufficiently
deep and extensive is to be immediately made, that the natter
may be evacuated as soon as possible. When matter is lodged
under the nail, a sufficient portion of it must be removed so as
to allow a free exit to the pus. When the bone is found to be
in a carious state, it is seldom requisite to expedite its separa-
tion by artificial means.
CLXIV. The ulcer ought not to be dressed with greasy
applications. Dry lint, or lint moistened with some native bal-
sam, may be applied to the bottom of the sore: when it is in
a healing state, Bates's camphorated water is a very good ap-
plication.
CLXV. Peruvian bark to support the system, and opium
in sufficient doses to alleviate pain, are almost the only internal
remedies that will be found necessary. '.
CLXVI. In the incipient state of the venereal parony-
chia, when no severe symptoms are present, it is not advisable
to make use of any external applications; it will only require
to be covered with a fine linen rag: by such gentle treatment,
it will often disappear gradually, without coming to suppura-
tion.
CLXVII. When matter is formed, the abscess may be per-
mitted to rupture spontaneously. It is very common to see
every species of dressing give great pain, and disagree with the
sore. An application composed of equal parts of balsamum
copaiba and tinctura thebaica, may sometimes be used with
a good effect.
CLXVIII. The principal object to which our attention
ought to be directed is, to keep the patient as easy as possible,





OF THE EMPYEMA PSOADICUM.
49
by the internal use of opium, until the sloughs be separated, and
the ulcer becomes clean ; it may then be treated as a common
sore. It will generally be proper to administer the Peruvian
bark.
CLXIX. It is never advisable to amputate the finger, when
the integuments exhibit that diseased appearance described at
No. 154 ; for the stump will be in danger of assuming an aspect
similar to that of the sore for which the operation was per-
formed.
CLXX. After the spontaneous rupture of the benign spe-
cies of the Paronychia, the germination of a fungous excres-
cence, or fleshy caruncle, may be frequently observed. It
most commonly appears at the angle made by the nail and the
skin, on one side of the finger, and it is seen almost as fre-
quently on one of the toes as on a finger. This morbid ap-
pearance is usually attended with exquisite pain, and if it be
treated with emollient and relaxing applications, it will be ex-
asperated and endered more difficult of cure.
*CLXXI. The mode of treatment is very simple. That
portion of the nail which penetrates the fungus ought to be
carefully removed: the sore must then be dressed down to
the bottom, with small portions of dry lint; and a little lint
must be insinuated, if possible, under the nail, that by elevating
its edge, the confinement of matter, and undue pressure may
be prevented. The fungus must be reduced by lunar caustic,
red precipitate, Bates's camphorated water, &c. This kind
of sore has sometimes had the appellation of Ulcus Mali
Moris.
1
CHAPTER V.
SECTION 1.
OF THE EMPYEMA PSOADICUM, OR PSOAS ABSCESS,-LUMBAR
ABSCESS.
CLXXII. THE Psoas Abscess, as it is termed, is seated in
that portion of the cellular membrane which is immediately
connected with the psoas muscle, and Iliacus Internus,

50
OF THE EMPYEMA PSOADICUM.
CLXXIII. This disease may very often be considered as a
specimen of chronic inflammation. It is sometimes pro-
duced by a violent overstretching, or bruising of the muscles
about the loins : it has followed an imprudent application of
cold and moisture, as lying upon the damp ground. Any of
the remote causes of inflammation that can be applied; may
give rise to this affection; and not uncommonly, it is connect-
ed with some vice in the general habit of body, as scrofula,

&c.
CLXXIV. The first invasion of this complaint may be at-
tended with symptoms resembling a severe lumbago. There
will be more or less difficulty in standing with the body erect;
the seat of the pain is referred to a little below the region of
the kidney, and it often extends very low down the outside of
the thigh : the testicle, on that side, sometimes becomes pain-
ful; it is drawn close to the body by the cremaster muscle, and
there is an uneasy sense of constriction in the course of the
spermatic chord : these symptoms are accompanied with a
painful sense of contraction at the upper part of the thigh, as if
the liinb were actually shortened. The kidney and ureter
on the affected side, suffer more or less from the vicinity of the
disease; the secretion of urine is often diminished, and that
which is discharged deposits a lateritious sediment. As this
first order of symptoms abates, it is succeeded by others of a
different kind, as rigors, languor, and loss of appetite, hectical
complaints, wasting of the body, &c. The inflammatory
symptoms being seldom severe, the suppurative process takes
place slowly; and several months will very commonly elapse,
before the abscess appears externally.
CLXXV. The situation of the external tumour, is not uni-
form ; most commonly it is at some distance from the original
seat of the disease : nor is the point at which the matter pro-
jects to be considered as forming a portion of the abscess.
The fluctuation of the matter may therefore be most palpable
about the loins, in the groin, or near the rectum, and some-
times it points towards the lower part of the thigh, in the di-
rection of the large blood-vessels.
CLXXVI. During the progress of suppuration, as there is
a remission of the more severe symptoms, the patient often
imagines that he is recovering his health; some degree of pain,
however, and an inability of duly performing the motion of the
parts, always remain. He is sooner or later alarmed by the



OF THE EMPYEMA PSOADICUM.
51
appearance of a soft tumour, which arises in one or more of
the parts enumerated above. At the first, it is rarely accom-
panied with any discolouration of the integuments, or pain, un-
less it be compressed. When the person stands erect, the tu-
mour becomes more prominent; but its contents recede, either
in whole, or in part, when he assumes a horizontal posture.
CLXXVII. Whether the abscess be opened artificially, or
it be permitted to open by a spontaneous rupture, a very large
quantity of purulent matter, of the density of good pus, but
often inclining to a cineritious colour, is generally evacuated
ceeds the quantity that might be expected from a tumour of
that apparent magnitude. The sore frequently puts on a scro-
fulous aspect; all the hectical symptoms increase, and the pa-
tient is gradually destroyed. I
CLXXVIII. As the purulent matter is situated behind the
peritonæum, and the erect position of the body is favourable to its
progression downwards, we have no well authenticated instances
of its having been effused into the cavity of the abdomen. If
such an event should take place, the most dangerous conse-
quences are to be apprehended.
CLXXIX. If the contents of the abscess be included in a
firin cyst, the long-continued pressure of so large a body upon
the lumbar vertebræ will sometimes induce a paralysis of
the lower extremities.
CLXXX. Although the larger arteries have been known to
lie surrounded with purulent matter, for a considerable length
of time, without suffering any injury, yet this is not universally
the case : there have occurred many instances, where erosion
has taken place, and the person has been suddenly destroyed
by the hæmorrhage. The bones also to which purulent mat-
ter has had free access, are not unfrequently found in a carious
state.
CLXXXI. The empyema psoadicum ought to be distin-
guished from nephritic complaints ;—from Bubo-Hernia-
Aneurism-Fistula in Ano-Hæmorrhoids-lliac Abscess-
Abscess in the thigh joint, &c. The discrimination of this dis-
ease is sometimes difficult; and it ought also to be observed,
that it may be conjoined with any of these complaints.



5%
OF THE EMPYEMA PSOADICUM.

SECTION II.
THE MODE OF TREATMENT.
CLXXXII. This disease, in the incipient state, may be con-
sidered as a local and chronic inflammation; the treat-
ment therefore in general is similar to that which is appropria-
ted to a common inflammation ; but the debilitating plan ought
not to be carried to so great an extent.
CLXXXIII. First Indication.
To obtain an early resolution, if possible, by
1. Topical blood-letting.
2. Alkalised purgatives.
3. Antimonial medicines.
4. Abstinence from animal food, and fermented liquors.
5. Perfect quietness, and a supine posture with confinement
to a bed.
6. Blistering plasters applied near the part affected.
7. I have found immediate advantage from the application
of a large caustic near the lumbar vertebræ, after premising
due evacuations.
CLXXXIV. Indication the Second.
When suppuration has actually taken place, the diet must be
improved and rendered cordial and nourishing. The Peruvian
bark, vitriolated zinc, vitriolic acid, or iron, may be employ-
ed with advantage. To these tonic remedies it will be prop-
er to add a pure air, gentle exercise, and, with certain re-
strictions, sea bathing.
CLXXXV. There have been various opinions concerning
the best mode of treating the abscess when it points external-
ly. Some of the older surgeons, as HILDANUS, WISEMAN,
&c. and the French surgeons in general, advise a free open-
ing to be made, or the introduction of a seton.
Several of the modern surgeons recommend a very small
aperture to be made and the ulcer to be dressed quite super-
ficially.
I have treated many cases in this manner with the greatest
success. Mr. Abernethy recommends the puncture to be
closed, and healed imniediately after the evacuation of the
matter. It has been thought more advisable, by other sur-




OF GANGRENE AND SPHACELUS.
53
geons, to permit the abscess to burst spontaneously ; and on
comparing the result of the different modes of treatment, in
my own practice, I find that a greater number of patients have
recovered, where this latter method was pursued.
CLXXXVI. Some of the older writers forbid the use of
injections in the lumbar abscess; but their reasons seem to
be founded upon mistaken ideas of the true situation of the
disease.
Solutions of copper, zinc, or even tepid sea water, may
sometimes be employed in this way, with considerable ad-
vantage.
CLXXXVII. The instances of those who perfectly recover
from the empyema psoadicum are few in numb
pared with those to whom it proves fatal; hence it will never
be prudent to give a favourable prognostic at an early period
of the disease.
When the abscess bursts in the loins, the patient is more
likely to recover, than when the opening is in the groin.
CHAPTER VI.
SECTION I.
OF GANGRENE AND SPHACELUS.
CLXXXVIII. It has been usual among many of the later
writers, to enumerate Gangrene as a third mode, in which an
inflammation frequently terminates; but although custom and
authority may be sufficient to justify such an arrangement, yet
there certainly is not a necessary connexion between the two
diseases*. Gangrene does indeed sometimes supervene to
inflammation ; but this order is not absolute and immutable, for
it very often originates from causes, which imply a state of the
part, or of the system, that is the reverse of inflammation.
CLXXXIX. As a gangrene most commonly terminates in
sphacelation, there is some propriety in treating both of them
under one head; yet the difference between a gangrenous
* Morgagni de Sed. et Caus. Morb. Lib. iii. Epist. xxxv. Art. 19
54.
OF GANGRENE AND SPHACELUS.
and mortified part is so very considerable, that the terms ought
never to be employed as synonymous ones. The distinctions
proposed by some modern physicians, which are founded

which the disease has penetrated, seem inadequate and useless.
The antient practitioners, who attended more carefully to the
actual state of the morbid parts, than to the quantity of disease,
have left us more useful definitions.
carries, in its composition and structure, the principles of disso-
lution and decay. This is not only true of the entire machine,
considered as an organized whole, but may be applied to the
several constituent parts; so that whatever possesses a vital
power and action may be deprived of that quality by a variety
of causes; and when any part has once lost its living powers,
all relation between the dead portion and the animated machine
is irrecoverably destroyed.
CXCI. Although a mortification implies, the death of the
part affected by it, yet every dead part is not in a sphacelated
state. The terms Gangrene and Sphacelus can only be ap-
plied with propriety to certain modes of dying, in which pe-
culiar alterations, the effects of some specific and determinate
disease, have preceded the destruction of life.
CXCII. The phenomena which attend the sphacelation of
different parts of the body, are by no means similar; they will
be considerably influenced by the organization of the part; by
the previous state of the system; and by the nature of the re-
mote cause.
CXCIII. As a knowledge of the remote causes affords
considerable assistance, in the forming of a just diagnosis of
gangrene, this will be the most proper time to enumerate
them : the history and treatment of the disease will be con-
sequently delivered with less interruption.
CXCIV. Among the remote causes that have a powerful
influence in producing gangrene, may be assigned,
1. The application of severe stimuli, to a diseased, or de-
bilitated part.
CXCŮ. There is a certain degree of excitement, which the
nervous system can support, without inducing a state that is
inconsistent with the welfare of the body: if the stimulating
powers act beyond a determinate point, they destroy sensibility,
and induce torpor or death. It may also be remarked, that




OF GANGRENE AND SPHACELUS.
55
if a vital moving part be suddenly or durably excited to a ve-
locity and force of action, greatly beyond what its natural and
inherent powers are calculated to sustain, a loss of tone in the
moving fibres, debility, or even destruction of its vitality, must
be the consequence. These observations may be fully illus-
trated, by applying them to the effects of lightning to intense
inflammation, erysipelas, the action of acrid substances, poi-
sons, fractured bones, &c. strong stimulants applied to drop-
sical, or paralytic limbs, &c. in the production of gangrene
and sphacelus.
CXCVI. 2. Obstruction to the due transmission of blood;
as, in strangulated hernia, tight bandage, compression of
large blood-vessels by tumours, aneurism, ossification of ar-
teries, &c. Some of these causes act more powerfully when
the circulation of the blood is accelerated.
3. Whatever destroys the organization of a part, so that it
becomes incapable of carrying on its natural functions; as in
arge wounds, where the most considerable blood-vessels of a
part are divided ; violent contusion, by which the contexture
of a part is subverted, and the contents of the vessels are either
effused or rendered incapable of being circulated.
4. Certain changes induced upon the living solids and flu-
ids-by cold, heat, actual and potential, and also from
the use of unwholesome food.
5. A sudden diminution of sensibility and repression of ac-
tion in a diseased part, by the improper application of repellent
remedies, as issometimes seen in erysipelas, &c.
· 6. Sphacelation sometimes appears suddenly, without any
evident procatarctic cause.
CXCVII. The previous state of the general system has
very extensive influence in determining the action of the re-
mote cause, to the production of gangrene, or sphacelous :
exempli gratia, previous fever, dropsy, paralysis, languid
action of the extreme blood-vessels, as in old age, &c,


SECTION II.
THD SYMPTOMS OF GANGRENE.
CXCVIII. The supervention of this disease is sometimes
marked by the appearance of symptoms in the following order :

56
OF GANGRENE AND SPHACELUS.

1. An exquisitely painful sensibility of an inflamed part.
2. An intense sensation of burning in the part.
3. A purple, bluish, or livid appearance of the skin.
4. Subsidence of an inflammatory tumour.
5. Flaccidity of the part affected.
6. Phlyctenæ, with a livid circle round their base.
7. Where an ulcer exists, the surface becomes dry and
discoloured.
8. Under some peculiar circumstances, a white tenacious
substance, resembling the jelly of the serum, when coagula-
ted, is thrown out in considerable quantity upon the surface of
the diseased part, and adheres firmly to it.
CXCIX. The termination of gangrene in sphacelation
is indicated by,
1. An effusion of the red globules of the blood under the
cuticle, resembling diffused petechiæ.
2. Edema : sometimes, emphysema.
3. A total cessation of pain in the diseased part.
4. A sense of great weight in the lib.
5. The affected part becomes black, and the blood is coagu-
lated in the vessels. -
6. Cadaverous smell, and appearance of putrefaction.
These phenomena attend the progress of the humid
gangrene; but occur with some variation in the dry gan-
grene.
CC. A part of the body that is affected with gangrene,
does not immediately lose its sensibility : the fluids continue to
circulate in their vessels; and within certain limits, the part is
capable of being restored to its former offices in the animal
economy. “A Gangrene, therefore, strictly speaking, is a
mortification not actually formed, but approaching, being the
intermediate state betwixt the height of inflammation and
sphacelus.” (See Kirkland on Gangrene and Sphacelus.
Also, Chirurgia Francisci Peccettii, &c.) Sphacelation implies
the total loss of life in the part, an absolute derangement of its
structure, the abolition of all its functions, and an utter
incapacity of its being restored to any service in the animal
economy.
CCI. It is obvious, that the regular progression of an in-
flammation into gangrene and sphacelus, can be distinctly
marked in external diseases alone. But the approach of a
mortification in any part, is not necessarily preceded by the
OF GANGRENE AND SPHACELUS.
57

clear and evident characters of gangrene. A small portion
of the body may suffer sudden death, as well as the whole
system.
CCII. A sudden attack of severe pain in a part that is ap-
parently sound, frequently indicates the approach, or accom-
panies the first invasion of sphacelus. Sometimes there is a
small black spot upon the part affected. The progress and
extent of the disease in such cases, is often marked by an
cedema, or an emphysematous inflation of the tela cellulosa.
CCIII. A mortification may frequently be regarded as an
affection entirely local, which depends upon an external cause
for its appearance; in such cases, the effects do not always ex-
tend beyond the diseased parts.
CCIV. More commonly, sphacelus is accompanied with a
general and dangerous affection of the whole system. This
state is indicated by a remarkable deviation of the patient's
countenance from its natural and healthy appearance; there is
often a peculiar wildness of aspect, anxiety, vomiting, diar-
rhæa, great depression of strength, a frequent, soft, and some-
times intermitting pulse, and more or less of delirium. When
a severe inflammation of a tense part has proceeded rapidly to
gangrene and sphacelus, the brain is affected at an early pe-
riod, and the delirium is often furious; but in a languid system,
where sphacelation has approached more gradually, the deliri-
um may be moderate, interrupted, and perhaps does not ap-
pear, till near the conclusion of the disease ; and sometimes
the patient dies comatose.
CCV. In old people, a gangrene and sphacelus will fre-
quently succeed to the slightest accidents. Under these circum-
stances, the disease will sometimes seem to be almost station-
ary, and continue during several months without producing ex-
tensive mischief; on the other hand, so variable and uncertain
will be the progress, that the termination shall follow a few days
after the attack of the disease.
CCVI. Many valuable writers, both ancient and modern,
have divided gangrene into different species, and their distinc-
tions have been founded upon the various remote causes that
produce this disease ; and as the progress of mortification will
very much depend upon the perpetual operation of the remote
cause, some practical advantages may possibly attend such a
mode of division. It is probable, however, that, let the remote
cause be what it may, the form of the disease is an uniform and
58
OF GANGRENE AND SPHACELUS.
general one; and if it be, the principles that we have
delivered are capable of application to every form of the dis-
ease.
CCVII. As a sphacelated part no longer possesses a vital
union with the general system, it may be regarded as an ex-
traneous substance, the removal of which is generally essential
to the comfort and welfare of the living parts.
CCVIII. If the mortified mass be so situated as to be ex-
posed to the effects of warmth and moisture, putrefaction will
take place, as in dead animal matter separated from the body.
Sometimes a sphacelated member becomes dry and incorrup-
tible, as if it had been defended from putrefaction by artificial
means.-La Gangrene Sêche. *
CCIX. The separation of the dead part from the living is
a natural process; it is explicable upon known physical princi-
ples, and generally takes place in the following order :-'The
living parts that surround the mortification first appear to be
lightly inflamed, and they sink below the level of the sphacel-
ated edge; the process of suppuration soon commences, a
small quantity of matter issues from the line of separation, and
as exfoliation proceeds, the matter is evacuated in greater
quantity and assumes the form of wood pus: while this process
goes on, the distance between the living and the dead part be-
comes more evident until they cease to cohere.
CCX. The inflammation which immediately precedes the
separation of the dead part, and which is essential to the com-
pletion of that process, seems principally to depend upon the
presence of the eschar: this dead substance stimulates the
surrounding living solids as an extraneous body, and thus pro-
duces a determination of blood to that part; the contiguous
surface consequently suppurates, and the matter that is found
between the receding parts is principally furnished by the living
vessels.
CCXI. The period of exfoliation is considerably influenced
by the situation and structure of the affected part, and by the
general state of the constitution.
CCXII. Bones are susceptible of inflammation and sup-
puration, as well as the softer parts of the body; they may



* For an account of the Dry Gangrene, see the writings of Hildanus
Tulpius, Quesnay, Memoires de la Société Royale de Medicine, Tom, 1.
Opere di Bertrandi, Medical Museum, &c. &c.
OF GANGRENE AND SPHACELUS.
59
11
likewise be deprived of their vitality by disease. When a bone,
or a portion of bone, is in this state, it is said to be carious.
CCXIII. As there exists a considerable difference between
the sensibility, structure, and functions of bones, and those of
the soft parts, so the phenomena of their several diseases are
not exactly similar : a general and gross analogy obtains, but
it is not sufficiently precise to warrant an equal application of
all the preceding observations. It is highly probable however,
that the desquamation of bone is effected by a process, analo-
gous to that of the exfoliation of the softer parts.
CCXIV. Various explanations have been offered of the
means by which the dead animal solid is separated from the
living parts. It will be sufficient for the present purpose, to
take notice of the three following, viz.
: 1. That the efficient cause is a mechanical one, the force
with which the new granulations of flesh germinate, being sup-
posed sufficient to push off the mortified mass. Platner, Ten-
on, &c.
2. That the living solids at the line of union are removed by
the mouths of absorbent vessels.
3. That a fermentation and dissolution of that part of the
eschar, or carious bone, takes place, which forms the line of
adhesion.
CCXV. The assignment of the first enumerated cause must
have been the result of very gross observation; it is at once
inadequate for the purpose, and the action assigned to the
granulations is quite inconceivable. It may account for the
extrusion of a loose eschar, but we are not at all assisted by it
in conceiving of the mode by which separation is effected in
the middle of a solid fibre.
CCXVI. There is considerable ingenuity displayed, in re-
ferring the process of exfoliation to the mordicant powers of
absorbent orifices; but this opinion is not wholly free from dif-
ficulties,
d. If the dead part be separated from the living by the ab-
sorption of the line of union; as this line is always of equal
thickness, and according to the supposition, is studded with
mouths of absorbents, the time in which different portions of
dead matter exfoliate, ought not to bear any proportion to the
depth, extent, nor seat of the disease; but this is contrary to
daily experience.
b. The dead bone acting as an extraneous substance, must




60
OF GANGRENE AND SPHACELUS.

stimulate the absorbents that are at the point of contact to ac-
tion; but if these vessels absorb the line of union, it will fre-
quently be necessary for them to elongate themselves.
C. As there cannot be any given portion of a bone that
may not become carious and exfoliate, so there cannot be any
point assigned, that may not be absorbed; and if any given
point may be absorbed, then every given point may be absor-
bed: but if the smallest assignable line cannot be drawn
through any part of a bone, which may not be absorbed, then it
will follow, that no point can be given, however small, at which
it may not be affirmed that the orifices of absorbent vessels
exist : but if these orifices exist in every possible point, where
are their trunks? where are the other constituent parts of the
bone ?
CCXVII. It is probable, that in the separation of the dead
portion of the animal fibre from the living, the process that ter-
minates in a solution of continuity first begins in the eschar, or
in the carious portion of bone ; for
1. Warmth and moisture expedite the process of exfolia-
tion; and at the line of union, these circumstances are gene-
rally present.
2. A fetid sanies, or sordes, is generally to be found
about the line of separation.
3. When bones of a spongy texture become carious, there
is not always a regular desquamation, but the dead part is
evacuated in fragments along with the discharge, as if the
bone had suffered comminution.
4. The presence of putrefaction is very evident, and the
effects of that process in destroying the cohesion of animal
fibres, is too generally known, to require insisting upon; and
although the most inferior stratum of the mortified substance be
not exposed to the action of atmospheric air, so as to permit
the putrefactive fermentation to go on regularly ; yet we know,
that decomposition and dissolution of animal substance can take
place, where the access of air is excluded.
5. The suppuration of the living surface, immediately in
contact with the dead part, has a very considerable share in
the process of exfoliation.
CCXVIII. Mortification should be distinguished from
ecchymosis, and large extravasations of bloody fluids into the
cellular membrane. But the diagnosis and prognosis will
be more conveniently delivered, when we treat on particular
diseases.

OF GANGRENE AND SPHACELUS.
SECTION III.
I
THE TREATMENT OF GANGRENE.
CCXIX. The mode of treating a Gangrene, may with
propriety be divided into two distinct parts.
1. The internal remedies, &c. which are indicated by the
state of the general system.
2. The local applications.
CCXX. Indication the first:
To diminish increased vascular action, by a moderate and
judicious use of the remedies recommended at No. 83, 84,
88, 91.
It is here supposed, that intense inflammation is the cause,
or the antecedent of the gangrenous symptoms. The evacu-
ations however, must be made with great circumspection ; for
an erroneous notion of the nature of the disease, or the state
of the general system, may be attended with fatal consequences
to the patient.
Indication the second :
To diminish pain and irritability by a very liberal use of
opium.
Indication the third :
To prevent its progress into sphacelus, by supporting the
tone and vigour of the system, with
Peruvian bark, mineral acids, port wine, Madeira, cider,
porter, or ale, brandy, æther, &c.


SECTION IV.
THE LOCAL TREATMENT.
CCXXI. Indication the first :
To remove the remote causes, if possible, as tumour,
ligature, acrimonious substances, &c. and to correct or de-
stroy any particular virus by its proper remedy.
Indication the second :
To promote the equable circulation of blood in the part, and
to obviate the effects of distention, by warm, soft and lenient


OF GANGRENE AND SPHACELUS.
applications frequently repeated : as cataplasms made with
linseed, mixtures of wheat bread and linseed, or fenugreek,
or camomile flowers powdered, &c.
When cold is the remote cause of this disease, warm and
emollient applications are to be avoided, and in their stead,
substitute friction with snow, gentle chafing of the parts with
the hand, &c.
SECTION V.

CXXII. When the symptoms enumerated at No. 204 begin
to appear, no evacuations ought to be promoted, except such
as are natural to the body in a state of health. The first indi-
cation that presents itself is to check the progress of the dis-
ease, by large doses of Peruvian bark joined with opium, ex-
hibited in as quick succession as the stomach will bear. To
which may be added, the strongest wines and other fermented
liquors, brandy, æther, musk, volatile alkali, essential oils, aro-
matics, &c.
Indication the second :
To administer opium when pain renders its use necessary.

SECTION VI.
CCXXIII. Where a mortification arises from compression,
or any other external remote cause, and the general health
seems to be wholly unaffected, the removal of the remote
cause will be generally succeeded by a termination of the dis-
ease. In such cases, the mortified part requires no more at-
tention than what is usually paid to an eschar made by a caus-
tic. But a sphacelus is not necessarily local, I because it
originated from an external cause; the judgment must here
be determined by the consideration of several other circum-
stances.
CCXXIV. As the sphacelated part is dead, no benefit can


OF GANGRENE AND SPHACELUS.
63
be derived to it from any external applications whatever ; the
living parts that surround it are the only proper objects of at-
tention.
CCXXV. The external remedies that have been principally
recommended, are
a. Scarifications of the part.
6. Applications actually' or potentially warm.
C. Antiseptic cataplasmns, &c.
CCXXVI. The chief advantages to be derived from scari-
fying a mortified part, seem to be, an evacuation of putrid sa-
nies, or confined air, and the affording an opportunity of apply-
ing proper dressings to the living parts that are beneath the
eschar. When there is a large mass of ragged and putrid
slough, it will be proper to remove it, without wounding the
living parts.
CCXXVII. The surrounding parts may be invigorated, by
the application of alcohol, oil of turpentine, poultices made with
oatmeal and stale beer, to which may be added, cataplasms
containing Theriaca Londinensis, &c. Lixivial applications
are wholly improper, unless we mean to do no more than wash
away the offensive matter from the diseased part. The actual
cautery is very seldom used; and it may be doubted how far
the vapour of hot water can be applied to a sphacelated part
with perfect propriety. Great attention should be also paid
to maintain a due degree of warmth in a limb affected with
sphacelus.
CCXXVIII. Antiseptic applications, as the powder of Pe-
ruvian bark made into a cataplasm :-charcoal mixed with
farina lini, or oatmeal-mineral, or vegetable acids diluted :
-mephitic gas :-carrot poultice :-the fermenting cata-
plasm, &c. may be used with advantage, as they correct the
fetor, and do no injury to the living parts. I have seen the
most pleasing effects to follow the use of the fermenting poul-
tice, and also the application of the fresh leaves of cicuta, to
gangrenous ulcers.
CCXXIX. It is sometimes necessary to remove the morti-
fied part by a chirurgical operation ; but excision ought not
to be attempted until the separation of the living part from the
dead be in some forwardness. This rule may be admitted as
being generally true, yet it is not absolutely without exception.
But this subject will be prosecuted with more propriety under
the head of Amputation.



64 '
OF THE ANTHRAX, OR CARBUNCLE.
CCXXX. Asphacelated limb is sometimes separat
from the body by a natural process, and the cure will be com-
pleted without any assistance from art. This takes place most
frequently in the dry gangrene.
CHAPTER VII.
I
SECTION I.

OF THE ANTHRAX, OR CARBUNCLE.
CCXXXI. THE Anthrax is a deeply-seated, hard, im-
moveable, distinctly circumscribed tumour, attended with an
intensely painful sense of burning in the part, and considerable
discolouration of the skin.
CCXXXII. This disease is rarely idiopathic; it is as-
signed by writers, as a very common appearance in
tial diseases :—and when there is no reason to suspect the
plague as a cause, that state of the system is commonly pres-
ent which is characteristic of putrid fever.
CCXXXIII. The Carbuncle is often sudden in its appear-
ance, the tumour is very little elevated above the surface of the
skin; about the centre, it is of a dusky red colour, but is much
paler, and often variegated towards the circumference. Small
prurient vesications or pustules appear upon its surface, which,
when they are ruptured, evacuate a dark coloured sanies, and
discover a sphacelated base. The commencement of the dis-
ease is sometimes accompanied with symptoms resembling gen-
eral inflammation ; but most commonly, it is attended with
rigors, sickness, great restlessness, and depression of strength,
fainting, delirium, &c. A miliary eruption or even pete-
chiæ, are sometimes found dispersed in different parts of the
body
CCXXXIV. It hath been usual to divide the anthrax
into two species, the benign, and the malignant: this dis-
tinction, however, seems to be merely applicable to the vio-
lence and extent of the disease, and implies no real diversity
in the species.


OF THE ANTHRAX, OR CARBUNCLE.
65

CCXXXV. The cellular membrane is the principal seat of
e carbuncle; and, as in gangrene and sphacelus, the
extent of its ravages cannot always be known by the appearance
of the superincumbent integuments. However large the sur-
face may be that is occupied by this disease, it is generally
destroyed and rendered totally unfit for performing its natural
offices in the animal economy.
CCXXXVI. The anthrax never evacuates laudable pus;
in general, the affected part suffers complete sphacelation : but
if the disease be less malignant, nothing but an offensive ichor
or sanies accompanies the exfoliation of the putrid sloughs.
CCXXXVII. Sometimes a carbuncle is solitary in its ap-
pearance, and is of a surprising magnitude : but not unfrequent-
ly, like furunculi, they appear in different parts of the body at
the same time. When the anthrax is a symptom of the plague,
the pestilential bubo frequently accompanies its appearance.
CCXXXVIII. The anthrax must be distinguished from
phygethlon, gangrenous abscesses, and phlegmonous tumours
in general.
CCXXXIX. The prognosis of the carbuncle will be con-

bers that invade the body at the same time. The state of the
patient's health will also greatly influence the prognostic.

SECTION II.
THE TREATMENT OF ANTHRAX.
CCXL. From the preceding history of carbuncle, it is
evidently a disease so very analogous to gangrene and sphace-
lus,that the treatment which was appropriated to these mor-
bid affections, is perfectly applicable in the present instance.
The extirpation of the tumour, or the application of cauteries
and caustic, are modes of practice justly exploded.* It has
been said, that opening the superficial abscess, in the centre of
the anthrax, early, has checked the progress of the disease.
CCXLI. It ought to be constantly remembered, that no ex-
ternal applications are to be depended upon alone. The vigor-
* M. Pouteau, who was extremely fond of the actual cautery, recom-
mends the application of it in the anthrax.--Oeuvres Posthumes.

66
ous and decided use of those remedies which operate upon
the general system, is of the greatest importance.
CCXLII. Where considerable sinusses remain after the ex-
foliation of the sphacelated part, injections made with solu-
tions of vitriol, copper, lunar caustic, &c. will be sometimes
serviceable, in promoting the separation of the dead portions
of cellular membrane, &c.
CHAPTER VIII.
SECTION 1.
OF THE PERNIO, OR CHILBLAIN.
CCXLIII. THE Pernio is a painful tumefaction, and some-
times ulceration of an extreme part, in consequence of expo-
sure to a great degree of cold.
CCXLIV. This is a disease to which the inhabitants of
temperate climates are more peculiarly liable; its produc-
tion seems to depend rather upon the successive alternations
of warmth and coldness, than to be the effect of the long-con-
tinued action of severe cold. In the frigid zone, congelation,
and the total death of the part, is almost always the conse-

inclement seasons.
CCXLV. Although the Chilblain is a very common com-
plaint, and is not generally the object of chirurgical treatment,
yet it ought not to be overlooked as a disease of no importance,
for it sometimes proves destructive to the part that is affected :
it is always slow in its progress towards amendment; and those
that have once been sufferers, are subject to have a return of
the disease in every succeeding winter.
CCXLVI. In our attempts to investigate the effects of the
application of cold upon the human body, in the production of
this, or any other morbid alteration, we cannot reason from its
known action upon inanimate substances; since the phenomena
are not similar, except in some very gross instances. No par-
ticular alterations are produced in dead matter by exposure to
a cold atmosphere, &c. until it be frozen ; but the congelation
OF THE PERNIO, OR CHILBLAIN.
67
of a living part is usually attended with the loss of its vitality,
and it then ceases to fall under our consideration as a proper
subject of disease.
ČCXLVII. The effects of cold upon the living body are
more sensible and intense, in proportion as the transition is
more sudden, from a very high to a very low degree of tem-
perature. But even in the coldest seasons of northern cli-
mates, a sudden increase of its severity, especially if there be
much wind, will occasion internal or external mortifications,
and not unfrequently sudden death.--See Boyle's History of
Cold, &c.
CCXLVIII. The natural standard of heat generally found
in the living body is about 98° of Fahrenheit's thermometer,
and this degree can be supported when the surrounding atmos-
phere is in very different states of temperature, by the original
and inherent powers of the system. The application of a cold
atmosphere, &c. to the living body, has not an unrestrained
power of reducing it to its own state of temperature; for as
long as the vital powers are vigorous and active, it can sub-
tract little more than the excess of heat that may be present
above the natural standard. But where the cold is excessive,
and its application is long-continued, a morbid alteration will be
induced in the sensibility and motion of the part, and conse-
quently there must be an unnatural reduction of the state of
animal heat.
CCXLIX. Those parts of the body that are naturally pos-
sessed of little or no sensibility, and where there is a languid
circulation of the blood, or perhaps none at all, may be frozen,
and undergo the same changes that take place in lifeless mat-
ter, while the system in general shall suffer little or no injury :
exempli gratia, the cuticle, hair, and extremities of the nails.
CCL. The proper and direct effects of cold upon solid in-
animate bodies, are dryness and contraction; but it is said, that
fluids suffer expansion at the instant of congelation. When it
is considered, that the experiments which seem to prove this,
were made with nearly incompressible fluids inclosed in a hol-
low vessel, and that the sides of the vessel would contract with
great force upon an elastic substance : when it is also taken
into consideration, that high degrees of cold separate the air
naturally combined with water, and thus augment its bulk, and
diminish specific gravity : when the different degrees of specific
gravity, of different masses of ice, and of the same portion at



68
OF THE PERNIO, OR CHILBLAIN.
U
different periods, the phenomena attending the absorption of
vitriolic acid air by water,* the effects of the air-pump, &c.
are added to the account, and also the change that takes place
in the figure of liquids by the act of congelation, perhaps our
general position, that cold by its proper effects, contracts all
bodies, may be capable of application to fluids, as well as to
solids.
CCLI. The proper and direct effects of cold upon living
bodies, are, a diminution of insensible perspiration, a dryness,
corrugation, or fissured state, of the cuticle, and sometimes of
the skin : the sensibility is more or less impaired; there is a
languid circulation of the blood, especially in the smaller ves-
sels; these are succeeded by a considerable diminution of heat
upon the surface of the body; respiration is often painful, or
laborious; and there is a general diminution of the tonic action
of the moving fibres, accompanied with actual debility.
CCLII. As the human body is an organized whole, where
the combined parts exert a perpetual and reciprocal influence
upon each other, a powerful application is never followed by a
solitary effect. Animal heat depends greatly upon the state of
the brain, and the sensibility of the nerves, and vice versa ;
both these conditions are intimately connected with the due
transmission of blood ; and the tonic state of the moving fibres
depends upon the joint operation of all these, and perhaps of
other causes.—See OBSERVATIONS ON ANIMAL HEAT, in the
London Medical Journal, vol. 7. p. 169.
CCLIII. When the sensibility, tone, &c. (No. 251), of any
portion of the body is greatly impaired, if it were to be still
longer exposed to the action of intense cold, a livor, rigidity,
brittleness, and death of the part, would be the consequence.
CCLIV. The firmness which is produced in a body by con-
gelation, ought to be distinguished from that state of contraction
in living muscular fibres, that is called Tone : nor ought it
to be assumed as certain, that cold, while it contracts bodies,
also augments the attraction of cohesion between the particles
of matter. But whatever may be its effects upon dead sub-
stances, it was long ago observed by Lord Bacon, that “ Cold
has a relaxing effect upon the living body."
CCLV. In robust and athletic constitutions, where intense
and long-continued refrigeration can be sustained without in-
jury, from the influence of habit, or the effect of exercise, a


Que
* Nicholson's Chemical Dictionary.
OF THE PERNIO, OR CHILBLAII
69
cold atmosphere may be said to increase the general strength
of the system. Upon the same principle, transient changes of
temperature, (as cold-bathing, &c.) repeated within certain
limits, will have a tendency to invigorate the feeble and debili-
tated; but these secondary effects of cold, which are the con-
sequence of re-action, no more prove it to be tonic in its
own nature, than the debility that succeeds inebriation demon-
strates the primary properties of alcohol to be relaxing.
CCLVI. That degree of heat which is most grateful to the
healthy state of sensation, is about the medium point, between
the heat of human blood and the freezing point. But when a
part is considerably refrigerated, if a degree of heat not greater
than would be pleasant to a healthy body be suddenly applied,
the effect will be as fatal as absolute congelation. It must be
very obvious, however, that the manner in which death is oc-
casioned by these two opposite causes, is very diverse : in the
latter instance, vitality is destroyed, by arresting all motion; in
the former, by the violent incitation of the moving fibres of a
part to a velocity and force of action, which their debility ren-
ders them unable to perform.
CCLVII. The general principle, by which many of the ef-
fects of actual cold are produced by substances that are poten-
tially cold, may perhaps receive some elucidation from an ap-
plication of the preceding observations.
CCLVIII. The first symptoms of the pernio, are a pale-
ness of the refrigerated part, which is quickly succeeded by
more or less of redness, and a troublesome pruritus, or some-
times pain'; the skin gradually acquires a purple hue : the cu-
ticle separates, and this separation is often preceded by a se-
rous effusion between that and the cutis ; beneath the cuticle,
there appears a painful ill-conditioned ulcer, irregular in its
figure, and difficult of cure.
CCLIX. The foregoing account may be considered as a
very general description of the chilblain; but as there is
some variety in the appearance and progress of the disease, it
may be proper to divide it into two species :
The simple, and the ulcerated pernio
CCLX. The simple pernio is characterized by redness



especially on being suddenly exposed to heat; more or less
of edema possesses the surrounding parts, and sometimes all
the fingers and back part of the hand will have an anasarcous
70
OF THE PERNIO, OR CHILBLAIN.
appearance; very frequently there is also a livid colour, which
extends to a considerable distance. This species may re-
main in its simple state during the whole winter, and gradu-
ally disappear as the summer advances.
CCLXI. The ulcerated pernio is frequently preceded
by the simple species, to which, there supervenes a vesication,
or simple separation of the cuticle; below this, there appears
a painful, foul, irregular ulcer, which by neglect will increase
to a considerable magnitude ; sometimes the ulceration pene-
trates as low as the tendons, or even exposes the su rfaceof
the bone. In a severe winter, there are generally several in-
stances of a total sphacelation of one or both the extremities,
from the application of cold. A sudden and imprudent appli-
cation of heat to a benumbed limb, may prove equally de-
structive of the life of the part.
CCLXII. A long-continued and partial exposure to a cold,
not much below the freezing point, will sometimes produce
the dry gangrene; especially if there be a previous state of
debility in the system.
CCLXIII. It is worthy of observation, that the simple
chilblains do not so often appear during the continuance of
frost, as during the thaw that succeeds it; and it is a well-known
fact, that frequent alternations of heat and cold, within short in-
tervals, have a very pernicious effect upon parts that are al-
ready debilitated.
CCLXIV. The ulcers that appear in consequence of the
application of cold, very much resemble those that are seen on
the lower extremities of cachectic patients, and of those in
general, where the circulation of the blood in the extreme ves-
sels is remarkably languid.


SECTION II.
THE TREATMENT OF CHILBLAINS.

CCLXV. As it is easier to prevent the accession of Chil-
blains than to cure them, our attention ought first of all to be
directed to the means of prevention.
The methods proper to be employed for this purpose, are,
1. To defend the part carefully from the action of extreme
cold, by warm clothing.
OF BURNS AND SCALDS.
71
2. To avoid sudden and great transitions from cold to heat.
3. To give tone and action to the vessels by exercise or
friction.
4. To harden the cuticle, and promote the circulation of
blood in the parts most exposed to the effects of cold, by stim-
ulants, as alcohol-spirit of turpentine-diluted volatile alkali
warm plasters-hot sea water, &c.
CCLXVI. The simple pernio will generally disappear as
soon as the weather becomes permanently mild. Little more is
requisite than to rub the part frequently with warm spirituous
embrocation, and to apply a plaster of simple diachylon. Ex-
posure to a very strong heat has been recommended, and will
prove successful; but it is too painful a mode to be generally
adopted.
CCLXVII. The ulcerated chilblain may be treated as a
common ulcer, varying the applications according to the state
of the affected part. An ointment containing hydrargyrus ni-
tratus ruber, is commonly an useful application.
CCLXVIII. The mode of treating a gangrene that is the
consequence of exposure to cold, ought to be different from
that which was recommended at No. 220–221. We are ad-
vised, first to attempt a restoration of the part, by chafing it
with ice or snow, or plunging it into cold water; and cautious-
ly to avoid introducing a sudden change in the temperature of
the part. Cordial remedies are to be exhibited internally.
But when a part is completely sphacelated by cold, the mode
of treatment does not differ from that which was recommended
in the chapter on Gangrene and Sphacelus.


CHAPTER IX.
SECTION I.
AMBUSTIONES.-OF BURNS AND SCALDS.
CCLXIX. A burn, is a solution of continuity from the appli-
cation of fire.
CCLXX. In our attempts to investigate the operation of
various active powers upon the human body, we are not to form

12
OF BURNS AND SCALDS.
an estimate of their proper and absolute effects, by means of
analogical reasonings founded upon the changes they produce
on inanimated matter ; their action upon the living fibres, with
in certain limits, is relative, and is connected with the present
and immediately preceding state of the system; for every ap-
plication that does not immediately destroy the vitality of the
part to which it is applied, scarcely extends its primary action
beyond the organs of sensation. These observations are
eminently true when applied to the operation of heat and cold,
cominunicated within a certain degree to the living system.
CCLXXI. It is a well known fact, that a living healthy ani-
mal is endowed with an inherent power of generating and sup-
porting a certain degree of heat, in a great measure indepen-
dently of the state of temperature of surrounding bodies. And
when the body is placed within the sphere of action of masses
of matter, considerably heated beyond its ordinary standard,
there will be an accession of heat exceeding the natural quan-
tity ; but in proportion to the adventitious heat that is commu-
nicated, the inherent powers of the system will be less vigorous-
ly exercised in the generation of animal heat: hence there
ought to be a distinction constantly made, between innate, and
supervenient heat.
CCLXXII. When heat is considered with relation to the
senses of an animal, it may be regarded as a very powerful
stimulant inciting the moving powers of the living fibres to ac-
tion ; but when it is viewed with reference to its absolute ef-
fects on matter in general, it will appear to be a very active
and potent chemical agent, capable of destroying the contex-
ture, and separating the component parts of bodies. The effect



the human body, will be different according as their action
chiefly terminates on the organs of sensation, or as they destroy
the vitality and subvert the organization of the machine.
CCLXXIII. The effects produced by high degrees of actu-
al heat, and by caustic substances applied to the living body,
are very analogous; and the sensations excited by actual and
potential heat are so extremely similar, that it perhaps merits
inquiry how far their effects depend upon a principle common to
both.
CCLXXIV. If a substance possessed of above 120° of heat
be applied to the living body, it will accelerate the motion of
the blood-vessels of that part, increase the contractility of their

OF BURNS AND SCALDS.
73
.

parietes, produce redness, and augment sensibility. Increase
this degree of heat to 213º, and there will follow a serous effu-
sion under the cuticle ; and a still greater accession of heat
will coagulate the fluids and solids, deprive the part of its vitali-
ty, and be attended with other consequences of combustion,
more or less extensive, according to the intensity of the heat,
CCLXXV. As the quantity of heat which different sub-
stances are capable of receiving, and the readiness with which
they transmit it, is very various; so the effects that result from
the application of heated vapours and ardent metals are very
dissimilar. If an intensely heated metallic substance, &c. be
suddenly applied, the burning effects will be more extensively
injurious, but the painful sensation not so severe as that which
immediately follows the application of boiling water. And
when heat is communicated in a gradual manner, very consid-
erable medical effects may be produced; for the pain occa-
sioned by a light substance in the state of actual combustion, is
by no means insupportable.
motion in all dead matter; whereas, such a degree as is
consistent with life and health, occasions a contraction and
increase of tone in the living fibre. But we are not to con-
found the expansion and condensation of inanimate substances
with the contraction and relaxation of the vessels, &c. of a liv-
ing animal : the former effects are in proportion to the degree
of heat that is applied ; the latter are not in the ratio of its ac-
tual temperature ; for the thermometer may demonstrate the
animal heat to be uniform in winter, and in summer, while the
state of tonic contraction shall be widely dissimilar. *
CCLXXVII. If a living animal be confined in a degree of
heat a little below that which would produce coagulation, al-
though the primary effect would be a contraction of the living
fibre, yet, by supporting a violent and unnatural degree of ac-
tion in the moving parts, the powers of the system would be
gradually exhausted. And it is no more extraordinary, that

* A greater' attention seems to have been paid to the temperature of the
this last circumstance ought not to be overlooked, for daily experience
demonstrates the great and important changes that are produced in the
tonic state of the system, by variations in the degree of atmospheric
pressure.
10
174
OF BURNS AND SCALDS.
the application of different degrees of heat should be attended
with varying effects, than that the exhibition of different doses
of the same medicine should be followed by very unequable op-
erations.
CCLXXVIII. In judging of the morbid effects and probable
consequences of fire when applied to the living body, it is ne-
cessary to inquire into the degree of heat that was brought into
contact ; the duration of its application ; the situation of the
injured part, and the extent of the injury : exempli gratia, a
burn upon the head is more dangerous than upon an extremity;
and even the application of a strong caustic to the scalp de-
mands circumspection. A considerable portion of the integu-
ments may be destroyed, so as to produce an ulcer that will
be cicatrized with difficulty.—The situation of the injury may
be such, as to be followed by inconvenient adhesions, contrac-
tions, or great deformity.—The subject of the accident, may
possess a habit of body in which gangrene and sphacelus read-
ily supervene.—The age of the patient is also a circumstance
of moment, as extensive burns in old people, and in children,
are extremely dangerous.
CCLXXIX. Burns may be divided into
The Superficial,
The Ulcerated,
and the
Carbunculous.
In the superficial burn, the connexion between the epidermis
and cutis is generally destroyed, but there is no serous effu-
sion, nor does the injured cuticle separate until a new one is
nearly formed beneath it. This is attended with moderate
pain, and no danger, except the injury be very extensive.
The ulcerated burn is accompanied with effusion under the
cuticle, and very commonly the cutis is considerably injured,
so that a deep and foul ulcer is formed. The heat of boiling
water may produce these effects. N
In the carbunculous burn, the whole organization of the in-
jured part is destroyed, and a perfect eschar or dead crust is
formed, the profundity and diameter of which will depend
upon the degree of heat that was applied, and the duration of
its application. Ignited or melted metals, burning coals, boil-
ing oil, &c. will produce these effects.
CCLXXX. The danger to be apprehended from a burn, or
scald, cannot always be estimated from its profundity, or mag-




OF BURNS AND SCALDS.

nitude; for as superficial burns are now and then extremely
painful, so a very slight injury from fire upon a lower extremi-
ty, sometimes terminates in gangrene and death.
CCLXXXI. When the body is extensively injured by the
explosion of gun-powder, or inflammable gas, when the burn
has been inflicted by a fiery meteor, or the application of hot
vapour, the accident is often immediately succeeded by rigors,
and a temporary depression of strength : but the subsequent
symptoms are commonly such as indicate the presence of in-
flammation.
CCLXXXII. Heated vapour, or boiling water, more fre-
quently produce ulceration when they pass to the body through
the clothes, than when they are immediately applied to the
naked surface.

SECTION IT.
THE TREATMENT OF BURNS AND SCALDS.
CCLXXXIII. The first indication :
To obviate the effects of inflammation, by employing the re-
medies recommended in the first chapter.
CCLXXXIV. Indication the second :
In the superficial burn, to prevent if possible a hasty separa-
tion of the cuticle, by the application of rectified spirits of wine,
vinegar, the heat of a moderate fire, cold water, ice, prepara-
tions of lead, &c.
CCLXXXV. In the ulcerated burn, to apply oil, sapo-
naceous lotions—preparations of lead—ice cataplasms of white
bread and milk with oil-linseed poultice, &c. The applica-
tion of warm oil of turpentine and warm digestives, during
some of the first days after the injury has been inflicted, have
been strongly recommended by Dr. Kentish.*
To dress the ulcer, after the inflammation is subdued, with
mild digestives. When it heals with difficulty, the Ungt. Basil.
Nigr. may often be used with advantage.

* Mr. Birch, surgeon of St. Thomas's hospital, informed me, that he
uses with great advantage, a strong solution of soap in water, agitated in-
to a foam, or lather,
176
OF THE ERYSIPELAS.

CCLXXXVI. Indication the third :
The effects of pain are to be obviated by the use of opium ;
and if a considerable portion of the integuments be remove
to support the strength, by Peruvian bark, wine, &c. and the
tonic remedies formerly recommended.
CCLXXXVII. The treatment of the carbunculous burn
must be conducted according to the directions given in the
chapters on Gangrene and Anthrax.
CCLXXXVIII. Indication the fourth :
To prevent, as much as possible, contractions, unnatural ad-
hesions, and great deformity, by mechanical means properly
adapted to the situation of the part affected.
CHAPTER X.
SECTION I.

OF THE ERYSIPELAS.
- CCLXXXIX. Medical and chirurgical writers have gene-
rally classed Erysipelas under the head of inflammation, and the
principal difference between this affection and pure inflammation,
has been supposed to consist, chiefly, in the seat of the disease.
The erysipelas is commonly seated on the skin, which is an ir-
ritable surface : a phlegmon is situated more deeply, in the
substance of the part; and this difference of situation hath
been esteemed fully sufficient to account for the very dissimilar
phenomena that are exhibited by the two diseases.
CCXC. A long and careful attention to this disease, hath,
however, induced me to suspect that the relation between
erysipelas and inflammation is extremely remote. It appears to
me proper and justifiable to consider erysipelas as a genus,
the specific characters of which are as widely differing from
inflammation, as those of inflammation are dissimilar from the
phenomena proper to fever. This opinion will receive further
illustration, if we advert to the mode of treatment that is ap
propriated to each ; the very different manner in which the
two diseases terminate ; the analogy between erysipelas and
those exanthematous diseases which have a determinate period;


OF THE ERYSIPELAS.
1977
and also to this remarkable fact, that the two diseases are not
reciprocally convertible into each other. To propose trivial
or verbal innovations into science, through an affectation of
novelty, or to attract the public attention, is unworthy the in-
terpreter of nature ; but it is hoped that the present instance
will not incur such a censure froin the candid and intelligent
practitioner.
CCXCI. As there is a considerable similarity in the phe-
nomnena which constitute erysipelas, wherever it is seated, the
general history of the disease will be less interrupted if a de-
scription be first given of its appearance and progress in some
one particular part; and we shall, afterwards, deliver such ob-
servations as will be applicable to the various circumstances
that may accompany the disease. We propose therefore, first
of all, to speak of erysipelas in the face, when connected with
general affection of the system.
CCXCII. This complaint is very frequently sudden in its
attack, but sometimes it is preceded by shiverings, nausea, and
symptoms that resemble the approach of an intermittent. The
forehead, cheeks, nose, or eye-lids are tumefied; the eleva-
tion is smooth and equal, but not distinctly circumscribed.
The skin is of a bright scarlet colour, or it is tinged with yel-
low, or it approaches to a dusky redness : on pressing the part,
this discolouration disappears, but it returns again as soon as
the finger is removed. The redness comonly terminates ab-
ruptly, and does not gradually lose itself in the colour of the sur-
rounding parts, as in the phlegmon. These symptoms are ac-
companied with an ardent heat, and an uneasy sense of ting-
ling in the part, rather than with acute pain ; sometimes the pa-
tient complains of a distressing pruritus. The tumeſaction
generally presents a shining, and perhaps a semi-pellucid ap-
pearance, but is without tension, hardness, or a sensation of
throbbing. The eye-lids are often so considerably tumefied
as to obstruct vision, and the whole face is extremely disfigur-
ed. Small pustules, containing a transparent fluid, and very
much resembling those that are produced by boiling water,
occupy more or less of the surface affected with this disease ;
and if they burst, the effused fluid will excoriate the neighbour-
ing parts. There is frequently some degree of exulceration at
the base of these vesications, which sometimes proceeds rap-
idly into gangrene, or sphacelus. When the disease terminates

78
OF THE ERYSIPELAS.

favourably, the pustules dry, and a furfuraceous desquamation
takes place in a period from about eight to twelve days.
CCXCIII. The seat of the erysipelas is said to be in the
rete mucosum; and without doubt this membrane is consid-
erably affected; but it is not confined to this part, for the tela
cellulosa is always, and to a considerable degree, the subject
of the disease; the situation of the complaint, therefore, is not
that which discriminates erysipelas from phlegmon. And on
the other hand, it is equally certain, that internal irritable sur-
faces, (as they are called) are as frequently attacked with in-
flammation as erysipelas.
CCXCIV. But although the cellular membrane is more or
less interested in this complaint, the progress of the disease and
its mode of termination, are widely different from the progress
and general termination of a phlegmon. A circumscribed
cavity containing laudable pus is never seen in legitimate ery-
sipelas; and where a purulent effusion happens in any consid-
erable degree, when the part is examined, it affords a sensation
similar to that which is excited by a quagmire or morass. In
that sort of suppuration which sometimes supervenes to erysip-
elas, the cellular membrane suffers great injury, and not un-
commonly the part is in a gangrenous condition.
-CCXCV. It is not an easy task, distinctly to ascertain the
remote causes that give rise to this disease. From among
many others we have selected the following:
1. Violent passions of the mind, as anger, &c.
2. Undue exposure to the rays of the sun, or to the action
of fire.
3. A blast of cold moist air.
4. The application of poisons, vegetable, mineral or animal.
5. Wounds, punctures, &c. of the periosteum, pericranium,
and of a tendinous expansion, or a nerve in phlebotomy.
6. Fractured bones.
7. Abscesses formed under an aponeurotic expansion, or
any other very tense membrane.
It often appears, when we are unable determinately to as-
sign any particular cause.
The erysipelas is sometimes a congenital disease.
The efficacious action of the causes enumerated above in
the production of this specific form of disease, will be greatly
influenced by the previous state of the system.
CCXCVI. The erysipelas ought to be carefully distinguish-



OF THE ERYSIPELAS.
79
ed from phlegmon; and the following criteria will assist towards
forming a just diagnosis.
1. In the erysipelas, the tumefaction is less prominent, and
is never evidently circumscribed.
2. The skin often looks as if it were scorched or burnt.
25.
to a yellowish colour; it also vanishes on pressure.
4. It is not commonly attended with the lancinating pains,
and sense of throbbing, that attend the formation of a phlegmon.
5. The part affected is almost wholly free from tension, and
gives the sensation of an ædematous, or of an emphysematous
state, except that there is no crepitation.
6. That hardness of the pulse, which is a distinguishing
character of inflammation, is not present in erysipelas.
7. The general state of the system verges rather to debility,
or depression of strength, than to increased strength and vigour.
8. The erysipelas is susceptible of metastasis.
Some of these criteria will occasionally require qualifica-
tion; but never to such a degree as to invalidate the general
conclusion.
CCXCVII. From the foregoing narration of the phenomena
of erysipelas, it seems warrantable to form the following pro-
position :
In a part that is affected with an erysipelas, there is a mor-
bid sensibility of the nerves with a preternatural irritability of
the diseased parts; arterial contraction is performed with an
increased velocity, but with diminished vigour; and the parietes
of the blood-vessels give less resistance than natural to the vis
a tergo.
- CČXCVIII. The erysipelas is not a disease that is simple
and uniform in its appearance, nor does it always admit of a
similar mode of treatment: it will be therefore proper to divide
it into different species, and to appropriate to each its method
of cure. The following division is adopted as a convenient one:
1. The Acute Erysipelas.
2. The Edematous Erysipelas.
3. The Malignant, or Grangrenous Erysipelas.
Each of those species may be an
Idiopathic, or symptomatic disease.
The erysipelas indeed is susceptible of metastasis, but this
property does not seem to be sufficiently limited, so as to jus-


JUICI
80
OF THE ERYSIPELAS.

tify the admission of it as a foundation for establishing a fourth
species.
CCXCIX. The acute erysipelas is most commonly seen in
those of a sanguine and choleric temperament; it is gener-
ally sudden in its attack, and usually affects the face. Symp-
toms resembling those of general inflammation are often pre-
sent immediately after the accession of the disease; but they
gradually diminish, as the erysipelas becomes more distinctly
formed: there is a considerable heat, and great uneasiness in
the part affected ; the skin is of a brighter scarlet colour than
in the other species; if pustules appear, they are distinct, but
sometimes there are no vesications on the surface.
CCC. There is very seldom any matter formed in this spe-
cies of erysipelas, and the violence of the disease commonly
subsides in three or four days. The part then grows yellowish,
and throws off furfuraceous scales, and the disease terminates
about the tenth day. A tenderness of the hairy scalp will
often continue for a considerable time after the disease has dis-
appeared.
CCCI. In order to understand the reason of some of the phe-
nomena enumerated at No. 299, it will be proper to consider
erysipelas in a twofold view; as a morbid affection of the sys-
tem, and as a stimulus, capable of acting as the remote cause
of another disease. When it is situated in the face, an inflam-
mation of the brain may be produced by its determining a
preternatural flow of blood to the head; but such an accident
no more proves the erysipelas to be properly inflammatory in
its own nature, than it proves that every effect is the copy and
resemblance of its cause. When con
matters are ad-
mitted into the system, a temporary train of symptoms resem-
bling general inflammation, commonly appear; but it is never-
theless thought proper to distinguish exanthematous diseases,
from simple inflammation.
CCCII. The acute erysipelas may be an idiopathic affec-
tion, and the same person will often have one or more regular
attacks at certain periods of the year, but more especially
about the time of the equinoxes. This disease is also a com-
mon symptomatic attendant on wounds of the membranes that
cover the bones, &c.
CCCII. The ædematous erysipelas is not, in general, so
sudden in its attack, nor so severe on its accession; the disease
increases gradually, is more diffused, and attended with less of

ON
OF THE ERYSIPELAS.
81

ardent pain : if symptoms resembling general inflammation ap-
pear, they never run high, nor are they of long duration ; most
commonly there is a depression of strength, and a soft, fre-
quent, or perhaps irregular pulse. But in this species of the
erysipelas, the system is not relieved on the appearance of the
local affection; on the contrary, the danger increases with the
progress of the external disease.
CCCIV. When the face is the seat of ædematous erysipe-
las, the whole visage has a bloated appearance; the red col-
our of the skin is mingled with yellow or brown; it is accom-
panied with rigors, vomiting, and more or less disturbance to
the functions of the sensorium commune. The vesications are
often small and numerous, and when they have been exposed
for a few days to the air, the countenance will be covered with
a dark coloured crust, very much resembling the appearance
of the confluent small-pox. Although the face appears to be
much inflated, yet it gives a very slight resistance to pressure,
and excites the peculiar sensation we described before.
• CCCV. This species of erysipelas is attended with consid-
erable danger; the patient often dies delirious, or in a coma-
tose state, about the seventh day; the fatal terinination is
sometimes protracted a few days longer.
CCCVI. When this species of erysipelas appears, it is com-
mon to see many people afflicted with it about the same period;
and, in hospitals, I have seen several persons in the same ward
successively attacked with it: there is also some reason to con-
clude, that it is occasionally an epidemic disease ; but I am
unable to decide how far it is, or is not contagious.*
CCCVII. The ædematous erysipelas may attack persons of
any age, or temperament; but those are chiefly affected by
this species, whose constitutions are debilitated by age, or ex-
cess: we also frequently meet with it in dropsical patients, in
children, and in new-born infants.
CCCVIII. When this complaint is symptomatic, it is not
nearly so dangerous as when it is idiopathic ; but whenever the
face is considerably affected by this species of erysipelas, it is
always to be regarded as a serious disease, whatever be the re-
mote cause. There is seldom much danger or inconvenience
when it attacks an extremity, except it be treated improperly.


* A paper by Dr. Wells, in the Transactions of a society for the im-
provement of medical and chirurgical knowledge, Vol. II. may be con-
sulted on this point.
OF THE ERYSIPELAS.

1
-
I have seen this species of erysipelas make its first appearance
upon the face, and by a gradual and regular progression, pro-
ceed downwards to the extremities, successively appearing
upon an inferior portion of the body, as it disappeared from a
superior part; each renewed accession of the complaint was
less and less severe, as it receded to a greater distance from
the part that was primarily affected.*
CCCIX. The erisypelas is a disease which is subject to
sudden and dangerous translations from the external to the in-
leg alternately, and be transferred suddenly from one to the oth-
er, several times, during the continuance of the complaint.
When a metastasis takes place from an extremity to the brain,
it will immediately be followed by a delirium and other alarm-
ing symptoms. I never saw an instance of metastasis in the
acute erysipelas.
CCCX. The first appearance of the malignant or gangre-
nous erysipelas is somewhat similar to that of the cedematous
erysipelas, but it is much more rapid in its progress. Phlyc-
tena with a livid base very quickly appear upon the surface of
the skin, and gangrenous symptoms speedily supervene. A
state of the system similar to that which is present in putrid
fever, makes an early appearance in this complaint.
CCCXI. This species of the disease is most frequently
seen upon the face, neck, breast, or shoulders ; the degree of
danger attending it must generally be estimated by the state of
the system.
CCCXII. The gangrenous erysipelas is often a fatal disease,
but it is irregular in the period of its termination. When it
terminates favourably, we often meet with little caverns, and
intercurrent sinusses in the tela cellulosa, containing an ill-con-
ditioned pus, and in those cases, considerable sloughs formed
by cellular membrane, &c. are evacuated from the ulcer.
CCCXIII. The erysipelas is sometimes deuteropathic,
and not uncommonly it may be regarded as the critical termi-
nation of another disease : exempli gratia, obstructed men-
struation, quartan ague, suppressed suppuration, spasmodic
and convulsive diseases. Indeed, exanthemata in general,
seem to have a remarkable efficacy in suspending or carrying
off convulsive diseases.
* A case somewhat resembling this may be found in Alix: Obsery :
Chirurg: Fascic: iij.
OF THE ERYSIPELAS.
83
CCCXIV. After the favourable termination of erysipelas,
especially when the lower extremities have been affected, more
or less of ædema will often remain about the ankles for a con-
siderable time, and be very difficult to remove.

CCCXV. The Zoster, Zona, Herpes miliaris, or Shingles,
is a disease that was well known to the ancients : it has been
considered by some moderns as a species of erysipelas; but
this arrangement would be extremely improper, for the two
diseases are very diverse from each other.
CCCXVI. That eruptive complaint to which we give the
name of shingles, appears in the form of small vesications,
which are filled with an almost transparent fluid : when they
are large and distinct, there is very little redness in the inter-
stitial spaces between their base; but when confluent, there is a
more considerable discolouration of the surface. The erup-
tion is usually, but not invariably, preceded by slight rigors,
sickness, and even vomiting ; the pustules are more commonly
situated about the breast, back, abdomen, or loins, and some-
times they form a portion of a circle ; at other times, they
are seen in distinct and distant clusters upon different parts of
the body. The feverish symptomis do not wholly disappear
on the eruption of the pustules, but they gradually subside, as
the contained fluid acquires a denser consistence; the surface
of the pustules then begins to dry; they fall off in the form of
dark-coloured crusts; and the disease terminates in a period
of from eight to twelve days.
CCCXVII. Although the shingles derive their origin from an
internal cause, and the eruption is usually connected with a
general affection of the system, more or less severe, yet it is a
disease very seldom dangerous in its consequences. A vulgar
notion indeed prevails, that iſ the eruption forms a circle round
the body, the termination will be certainly fatal. I never saw
it encompass the body ; but it is more than probable that this
prognosis is as well supported as the generality of vulgar
opinions.
CCCXVIII. This disease ought to be distinguished from
erysipelas--from ignis sacer-varicella-herpes—and esse-
ra. A history of the nettle-rash is given in the second vol-
ume of the Medical Transactions, by the very learned and res-
pectable Dr. Heberden.

OF THE ERYSIPELAS.
SECTION II.
THE MODE OF TREATMENT.
CCCXIX. As the same method of treatment is not appli-
cable to each species of the erysipelas, it will be proper in the
first place to speak of the general remedies that are to be em-
ployed, in the order of our division, and afterwards we shall
deliver the local treatment.
CCCXX. Indication the first :
To diminish increased vascular action in the acute erysipelas,
and to take off particular determination to the head, by
1. General and topical blood-letting.
General bleeding is not recommended in this place as a cure
for erysipelas, in the same sense in which it may be said to re-
move an inflammation ; it is advised with the intention of ob-
viating the effects produced in the system by so severe a stimu-
lus as acute erysipelas. Indeed cases very rarely occur in
large towns, where bleeding is at all admissible; and a repeti-
tion of the operation will very seldom be necessary or ad-
visable.
2. Gentle aperients of the saline and acid class. The ex-
hibition of emetics and severe purgatives have sometimes
been succeeded by the most fatal consequences.
CCCXXI. Indication the second:
To promote an equable determination of the blood to the
surface of the body, and to support a gentle diaphoresis, by
1. Nitre and antimony-sweet spirit of vitriol-saline
draughts with volatile alkali-Dover's powder-wine whey, &c.
CCCXXII. Indication the third :
To allay irritation, and remove uneasiness, by camphor and
opium.
CCCXXIII. It has been maintained by the most respecta-
ble authorities, that the early and liberal exhibition of Peruvian
bark will commonly shorten the period of erysipelas.
The patient ought to abstain from animal food, and to avoid
exposure to a cold atmosphere.


OF THE ERYSIPELAS.
85
SECTION III.
THE TREATMENT OF EDEMATOUS ERYSIPELAS.
CCCXXIV. Indication the first :
To obviate the effects of topical determination, when neces-
sary, by local blood-letting.
When this species of erysipelas is symptomatic, e. g. the
consequence of a wound of the head; the application of cup-
ping-glasses between the shoulders, so as to extract a few
ounces of blood, may sometimes be proper in an early stage
of the disease; but it will be very seldom advisable to repeat
the evacuation. General bleeding is inadmissible, almost with-
out exception. The propriety of topical bleeding is chiefly
applicable to those cases where there is danger of an affection
of the brain : but very great nicety is required in determining
upon this evacuation, where there is the least disposition to a me-
tastasis. I have seen the most dangerous symptoms immedi-
ately supervene to the loss of a very small quantity of blood.
2. To keep the body soluble by the remedies prescribed at
No. 320. The same observation with respect to the use of
emetics and purgatives is also applicable here.
CCCXXV. Indication the second :
To promote a diaphoresis by the medicines recommended
No. 321.
CCCXXVI. Indication the third :
To excite irritation in a distant part, by rubefacients, vesica-
tories, &c.
- These remedies are chiefly applicable in the transposed
erysipelas; or in cases where the brain is affected : they ought
to be employed with caution upon other occasions. to
*CCCXXVII. Indication the fourth :
To relieve pain and irritation by Hoffman's anodyne liquor ,
camphor, opium, London treacle.
Opium is a very valuable and necessary remedy in the cede-
matous erysipelas, and when given with a prudent freedom it
often produces the happiest effects. 2015
CCCXXVIII. Indication the fiſth:
To support the vigour of the system, and prevent a termi-
nation of the disease in gangrene and sphacelus, by tonic rem-


86
OF THE ERYSIPELAS.
edies, as Peruvian bark, wine, brandy, confectio cardiaca,
volatile alkali, &c.
CCCXXIX. The plan of treatment to be adopted in the
malignant erysipelas, is the same with that which is recom-
mended in the treatment of gangrene and sphacelus.
SECTION IV.
THE LOCAL APPLICATIONS TO BE USED IN ERYSIPELAS.
CCCXXX. The medicaments that have been recommend-
ed as suitable applications to a part affected with erysipelas
have been extremely various and dissimilar : I will enumerate
a few of the principal ones, and deliver some general re-
marks.
1. Repellent and astringent applications; as cold water, vin-
egar, lead, vitriol, &c.
2. Unctuous substances.
3. Rubefacients; as diluted volatile alkali, spirituous and
lixivial applications.
4. Farinaceous or earthy matters sprinkled upon the surface.
5. Warm emollient cataplasms.
CCCXXXI. The indiscriminate use of the remedies men-
tioned at No. 1, will certainly be often attended with great dan-
ger. There are cases of acute erysipelas in which they may
sometimes be used with safety, but I do not recommend them.
2. Mere unctuous substances ought never to be used.
3. Rubefacients may be commonly employed with safety,
and often with considerable advantage. It is of importance not
to apply them in such a concentrated state as to produce ex-
coriation. 200
4. The use of farinaceous substances, earths, &c. coun-
teracts one of our most principal indications, which is, to pro-
mote a gentle perspiration in the part: their application is also
attended with the further inconvenience of forming hard irrita-
ting crusts upon the diseased part. I have seen very disagree-
able and dangerous consequences to ensue from their use.
5. Mild, warm cataplasms, are the applications which a very
extensive experience hath induced me to prefer. They may
be composed of the powders of aniseed, fennel, camomile flow-



OF THE ERYSIPELAS.
87
ers, mixed with an equal quantity of oatmeal, or linseed meal,
and a sufficient quantity of a strong decoction of poppy heads.
Each application of the cataplasms may be preceded by the
use of a rubefacient. After the erysipelas is cured, the æde-
ma that remains may generally be removed by frictions with
the linimentum ammoniæ, the use of hot sea water, and a fan-
nel bandage.
CCCXXXII. The erysipelas that arises from the puncture
of a membrane, or tendinous expansion, very often requires a
free and extensive division of the parts, before any application
can be attended with advantage.
CCCXXXIII. The external applications necessary in the
malignant erysipelas are enumerated in the chapter on gangrene
and sphacelus.
CCCXXXIV. The ulcers that are produced by this dis-
ease do not require any peculiar mode of treatment.


SECTION V.
THE TREATMENT OF ZONA.
CCCXXXV. The Zona very often admits of a natural cure ;
but when it requires medicinal treatment, the indications are,
1. To promote an equable determination of blood to the sur-
face of the body, by
a. Living in a warm atmosphere.
b. Gentle diaphoretics, and light cordials with opiates, when
the irritation is very distressing. See No. 317.
Indication the second :
To exhibit a gentle purgative when the pustules are drying.
Diuretic medicines are also proper.
No particular external applications are necessary.

88
OF THE SCIRRHUS AND CANCER.

CHAPTER XI.
SECTIONI.
OF THE SCIRRHUS AND CANCER.
e
n
ION
CCCXXXVI. A Scirrhus is a circumscribed induration,
usually attended with tumour, and most commonly situated in a
glandular part: it is generally moveable, without redness, and
possessed of a very low degree of sensibility.
CCCXXXVII. It is not certain, that any of the soft parts
of the body are wholly exernpted from this disease ; but
chiefly occurs in the conglomerated glands and those surfaces
that are covered with a secreting membrane.
CCCXXXVIII. The remote causes of scirrhus have been
rendered very numerous by different writers upon the subject :
we intend to take notice of those only that are more generally
insisted upon.
1. The inflammation of a glandular part.
2. The repulsion or the coagulation of milk in the breast.
3. Contusion.
4. Pressure.—Attrition.
5. Obstructed or suppressed menstruation.
6. Depressing passions of the mind; as fear, grief, melan-
choly, &c.
7. An hereditary contamination.
CCCXXXIX. It has often been doubted, whether an in-
flammation ought ever to be regarded as the remote cause of
a scirrhus; and indeed the propriety of admitting it cannot
easily be demonstrated. Ancient and modern writers of great
authority have asserted, that an inflammation of the liver fre-
quently terminates in scirrhus; and it has been supposed, that
a similar cause has often been productive of a scirrhus in the
uterus. The nature of this work, however, does not admit
of a full discussion of the propriety or impropriety with which
the remote causes are assigned; it will therefore be sufficient
to observe in the general, that an inflammation seated in an
external part, is probably never a proper cause of scirrhus.
CCCXL. The share which other remote causes have in
producing a scirrhus, cannot always be clearly ascertained,

OF THE SCIRRHUS AND CANCER.
89
since it is certain that this disease will often appear without the
evident operation of any cause whatever.
CCCXLI. Many facts have occurred, which render it pro-
bable, that scirrhus and cancer are hereditary diseases.
CCCXLII. Scirrhous tumours of the breast very frequently
occur in women that lead a sedentary life; in cases of ob-
structed menstruation ; and about the period when the cata-
menia cease to appear. It hath also been observed, that the
uterus is frequently attacked with this disease, in those women
that have been accustomed to menstruate in a large quantity,
when that evacuation ceases to flow.
CCCXLIII. Scirrhous affections of one kind or other have
been found in the brain, eye, æsophagus, parotid gland, neck,
tongue, lip, breast, stomach, colon, rectum, liver, pancreas,
kidney, bladder, uterus, penis, testes, &c.
The symptoms and effects of this disease when situated in
these different parts of the body will vary considerably; and
can only be well understood by studying the history of eacli
particular complaint. se
CCCXLIV. It may be offered as a general observation,
that the presence of a scirrhus in any part of the body, will be
accompanied with all the ill consequences that can result from
a derangement of its particular organization; from an interrup-
tion to the due performance of its peculiar functions; and from
an undue compression made upon the neighbouring parts.
CCCXLV. When a scirrhous tumour is removed from the
body and subjected to examination, it exhibits an almost uni-
form appearance; for all the constituent parts seem to be so in-
timately blended together into one mass, that no distinct ves-
sels, cells, &c. can be traced : sometimes, a small quantity of
a yellowish, or dark-coloured fluid, is found near the centre of
the tumour; on other occasions, this fluid is met with nearer
the circumference. By long boiling, a quantity of a coagula-
ble fluid is obtained, which appears to have been contained in
cells that now become rather visible; there are few, or no tra-
ces of blood-vessels to be seen, nor is there any distinct re-
semblance of the primitive structure of the part. The sub-
stance that remains after boiling is hard and elastic, and not
very unlike a portion of fish, boiled till it becomes firm.
CCCXLVI. Pathologists of great eminence have described
a scirrhous tumour, as consisting of a hard centre with radiated
340 12
90
OF THE SCIRRHUS AND CANCER.

lines, like ligamentous bands, proceeding in every direction.*
This appearance is not, I believe, peculiar to scirrhus, since I
have seen similar alterations in diseased portions of the breast
and testicle, where appearances of a scrofulous affection existed
likewise.
CCCXLVII. Scirrhous tumours ought to be distinguished
from inflammation and suppuration of the breast: from tumours
occasioned by rnilk, struma, hernia humoralis, chronic inflam-
mation of the testicle—tumours containing hydatids, and those
which consist chiefly of vesicles-encysted tumours, &c.
Those tumours which contain phosphate of lime, or any such
saline concretions as are usually found in the animal body,
ought not to be regarded as scirrhi.
CCCXLVIII. The Prognosis of Scirrhus. All scirrhi have
a tendency to terminate in cancer. Some tumours however,
apparently of this class, have happily been discussed ; and more
CCCXLIX. The hardness that sometimes remains after the
termination of an inflammation, and the callosities that surround
the edges of ill-conditioned ulcers, fistulæ, &c. differ materially
from a true scirrhous affection.
The progress of a scirrhus in the breast.
- CCCL. The tumour that has remained, for some space of
time, hard, insensible, and almost stationary, gradually increases
in magnitude and sensibility, a gentle pruritus is first per-
ceived, which gradually changes to an obtuse throbbing sensa-
tion; and the uneasiness continues to increase, until it rises to
an acute, lacinating pain. The diseased part loses its mobil-
ity, and becomes irregular in its figure ; the skin is in folds, or
puckered, at some particular part, and contracts an adhesion to
the subjacent tumour; not uncommonly, little, hard, red tuber-
cles appear on different parts of the breast; the cutaneous
veins enlarge, and often become varicose; the glands under
the axilla, and about the clavicle enlarge, and become hard and
tender; and in one or more parts the skin acquires a flaves-
cent, purple, or livid hue : beneath these discoloured spots an
acrid and malignant fluid is contained, that will speedily erode
the integuments and produce ulceration. The general health
of the system is, at this period, more or less affected. When
the disease has arrived at this state, it assumes the name of
Cancer.
* Baillie's Morbid Anatomy. Home on Cancer.
OF THE SCIRRHUS AND CANCER.
91
SECTION II.
CCCLI. A Cancerous ulcer is irregular in its figure, and
commonly presents an unequal surface : it is usually attended
with a sense of ardent pain, which is subject to remissions and
exacerbations : it discharges a sordid, sanious, and often fetid
matter : the edges of the sore are thick, indurated, and ex-
tremely painful : they often exhibit a serrated appearance, and
are sometimes retorted, at other times inverted. The ulcer
sometimes spreads with great violence to a very considerable
extent, and in the course of its progress produces frequent
hæmorrhages, in consequence of the erosion of blood-vessels.
There is commonly considerable pain in the arm of the side
affected; it becomes highly edematous, and sometimes an ab-
scess, accompanied with erysipelatous appearances, takes place
in the vicinity of the shoulder, or at the angle formed by the
arm, and the scapula. The ulcer formed by the rupture of
the abscess is not cancerous.
CCCCLII. The cancerous ulcer often remains small in its
dimensions, and penetrates to no considerable depth; it is sur-
rounded by skin contracted into folds, nor is it always accom-
panied with acute pain. At other times, a fungus of a cauli-
flower-like appearance germinates from the bottom of the ulcer,
and several sores of this description will occupy the breast at
the same time.
CCCLIII. The manner and comparative rapidity with
which cancerous ulcers proceed, admits of considerable variety;
in some cases, the breast is destroyed, and life is terminated, in
the space of a few months. It sometimes happens that a spha-
celus supervenes, and the whole diseased part falls off, leaving
a smooth and apparently healthy surface; but the sore is always
cancerous. And I have known cancers, attended with moder-
ate hæmorrhage, to proceed slowly, without exciting any pain
or uneasiness, and gradually wear out the patient by the hec-
tical symptoms that supervened. There are also many cases
upon record, where cancers lrave remained in a dormant state
during many years, attended with little uneasiness, and produc-
tive of no derangement in the general health of the system.
CCCLIV. It has been thought advantageous in treating
onthis disease, to arrange cancers under different species ;

VE
92
OF THE SCIRRHUS AND CANCER.
but whatever be the reason, it does not appear that any division
which has yet been proposed, has met with universal appro-
bation; nor, indeed, is it to be expected that a satisfactory
arrangement can be formed, until we are better acquainted with
the natural history of the disease.
CCCLV. As a specimen of the divisions that have been
proposed, I shall exhibit the following :
It hath been divided into,
1. The occult cancer.
2. The ulcerated cancer.
But whether by the former of these, we are to understand a

e
a
concealed by the integuments, is a point not yet fully agreed
upon.*
If a part be suddenly attacked with the symptoms of cancer,
it has been denominated
A primitive cancer.
When a scirrhous tumour has terminated in this disease,
it has been called
A secondary cancer.
They have also been divided into,
1. Cancers originating from an external cause.
2. Cancers originating from an internal cause.
When the disease appeared to be unconnected with any evi-
dent constitutional affection, it hath been called
A simple cancer.
If the person were previously affected with lues venerea,
scurvy, &c. it was called
A complicated cancer.
The situation, the figure, or the remote causes have also
been severally adopted by various systematic writers to char-
acterize what have been termed different species of this dis-
ease.
CCCLVI. I shall not offer any observations upon the merit
or demerit of the several divisions enumerated above; but if
the term scirrhus be employed until the disease assumes the
appearances described at No. 350, and if afterwards we apply
the term cancer, perhaps our distinctions will be sufficiently ac-
curate for every practical purpose.
* See the Works of Hildanus, Peccetti, Wiseman, Van Swieten, Pouteau,
Le Cat, &c. and the Prix Memoires, de l'Academie Royale de Chirurgie,
&c. &c.

OF THE SCIRRHUS AND CANCER.
93
CCCLVII. The breast is sometimes attacked so suddenly
with scirrhus, that an acute pang in the part shall give the first
notice of the presence of a small, hard tumour. A retraction
of the nipple, an adhesion of the gland to the subjacent parts,
and a contraction of the skin into little folds, frequently pre-
cede or accompany the appearance of this disease. Some-
times there will be an occasional evacuation of a bloody serum
from the nipple, during several months, before any other com-
plaint appears; but in these cases the subsequent disease is
usually very rapid in its progress.
CCCLVIII. A cyst containing a dark-coloured liquor is
very often met with in some part of the substance of a malig-
nant scirrhus (No. 350). This fluid hath been found to be
so extremely acrid, that a very transient application of it to a
part covered with cuticle, left perpetual darting pains for seve-
ral hours after it was washed off. When applied to a surface
devoid of cuticular covering, it has produced ulcers that exhib-
ited the common appearances of cancerous sores. An insup-
portable and fatal nausea has been the consequence of impru-
dently tasting it; and even the fetid effluvia arising from a can-
cerous ulcer will sometimes produce very disagreeable effects
upon the attendants.
CCCLIV. It has been observed, that in certain cases where
suppurating plasters or cataplasms had been used, an impost-
hume, containing a very large quantity of a bloody serum, was
found in that part of the breast which had been previously oc-
cupied by a scirrhus tumour; and in all these instances the dis-
ease terminated fatally. Monro.
CCCLV. The imposthumated cancer, (if the term may be
allowed) appears also under other circumstances. After the
very free use of leeches, where the strength was considerably
reduced by the loss of blood, I have found a large quantity of
fluid, apparently contained in different cysts, within the breast.
By frequent discharges of a bloody fluid from the nipple, during
many weeks, the enlargement was entirely reduced, and the
patient finally recovered. In every instance that has fallen
under my observation, where the contained fluid was evacuated
by an artificial opening, the patient died in a very short space
of time.
CCCLVI. The breast sometimes exhibits the several char-
acters of the imposthumated cancer, where there is no fluid
effused. This form of the disease is always attended with ex-
94
OF THE SCIRRHUS AND CANCER.

cruciating pain, and the general health is greatly disordered.
An opening made into the breast, under these circumstances,
greatly aggravates the sufferings of the patient, and accelerates
the fatal termination of the disease.
CCCLXII. When a cancer attacks the surface of the skin,
it very frequently makes its first appearance in the form of a
wart, or small excrescence; very often it will give little dis-
turbance until it be irritated by improper treatment; and un-
der these circumstances, it will very quickly change its aspect,
and assume all the appearances of a cancerous sore. These
appearances most frequently take place upon some part of the
face, upon the skin that covers the tibia, or upon the parts of
generation.
CCCLXIII. The lupus, or noli me tangere, commonly ap-
pears first under the form of a small scaly tubercle, of a light
brown colour; and at an early period, it is not surrounded by
any redness. When this tubercle bursts, the ulcer spreads
gradually, sometimes in a circular direction, but more common-
ly the figure is irregular, and the surface unequal. When it
attacks a part abounding with sebaceous glands, as the face,
nose, upper lip, &c. the ulcer often exhibits an elevated sub-
stance in its centre, resembling fungus, but of a firmer texture,
and less disposed to bleed. The spreading of this ulcer is usu-
ally attended with a thickening and comparative induration of
the surrounding parts; but the edges do not acquire that thick-
ness which is so frequently seen in cancer, nor is the sore com-
monly accompanied with much pain. When it is situated on
the leg or foot, there is often considerable sloughing of the sur-
face of the ulcer : it penetrates more deeply and extensively,
and greatly resembles the noma, or ulcus depascens. The lu-
pus frequently removes large portions of the substance of the
part which it attacks, and leaves considerable deformity.
CCCLXIV. When the lip, alæ nasi, or the eye-lids, are
affected with a cancer, the disease most commonly contami-
nates the whole substance of the part in which it is seated;
and it is not unusual to meet with diseased absorbent glands,
and carious bone, in the vicinity of carcinomatous ulcers.
CCCLXV. If a part of the body that is naturally covered
with a secreting membrane, as the inside of the nose, mouth,
stomach, &c. becomes the subject of a cancerous affection,
the disease often appears in the form of polypous excrescen-
ces, or of fungi, possessing different characters. And, indeed,


OF THE SCIRRHUS AND CANCER.
fungi very commonly vegetate in cancerous ulcers, wherever
they are situated. The fungus and polypus like substances,
that are occasionally seen in the uterus, intestines, bladder of
urine, &c. do not always exhibit an appearance sufficiently
uniforın to render their real nature capable of accurate discrim-
ination.
CCCLXVI. A cancer of the uterus is generally preceded
by leucorrhæa, and sometimes by repeated hæmorrhages from
that organ. The patient complains of pain in the bones of the
pelvis, especially about the os sacrum ; and also about the
groins, and the hypogastric, and umbilical regions. When
the uterus adheres to the posterior part of the vagina, the pa-
tient often complains of a weight and painful sense of hardness
in the perinæum. The natural functions of the stomach and
intestinal canal are more or less deranged ; and very common-
ly, a state of the system somewhat resembling hectic fever is
present. The patient will often complain of an unnatural sense
of heat about the uterus ; and at certain times, she will have
pains accompanied with involuntary expulsive efforts, as if the
uterus were descending through the vagina. This disease is
often accompanied with a frequent and painful excitation to
void the urine ; but when the uterus descends lower down in
the pelvis, this symptom is frequently alleviated. The disa
ease may be seated either in the cervix or in the corpus uteri.
As the uterus enlarges, it gradually loses its natural mobility,
and becomes hard, inelastic, and more rotund, especially
about the os uteri. As these morbid alterations proceed, the
pungent sense of heat and pain increase in proportion ; and
these are attended with a considerable discharge of a flaves-
cent or cineritious coloured matter, offensive to the smell, and
very acrimonious : yet in many cases, there is no particular
discharge from the uterus, until a very advanced period of the
disease. The matter is frequently mixed with blood, especial-
ly when there is a fungus, or an ulceration of the uterus.
Sometimes the patient is attacked with considerable hæmor-
rhages from the uterus, at uncertain intervals, which usually
confer a temporary relieſ. On examining the state of the part
affected, it excites such sensations as might be expected from
an ulcer possessing the characters described at No. 351. In
this dreadful disease, the bladder and rectum are sometimes
eroded, so that their contents are evacuated through the va-
gina.
96
OF THE SCIRRHUS AND CANCER.
CCCLXVII. The vagina frequently partakes of the cancer-
ous affection at the same time. This may be known, by the
induration and contraction of this part, and fissures may be like-
wise observed on examination. In cancers of the uterus, we
sometimes meet with a discharge of a clear aqueous fluid, from
the first appearance of the disease to its fatal termination. ee
CCCLXVIII. Cancer of the uterus is occasionally accom-
panied with edema of the prolabia, which sometimes extends
to one or both of the lower extremities; at other times the
patient will be subject to erysipelatous appearances about the
groin and upper part of the thigh.
CCCLXIX. The cancer of the scrotum, to which chim-
ney-sweepers are peculiarly liable, was first described by
Mr. Pott, to whose valuable writings I would refer the reader,
not only for an account of this complaint, but also for the sake
of many important observations on cancerous diseases, which
are interspersed in different parts of his works.
CCCLXX. A cancerous affection of the penis may first
appear on the internal surface of the prætutium, or on the glans
penis. It is more commonly seen in the form of excrescences
arising from one or both of these parts; although it is some-
times met with in the form of an ulcer, on the internal surface
of the prepuce, or on some part of the glans penis. I have
known the cancerous ulcer of the penis several times mistaken
for a venereal chancre. !
CCCLXXI. Some surgeons of high reputation suppose,
that it usually originates from the under surface of the prepuce,
and that it is commonly connected with a natural phymosis.*
My own experience has not induced me to make a similar ob-
servation. I have seen so inany cases of painful verrucose
like excrescences, connected with a phymosis, which were
neither cancerous nor venereal, that I still entertain some
doubts on this particular part of the subject.
CCCLXXII. Where the cancer of the penis pursues its
natural course, the glands of the groin, and the skin of the
scrotum become extensively diseased, and sometimes the in-
teguments of the regio pubis.
CCCLXXIII. The cancer ought to be distinguished from
1. Venereal affections of the organs of generation.
2. From venereal ulcerations of the lips, alæ nasi, tongue,
&c.
* See Hey's Practical Observations; and Home on Cancer,




OF THE SCIRRHUS AND CANCER.
97
3. From ulcerations of the tongue in consequence of the use
of mercury ;—from enlargement of the papillæ, and excres-
cences of a doubtful nature about the root of that organ.
4. From ulcerations about the gums, inside of the cheeks,
fauces, &c. from various causes.
5. From a peculiar affection of the uterus, in consequence
of lues venerea:*
6. And from phagedenic ulcers in any part of the body.
CCCLXXIV. The prognosis of cancer. The natural ten-
dency of a cancer, is to terminate in the certain destruction of
those patients who are unhappily afflicted with it. The pow-
ers of the constitution can exert but a feeble and unavailing
resistance against its ravages; nor are we at present in posses-
sion of any remedy, external or internal, that merits the name
of an antidote against the dreadful effects of this fatal disease.
SECTION III.
OF THE LOCALITY OF A CANCER; AND WHETHER THE PRES-
ENCE OF THIS DISEASE IN ANY PARTICULAR PART, IMPLIES
* A CONTAMINATION OF THE GENERAL SYSTEM.
CCCLXXV. By a local disease may be understood, a
morbid alteration in a particular part of the body, the existence
of which is not necessarily connected with a similar morbid al-
teration, nor a certain tendency to such a state, in the general
constitution : e. gr. simple ulcer, encysted tumour.
CCCLXXVI. By a general or universal disease may be
understood, that state of the system in which a similar morbid
condition occupies the whole or the greater part of the living
body ; or where there is a certain and invariable tendency to
such a state : e. g. small pox, lues venerea, &c.
CCCLXXVII. It is probable, that the cancer cannot with
strict propriety be included within either of these divisions; for
as on the one side, we cannot prove that the cancerous
virus is susceptible of an indefinite multiplication, and a con-
sequent power of contaminating every part of the system; so
on the other side, there frequently appears so evident a dispo-
e
* See Practical Observations on Cancerous Complaints, by John Pear-
son, &c.
13

98
OF THE SCIRRHUS AND CANCER.
sition to the production of cancer in different parts of the body
about the same period, that we are scarcely warranted to haz-
ard a contrary decision. *
CCCLXXVIII. But whatever difficulties may arise when
our speculations are highly refined, and our expressions be-
come indeterminate ; they may be partly eluded, by attending
to the practical question, which may be stated in the following
manner :
In the treatment of a cancer, are we to consider the disease
as strictly confined to that part of the body which is the imme-
diate object of our attention ? And are we not taught by ex-
perience, that the disease is of so insidious a nature, as to
preclude the possibility of always assigning its precise limits
with certainty ?
CCCLXXIX. This question does not admit of a simple
and direct resolution in the affirmative, nor in the negative ; it
demands an attention to several collateral circumstances, before
the answer can be applied to a practical purpose in the prog-
nosis, &c. of the disease ; as
1. The general state of the patient's health.
2. The remote cause, and duration of the disease.
3. Its situation, magnitude, connexions, malignity, &c.
CCCLXXX. If we consult the records of medicine, it will
appear, that many cancers have been extirpated, and after the
expiration of several years there has been no appearance of
the disease, neither in the vicinity of the cicatrix, nor in any
other part of the body. But it is equally true, that in a great
number of cases where the patient has lived many years after
the operation, the disease has re-appeared in some part of the
body; it is therefore extremely difficult to determine the suc-
cess that will attend the extirpation of a cancer; for even a
knowledge of the remote cause, will not afford us much assist-
anice in our attempts to estimate the degrees of probability, for,
or against, a relapse. Nor are we authorized to promise suc-
cess from the earliest removal of the scirrhus, since we cannot
be certain, that the tumour we extirpate is the only part which
has undergone a morbid alteration.
* I have often seen cancer of the breast and of the uterus occur at the
same time; also cancer in each breast; and cancer of the breast with can.
cerous affection of the skin in the epigastric region. Sometimes an appa-
rently cancerous affection of the uterus will disappear, and after the lapse
of a considerable time, the breast will become cancerous.

OF THE SCIRRHUS AND CANCER.
99
CCCLXXXI. As the extirpation of a cancerous part, at
any period, does not confer an absolute security upon the sub-
ject of the operation, the reason of this uncertainty hath been
anxiously sought after, but I fear with more diligence than
success. Some práctitioners have conjectured that a certain
fluid, capable of communicating a cancerous affection, was al-
ways floating in the blood-vessels of those that laboured under
the disease, and that it was from time to time deposited in
parts of a glandular structure. The existence of such a lea-
ven, or ferment, hath been confidently denied by the ingenious
Monsieur Le Cat, M. Pouteau, and others; and they have
maintained, that the disease is propagated from a cancerous
sore, &c. to distant parts of the body, by an irritation sui ge-
neris, which is excited by the cancerous matter acting as a
peculiar stimulus.* As there is little probability in the former
of these opinions, and the latter is scarcely intelligible, we shall
not take any further notice of them at present. Vide Gaubius.
Instit: Pathol : Medicinalis. De Potentiis, quæ virus ha-
bent, $ 500.
CCCLXXXII. It is probable, that the cancer, at some
period not easily ascertained, acquires the power of contamin-
ating the circumjacent parts to a distance considerably beyond
the points of contact. But we possess no unquestionable proofs,
that the cancerous matter, when applied to a sound person, is
capable of acting as a contagion, so as to produce a disease
similar to that by which it was formed. Cancerous matter,
applied to an abraded surface, or to one destitute of the com-
mon cuticle, will sometimes produce an ill-conditioned and un-
tractable sore, but not a sore truly cancerous.
CCCLXXXIII. In cancerous affections of the breast, the
absorbent glands in the axilla are very frequently contaminated
with the disease ; and professor Camper discovered some ab-
sorbent vessels, passing from the breast into glands situated
under the sternum, which exhibited the same diseased appear-
ances with those seated in the axilla. Now, as the absorbent
glands that lie on each side of the under part of the sternum,
* Monsieur Pouteau is so extremely attached to explanations founded
upon the stimulating powers of contagious matter, to excite a peculiar ir-
ritation, similar to that which produced the poison, that he applies the
same mode of reasoning to small pox, lues venerea, &c. and strenuously
contends that the progress of these diseases is only from local to general
irritation.-Voyez, Les Eudres Posthumes.

100
OF THE SCIRRHUS AND CANCER.
communicate with each other by means of absorbent vessels,
it will be easy to understand in what manner the disease may
be propagated from one breast to the other.* As a cancer
may therefore be reproduced in a part apparently cured; or
propagated to a distant part, by means of diseased absorbent
vessels; and as these are exceedingly numerous, and often ex-
tensively affected, we may be assisted by considerations form-
ed upon the preceding narration, to form an opinion, in what
sense a cancer may be regarded as a local or constitutional
disease.
**
SECTION IV.
DESIDERATA.
CCCLXXXIV. To know distinctly the characters of that
scirrhous tumor, which will remain in a mild quiescent state,
unless it be exasperated by improper treatment.t.
CCCLXXXV. To be able to ascertain the precise period,
when a scirrhus assumes a malignant and cancerous nature.
CCCLXXXVI. To be able to decide upon the cases in
which the extirpation of the morbid part will be attended with
success; and also to know whether in other cases there be
any criteria, and what they are, by which we may be certain
that the operation periormed at any period of the disease will
be improper and hurtful.
CCCLXXXVII. Is the scirrhus, or the cancer, in any sense
susceptible of metastasis ?
SECTION 1
OF THE TREATMENT OF SCIRRHUS AND CANCER.
CCCLXXXVIII. It hath already been delivered as a de-
cided opinion, that there is no remedy yet made public, which
* Each of the breasts may be attacked with cancer, in quick succession;
but it is not meant to be asserted, that the disease is always propagated by
the absorbents below the sternum.
† Peccetti and Wiseman have said, that if hair grows upon the skin
covering a scirrhous tumour, the disease will not terminate in cancer.
This remark, however, I am sorry to say, is not correct.
and
The Property of
The Medical Society
City & County of Denver
City & Co

OF THE SCIRRHUS AND CANCER.
101
fects Asson
justly merits the naine of an antidote against the dreadful effects
of the cancerous virus. If this opinion be true, it is of great
importance to caution our patients against placing there confi-
dence in impotent or noxious medicines, at a time when the
diseased part is so situated, that it can be safely and perhaps
completely removed. The delusions of hope may be sweet under
such afflictive circumstances; but if they lead to experiment,
or delay, they add malignity to the poison, and give swiftness
and certainty to the fatal termination of the disease.
- CCCLXXXIX. When a scirrhus, or cancer, is situated in-
ternally, medical asistance alone can be employed. Sometimes
it seems to be employed with advantage, by diminishing the dis-
ease, or retarding its progress; but at all times remedies may
be exhibited, that will alleviate the tortures of pain, and thus
render the approaches of death less insupportable. But we
would protest against the man, who, by trusting to or trifling
with any remedies, in an external scirrhus, where all appear-
ances favour the expectation of permanent advantage from the
removal of it, makes his patient lose an opportunity that can
never be recalled.
CCCXC. Indication the first :
To preserve a benign scirrhus from assuming a malignant
form, by
1. Low and vegetable diet:
2. Saline purgatives, at due intervals :
3. The application of leeches, under proper regulations :
4. Avoiding all violent emotions of the mind :
5. Supporting, or defending, the part from injury and irrita-
tion, by means properly adapted to the situation of the disease.
6. Solutions of lead, combined with alcohol, have been found
beneficial in alleviating pain.
7. Great attention must be paid to the supporting of an uni-
form and agreeable temperature in the part.
All applications which tend to increase sensibility and action
in a scirrhous tumour, are to be carefully avoided.
CCCXCI. The term scirrhus, is frequently applied to cer-
tain diseases of the liver, mesentery, ovaria, &c. and in these
cases, it is not always to be taken in the strict sense to which it
is confined in the present chapter. It is also proper to be ob-
served, that in these cases, the use of internal remedies is often
followed by the happiest effects. The remedies which I have
administered with the greatest advantage, in these morbid affec-

102
OF THE SCIRRHUS AND CANCER.
tions, have consisted of mercury, in a simple or a combined
state, joined with digitalis, nicotiana, cicuta, mercurial frictions,
&c. vegetable and fossile alkali, moderate friction, gentle and
frequent gestation, electricity. When there is much pain, a
plaster, composed of the warm gums with a large quantity of
opium, applied to the abdomen, will frequently give a tempo-
rary relief.
CCCXCII. When the æsophagus, intestinum rectum, or
parts of a similar structure become scirrhous, mechanical means
seem to be best adapted to the relief of the disease; but the
expediency and advantage of employing them in every case, is
not yet sufficiently ascertained. It scarcely need to be observ-
ed, that if the diameter of a canal be diminished, in conse-
quence of compression from an enlarged neighbouring gland,
mechanical means will in general do more harm than good. It
is not improbable, that in some cases of obstructed deglutition,
where the introduction of mercury into the system removed
the disease, the complaint had originated from the compression
of a gland, &c.
CCCXCIII. When we enter upon the mode of treating can-
cer, there are three indications which naturally present them-
selves :
1. To remove, if possible, the external disease.
2. To prevent a relapse, or reproduction of the complaint.
3. If it be not thought advisable to attempt a removal of the
disease by an operation, to palliate the symptoms, and endeav-
our to retard their progress. We shall treat each of these heads
in its order.
CCCXCIV. As we are not possessed of any medicines that
will certainly cure a legitimate cancer, the only resource of
art will, consequently, be to remove the diseased part by a
chirurgical operation. There are two ways in which this end
may be obtained :
i. By the application of a caustic.
2. By the use of a cutting instrument.
CCCXCV. If a caustic be preferred for the removal of a
cancer, it ought to possess the power of suddenly destroying
the whole diseased part; otherwise the malady will be exas-
perated, and perhaps the use of other means will be rendered
less effectual. The difficulty of removing a breast by such an
application must be obvious; and where this is accomplished,
the method does not appear to possess any peculiar efficacy.

OF THE SCIRRHUS AND CANCER.
103
When the whole breast sphacelates and falls off from the body,
although the granulating surface, for a time, will look firm and
healthy, yet the disease has never failed to renew its ravages.
If it were necessary to reason against this mode of practice,
we should urge the severe pain that is produced ; the necessi-
ty there is of frequently repeating the application; the uncer-
tainty of its removing the whole disease, and that where the
whole disease has been apparently removed by the caustic, it is
no less liable to recur, than when the part has been extirpated
by the knife, &c.
CCCXCVI. In a cancer of the lip, or when the disease oc-
cupies but a small extent of depth and surface in any conveni-
ent part, the application of a caustic is not liable to the same
objections ; but it ought always to be so applied, as to produce
the sudden and complete destruction of the morbid part.*
CCCXCVII. The ulcers that are often termed cancerous,
but which are more properly classed under the heads of lupus,
noli me tangere, &c. (No. 363), may frequently be cured, by
the application of arsenic, corrosive sublimate, and even by
some of the milder mercurial ointments, &c.-Cancerous fungi
have been often successfully destroyed by the actual cautery.
CCCXCVIII. The excision of a cancerous part with the
knife, hath so many advantages over the use of a caustic, that
this mode is generally preferred by the best surgeons. The
general rules to be observed in the extirpation of this disease
are these, viz.
1. To remove the whole affected part, with every gland
or fibre in its vicinity, that exhibits the least mark of disease :
e. g. When the breast is extirpated, the glands in the axilla
are to be examined: if the penis be amputated, the state of the
inguinal glands, or those situated on the pubes, must be ascer-
tained, &c.
2. To save as much of the sound skin as possible, that the
surface of the sore may be rendered small, and its healing be
expedited.
• CCCXCIX. In the extirpation of a scirrhus, where the skin
is not diseased, the operation may frequently be performed by
means of a simple incision long enough to permit the tumour
** It may be worthy of observation, that the quality of the caustic we
employ, is by no means an indifferent circumstance. The acid and arsen.
ical caustics, and, on particular occasions, even the actual cautery, will be
found most proper in cancerous diseases.

104
OF THE SCIRRHUS AND CANCER,
to be dissected out: as soon as this is effected, if the lips of
the wound are kept in contact by the means of sutures, or ad-
hesive plaster, the patient will be perfectly well in a few days.
As the suppuration of the wound does not at all contribute to
the security of the patient, it is proper to heal the wound by
the first intention, wherever this is possible. See Garengeot,
Traite des Operations de Chirurgie, Ed. seconde, tome second.
chap. vii. p. 390, & Suiv. .
CCCC. If the situation and circumstances of the disease be
such that it cannot be completely extirpated, it will be by no
means advisable to propose an operation. Or if from the pres-
ence of a cough, attended with difficult respiration, an expec-
toration of matter, and hectic fever, there be reason to appre-
hend that the lungs are in a diseased state, no particular advan-
tage is to be expected from the excision of the breast. But
the mere attachment of the breast to the subjacent parts can
never constitute a valid objection against its extirpation, provi-
ded that the surface of attachment can be wholly removed.
CCCCI. When the lip is the subject of a cancerous affection,
the inucous membrane is generally discoloured to some little
distance beyond the circumference of the hardness, with a
tinge of deeper red than natural. Monsieur Le Dran has al-
ways observed, that this is a sure indication of the presence of
disease, and therefore advises, that the incision be made in the
sound part, beyond this discoloured surface, lest the operation
shall prove unsuccessful. After the extirpation of the cancer
ous part, the sides of the wound are to be brought into contact,
and the same mode of treatment is to be followed, as after the
operation for the hare-lip.
CCCCII. In aged persons, and where the cancer has been
of long continuance, the submaxillary glands are commonly in
a diseased state, or soon become evidently cancerous after
the extirpation of the morbid part of the lip.
CCCCIII. Portions of the tongue, in a cancerous state,
may be safely extirpated by the application of a double liga-
ture.--Home on Cancer.
CCCCIV. Indication the second:
The means that are to be employed in order to prevent a
return of the disease, are of very doubtful efficacy; but as
several eminent surgeons have thought it proper to attempt
something of this kind, it is necessary to hint, that among other
means they have recommended,
OF THE OZÆNA.
105

1. The insertion of issues, at a convenient distance from the
cicatrix.
2. An abstemious course of diet.
3. Proper evacuations at due intervals.
4. Sea bathing.
CCCCV. Indication the third :
The use of internal or external remedies, as palliatives in
this dreadful disease. Among these, we shall first enume-
rate some which have been supposed to possess powers capa-
ble of correcting the cancerous virus—as mercury; cicuta; bel-
ladona; arsenic; a solution of iron in a mineral acid; a
course of diet consisting of water only ; decoctions of sarsa-
parilla, Peruvian bark, &c.—Pain is to be moderated by the
use of opium.
CCCCVI. The exhibition of mercury will commonly ex-
asperate the disease, and it is certainly no antidote. I have
administered arsenic in considerable doses, for a very suffi-
cient length of time to ascertain its powers; and although no
disagreeable effects attended its use, I never saw it exhibited
with the least advantage.
CCCCVII. Among the external applications that have been
recommended we shall mention,
1. Preparations of lead.
2. Arsenic.
3. Solutions of iron.-Solutions of mercury.
4. Carrot poultice. The fermenting cataplasm.-Cicuta.
5. Peruvian balsam.
6. Oily mucilages, or pure oil.
7. Carbonic acid gas.-Carbonate of lime.-Rust of iron.
8. The electric aura.


CHAPTER XII.
SECTION 1.
OF THE OZÆNA.
CCCCVIII. THE Ozæna is an ulcer that is situated within
the cayity of the nose, discharging a fetid, purulent.matter, and
is sometimes accompanied with carious bone.
14
106
OF THE OZÆNA.
CCCCIX. The term ozæna is used by some writers to ex-
press a carious ulcer within the nose : it has been defined by
others, “ as a sordid carious ulcer within the maxillary sinus"
but as the word was used by the Greeks, before the nature of
the abscess within the Antrum Highmorianum was understood,
we shall confine the name, nearly, to its original signification.
CCCCX. At the first appearance of this disease, it is some-
times attended with many of the common symptoms of a ca-
tarrh ; there will be a trifling turnefaction and redness about
the ala nasi, accompanied with a discharge of mucus, partly in
a fluid and partly in an inspissated state; the air is transmit-
ted through the affected nostril with difficulty, especially during
sleep, and the orifice is often quite obstructed in the morning
by a viscid mucus.
- CCCCXI. As the disease advances, the matter that is


the greatest quantity in the morning; the discharge is some-
times accompanied with sneezing, and a slight hæmorrhage oc-
appears externally, and then gradually spreads like a herpetic
ulcer round the angle of the ala nasi upon the cheek; but it
very rarely destroys the ala nasi, or extends to any considerable
distance from the nose.
CCCCXII. This disease is very often connected with
scrofula, and with venereal complaints ; and in the latter case,
more frequently than in the former, some portions of the ossa
spongiosa generally come away in a carious state. Many vene-
real patients whose complaints have been treated very proper-
ly, will, nevertheless, sometimes complain of a discharge of
fetid matter from the nostrils, and troublesome incrustations
within their cavity, for a considerable length of time after the
perfect cure of their orignal disease.
These symptoms generally indicate the presence of carious
bone; and when that is exfoliated, the complaints will disap-
pear. In a few cases, where the quantity of carious bone was
very considerable, I have seen the whole ala nasi totally de-
stroyed.
CCCCXIII. When fungous or polypus-like excrescences
are connected with the ozæna, the disease commonly originates
from scrofula.
CCCCXIV. The ozæna frequently occurs as a symptom
of the cachexia syphiloidea. It will perforate the septum nasi,

OF THE OZEN Α.
107
destroy the ossa spongiosa, and sometimes render the ossa nasi
completely carious. The depression of the nose, from the
loss of the ossa nasi, is more frequently the effect of the
cachexia syphiloidea, in the present day, than of lues venerea.
CCCCXV. When purulent matter is formed within the
frontal, sphenoidal, or maxillary sinus, the symptoms will fre-
quently bear a near resemblance to those which occur in the
ozæna ; and indeed, the precise seat of the disease cannot al-
ways be distinctly ascertained at an early period of the com-
plaint. It is however necessary to be very careful, that we do
not mistake an abscess within the antrum highmorianum for
an ozæna..
CCCCXVI. As ulcers in those parts that are employed
in the function of respiration, frequently contaminate the breath
with an offensive odour; when we atternpt to ascertain the
cause of this inconvenience, it will be proper to examine the
state of the nasal cavity, as well as the condition of the mouth
and fauces.
CCCCXVII. The ozæna is generally connected with
some disease of the whole system.

SECTION II.

OF THE TREATMENT OF THE OZÆNA.
CCCCXVIII. Before we undertake the cure of an ozæna,
it will be absolutely necessary to inquire into the remote cause
of the disease; for if its presence depends upon the action of a
poison in the constitution, no plan of chirurgical treatment can
be of any utility until the virus be corrected.
CCCCXIX. The remedies to be employed internally, are
1. Preparations of mercury-preparations of antimony.
2. Sarsaparilla—elm bark-Peruvian bark-muriated bary
tes--muriate of lime.
3. Sea bathing, by improving the general state of the health,
is an useful remedy in the ozæna.
CCCCXX. The applications that will commonly succeed
when used externally, are
1. Preparations of copper-zinc-arsenic-mercury--pul-

108
OF THE CANKER OF THE MOUTH.
vis sternutatorius--mercurial fumigations-diluted vitriolic
acid, &c.
The older surgeons advise the use of the actual cautery;
but I never saw its application necessary.
CHAPTER XIII.
I
SECTION I.
OF THE CANKER OF THE MOUTH,
SYNONIMA.
Apthae Serpentes. Sennertus.
Labrosulcium, seu Cheilocace. Arnoldus Bootius.
Oris Cancrum. Muys. Stal part vander Wiel.
Gangræna Oris. Van Swieten.
Gangrene Scorbutique des Gencives. Auctores Gallici.

CCCCXXI. THE canker of the mouth is a deep, foul, ir-
regular, fetid ulcer, with jagged edges, which appears upon the
inside of the lips and cheeks, and is attended with a copious
flow of offensive saliva.
CCCCXXII. This disease is seldom seen in adults, but it
most commonly attacks children from the age of eighteen
months, to that of six or seven years. When the ulceration
begins at the inner part of the lip, it exhibits a deep, narrow,
sulcated appearance, and quickly spreads along the inside of
the cheek, which becomes hard, and tumefied externally,
The gums are very frequently interested in this complaint, and
in such cases, the teeth are generally found in a loose and dis-
eased state ; matter is often found in their sockets, and abscess-
es sometimes burst externally through the cheek, the lip, or a
little below the maxilla inferior : and it is not uncommon to see
an exfoliation of the alveolar processes, or even of the greater
part of the lower jaw. Among the children of poor people,
where this disease is neglected, or mismanaged, at the begin-
ning, a dreadful gangrene will sometimes supervene.
CCCCXXIII. The remote causes that produce this disease
are not very obvious. I think it occurs most frequently among
children that live in a marshy situation; that are sustained by
OF THE CANKER OF THE MOUTH,
109
unwholesome food, and where a due attention to cleanliness
has been wanting. The cancrum oris has been described by
some writers, as a complaint very common in England and Ire-
land, where it is sometimes epidemical anong infants. It how-
ever is commonly seen in other kingdoms, and prevails more
especially in those houses where a great number of children
are crowded together. I am not able to determine whether it
is, or is not, contagious.
CCCCXXIV. But adults are not wholly exempted from
this morbid affection, and it is not easy, in all cases, to distin-
guish the cancrum oris, from a scrofulous or cancerous ulcer
in the mouth, since the tongue, the inside of the cheeks, uvula,
and fauces, may be the seat of each disease. I have seen ul-
cerations on the uvula, velamen palatinum, and tonsils, with ma-
ny of the characters of a venereal sore, in patients where the
presence of such a virus could not be suspected ; and by
treating them as canker of the mouth, they have been speedi-
lycured.
CCCCXXV. The canker of the mouth ought to be distin-
guished from apthæ—the epulis and parulis—scurvy-cancer-
ous ulcers-venereal ulcers--cachexia syphiloidea—and ex-
ulceration from the use of mercury.

SECTION II.
THE MODE OF TREATMENT.
CCCCXXVI. It will be proper,
3.1. To remove the diseased teeth, and carious bone, &c. if
possible.
2. To prescribe a milk and vegetable diet, and to allow a
prudent use of fermented liquors.
3. It will be advisable to exhibit such remedies as
Peruvian bark-sarsaparilla--elm bark-mineral acids.
CCCCXXVII. The external applications that I have gen-
erally found successful have consisted of such as the fol-
lowing:
Preparations of copper—a diluted mineral acid-burnt al-
um-decoction of bark with white vitriol-tincture of myrrh-
lime water with alcohol, &c.
110
OF THE EDEMA.
L
CHAPTER XIV.
SECTION I.
H
OF THE EDEMA.-
CCCCXXVIII. The term Edema was employed by some
of the ancient writers, in a sense synonymous with eminence, ex-
tuberance, or tumour ; but since the time of Galen, it has been
more strictly confined to those tumefactions which are derived
from the effusion of a fluid into the cells of the reticular mem-
brane of a particular part.
CCCCXXIX. A part may be said to be preternaturally en-
larged, when there is either an actual addition of substance made
to the solid contents of the mass; or, when the volume of a
part is increased, the weight remaining nearly the same. Obesi-
ty will afford us an illustration of the former, and rarefaction of
air in the intestines, an instance of the latter. There is like-
wise a third case, in which the contained fluids being propelled
with an increased velocity through their elastic canals, these
become unusually distended, and produce an augmentation of
bulk : this state, probably, takes place in phlegmonous tumours.
CCCCXXX. Where there exists an addition of substance,
this may consist of an increased quantity of fluid in a particular
part, and consequent dilatation of the containing solids; as in
aneurism, varicose tumours, obstructed receptacles of secreted
fluids, dropsies, &c. Or, there may be a secretion of new matter,
as fat, the contents of encysted tumours, exostoses, &c. Or, the
augmented bulk may depend on an additional quantity of solid
and fluid matter; as in cases of polypi, fungi, and the several
kinds of sarcomata, and all preternatural enlargements of parti-
cular parts, where the vessels which convey nutriment are in-
creased in number and magnitude.
CCCCXXXI. The tumour which constitutes an essential
part of the disease termed ædema, consists of a distention of the
solids, from the accumulation of a preternatural quantity of the
interstitial fluid in the cells of the reticular membrane : hence,
the ædema appears as a diffused tumefaction of the common in-
teguments in some particular part of the body, unattended by



OT THE CEDEMA.
111
inflammation, yielding easily to pressure, and retaining, during
some time, the vestige of the impressing body.
CCCCXXXII. Among the supposed causes of cedema, the
following have been enumerated :
1. Obstruction to the returning venous blood.
2. Obstruction to the passage of lymph in the absorbent ves-
sels.
3. A debilitated or inert state of the absorbent vessels.
• 4. Loss of tone in the exhalent arteries.
15. An inordinate action of the exhalent arteries.
CCCCXXXIII. The agency of the two first assigned causes
in the production of ædema, is too well established to admit of
controversy. But, that atony of the absorbent vessels is a cause
of ædema, has never been proved satisfactorily by any experi-
ments yet made public. Indeed, a considerable number of
facts connected with the history of dropsy—as the abundant
absorption which is continually taking place on the surface of the
body—the celerity with which the water is absorbed and evacuat-
ed, under peculiar circumstances ;—the great emaciation which
usually attends hydropical cases—the very partial effusion of fluid
which takes place in dropsies of particular parts, as of the tu-
nica vaginalis testis, &c. and the enlarged and distended state in
which the absorbent vessels are commonly found in dropsical
subjects, on dissection, militate strongly against the correctness
of such an opinion. How far a morbid determination of Auid
to the exhalent arteries in those cases of dropsy, which are not
obviously the effect of an alteration in the structure of some
part connected with that which is the seat of the effusion, will
afford an adequate solution of the phenomena, may be deserving
of further inquiry.
CCCCXXXIV. As the ædema is the effect of different
causes, and appears under some variety of circumstances, it
may be convenient and useful to arrange it under the following
heads :

2. Edema simplex { flaccidum.
2. Claema simplex , durius. no
3. Edema symptomaticum, vel tumor ædematosus.
4. Edema deuteropathicum.
5. Edema cum erythemate.
6. Edema purulentum.
112
OF THE EDENA.
de
SECTION II.
OF THE EDEMA SIMPLEX FLACCIDUM.
CCCCXXXV. This form of the cedema is characterized by
a tumefaction of the integuments, commonly about the feet, an-
kles, and anterior surface of the tibia : there is no particular
discolouration of the parts; it is unattended with pain ; but
there is usually a sense of weight and tightness, and the free-
dom of motion is more or less impaired: firm pressure upon the
tumefied part produces a little cavity, which is not very quickly
effaced, and the feet are commonly somewhat colder than natu-
ral. The ædema usually increases towards the evening, but
in consequence of rest, and a horizontal position, it generally
subsides during the night.
CCCCXXXVI. Of the remote causes of the cedema sim-
plex flaccidun.
1. Compression of the larger veins, or of the trunks of the
absorbent vessels.
a. Obesity. Gravid uterus. Tumours within the abdo-
men. Sitting long on a hard seat. Riding long in a carriage, or
on horseback. Tight bandages, not carefully applied. Une-
qual pressure from splints, &c.
2. Whatever diminishes the powers which propel the return-
ing blood.
3. A sedentary life. Long exposure to cold, where no ex-
ercise is used, especially where persons are advanced in years.
Long exposure to cold and moisture, at any period of life. It
is often attendant on old age; but chiefly where the person has
been accustomed to inactivity.
3. Injurious effects produced on the stomach.
c. The excessive use of diluting liquids, as cold water, &c.
d. The taking freely of spirituous liquors, whether diluted,
or undiluted. Intemperance in the use of any fermented
liquors. Intemperance in eating.
*4. Profuse hæmorrhages. Hyper-catharsis.
5. Those diseases of the heart and lungs which obstruct the
due transmission of the blood through the pulmonary vessels.
6. Local injuries, as blows, sprains; also inflammation, or
erysipelas, of the lower extremities.



OF THE EDEMA.
113
CCCCXXXVII. The ædema simplex flaccidum is com-
monly slow and gradual in its progress, unless when induced by
some of the causes enumerated at Nos. 3 and 4; but where
great violence has been done to the stomach by intemperance,
it will sometimes appear suddenly and affect the body to a
very considerable extent. More or less of this form of the
ædema is commonly seen in the skin covering the anterior sur-
face of the tibia, in the greater number of persons who are be-
yond the age of fifty years. Where the skin has been a long
time distended with lymph, maculæ of a dark yellow colour
are often seen upon the lower parts of the legs.
CCCCXXXVIII. The prognosis of the ædema simplex
flaccidum. The comparative danger or unimportance of this
form of the ædema is influenced principally by the nature of
the remote cause. It may, however, be stated in general, that
when an ædematous state of the ankles is not connected with
any general disease of the system, it may continue during many
years without indicating a tendency to general dropsy, or pro-
ducing any material inconvenience.

SECTION III.
OF THE TREATMENT OF THE EDEMA SIMPLEX FLACCIDUM.

CCCCXXXIX. 1. The remote cause of the disease must
be removed, if possible; since the abstraction of that, will some-
times be sufficient for the cure of the ædema.
2. To effect a change in that state of the system by which
the disease is supported.
3. To promote absorption and empty the distended cells of
the reticular membrane, by such medicines as operate chiefly
on the intestines and kidneys.
CCCCXL. The local treatment of the ædema.
1. To facilitate the return of the blood, and the ascent of the
lymph, by a horizontal posture.
2. To support the parts and promote absorption, by the ap-
plication of a flannel bandage.
3. To increase the general vigour of the parts, by the use
of friction. It has been supposed, that such medicaments as
15
114
OF THE EDEMA.
the linimentum ammoniæ, linimentum saponis compositum,
oleum camphoratum, &c. have a beneficial effect.
4. The cure of the ædema is sometimes assisted, and a re-
currence of the disease prevented, by bathing the parts in hot
salt brine, or hot sea water, and the use of a laced stocking.

SECTION IV.
11. EDEMA SIMPLEX DURIUS.

CCCCXLI. This form of the disease appears in one or
both of the lower extremities: it is accompanied with pain,
and some degree of lameness; but there is no discolouration o
the skin, nor preternatural increase of temperature. The
tumefaction is pretty uniform, and extends from a little below
the knee to the ankle; but seldom molests the foot: the affected
parts are much firmer than in the ædema simplex flaccidum,
and yield very little to pressure.
CCCCXLII. This disease is evidently connected with a
morbid state of the deeper seated absorbent vessels, about the
calf of the leg. The patient commonly refers to the posterior
part of the leg, as the principal seat of his pain; on pressing
firmly on the gastrocnemius muscle, the absorbent vessels can
be felt in an enlarged and indurated state, and the pain is much
aggravated by compressing them. Sometimes, indeed, the pa-
tient complains of pain in the posterior part of his leg, espe-
cially on walking and standing, before any tumefaction of the
limb makes its appearance.
CCCCXLIII. In the ædema simplex durius, there is pro-
bably very little effusion of the interstitial fluid into the cells of
the reticular membrane : the intumescence never ascends quite
so high as the knee joint ; nor do the absorbent vessels, or
glands in the ham participate in the disease. The general ap-
pearance of the limb excites the idea of turgescence from an
increased quantity of fluid, contained within its natural canals,
rather than that of tumefaction from effusion.
CCCCXLIV. This disease may exist in only one of the
lower extremities; but more commonly both legs suffer from
it, at the same time. It occurs more frequently in women
than in men; and is seen as often in young persons, who have

OF THE EDEMA.
115
attained to adult age, as in those who are more advanced in
years.
CCCCXLV. The remote causes of this form of the adema
are not very numerous, nor are they always so obvious, as to
remove all doubt from the mind, of their agency. I have seen
it connected with amenorrhæa in some plethoric habits ; it
may arise from inaction, in those who are disposed to corpu-
lency; and very frequently it attacks those whose occupation
obliges them to stand many hours every day. I have also met
with this disease, where I could not discover any evident cause
of its appearance.
SECTION V.
OF THE TREATMENT OF THE EDEMA SIMPLEX DURIUS.
CCCCXLVI. d. The remedies which confer the most
speedy and permanent relief are brisk purgatives. These
should be administered once in four or five days, as the powers
of the constitution will permit.
b. Small doses of calomel with alkaline salt, may be given
on the intermediate days.
c. Rest and a recumbent posture must be enjoined, until the
pain shall have abated considerably.
d. The vapor of camphorated spirit of wine and volatile al-
kali may be employed with advantage.
e. When the hardness and extraordinary tenderness of the
absorbent vessels are considerably reduced, friction with the
linamentum ammoniæ may be used.
f. A flannel bandage must be applied, as soon as the leg can
bear moderate pressure; and it ought to be continued during a
few weeks, after the disease has been removed.
SECTION VI.
III. EDEMA SYMPTOMATICUM, SEU TUMOR EDEMATOSUS.
CCCCXLVII. This is not a distinct form of the ædema,
nor does it differ in its symptoms from the ædema simplex
116
OF THE CEDEMA.
flaccidum. It is arranged under a separate head, because it
occurs as a sign of some other disease, without absolutely con-
stituting a part of it.
CCCCXLVIII. Without attempting to include all the dis-
eases of which the ædema symptomaticum often indicates the
existence, the following enumeration may suffice :
1. Simple fracture.
2. Fracture of the cranium.
3. Collections of fluids in natural cavities : as extravasation
of blood within the thorax : effusions of pus within the abdo-
men, &c.
4. Suppuration in natural cavities within the capsules of
glands—under strong fasciæ and aponeuretic expansions-
deeply seated in muscular parts.
5. Gangrene.
6. Edema frequently occurs in the prepuce, from gonorrhe-
al irritation, and in the glans penis, from disease of the prostate
gland.
7. In parts afflicted with large and ill-conditioned sores.-In
cases of varicose ulcers. *
8. Diseases of the periosteum and of the bone.
9. Irregular appearances of the ædema in different parts of
an upper or lower extremity, sometimes indicate a failure of
the general powers of the constitution. .
CCCCXLIX. The most important matter which is attached
to the history of this form of the ædema, is the circumstance
of its sometimes indicating the presence of another disease, the
symptoms of which may not be sufficiently clear to conduct
us immediately to the knowledge of its existence. So, like-
wise, where this symptom is usually connected with any par-
ticular morbid alteration, an attention to it becomes necessary
in studying the natural history of the disease. The cure of
this complaint evidently depends upon the removal of the cause.



* When the ædema surrounds a varicose ulcer, or an ill-conditioned
sore, on the leg, the ulcer cannot be healed, as long as this morbid affec-
tion of the integuments remains. A tight bandage, with the occasional use
of purgatives, will commonly empty the loaded cells, and facilitate the
cure of the ulcer.

OF THE EDEMA.
117
SECTION VII.
IV. EDEMA DEUTEROPATHICUM SEU PUERPERARUM.

CCCCL. That swelling of a lower extremity, which some-
times attacks lying-in women, being attended with some par-
ticular circumstances which distinguish it from all other tume-
factions, seems to be connected with certain modifications of
the systern, peculiar to the puerperal state. It may be doubted
whether a disease exactly similar has ever occurred to women
who have not been pregnant.
CCCCLI. The period at which the ædema puerperarum
makes its appearance after parturition, is not constant and uni-
form; most commonly it occurs in about twelve or fifteen days;
although it has sometimes been seen as early as the day after
delivery, and at other times, three or four weeks bave elapsed
before the attack. It usually commences with pain about the
calf of the leg, succeeded by tumefaction in the labium pudendi
and groin, which gradually descends down the thigh, leg and
foot, so that, in the course of two or three days, the whole of
the lower extremity acquires a very considerable increase of
bulk. The limb is painful, preternaturally warm, and admits
of no motion without exciting great uneasiness; but the colour
of the skin is either unaltered, or it becomes whiter than natu-
ral. The integuments are firm, elastic, and do not yield to
pressure as in the ædema simplex flaccidum; no water is usu-
ally discharged on scarifying the part, nor is the tumefaction
of the limb at all reduced by a horizontal position. This dis-
ease is also commonly attended with the usual concomitants of
symptomatic inflammation.
CCCCLII. It is not usual to see both the lower extremities
affected by his disease at the same time; although instances
are not wanting of such an occurrence. It has been supposed,
that a woman cannot be afflicted with it in the same limb more
than once; but although I cannot controvert this opinion from
my own experience, yet, I have attended women in this dis-
ease, who have assured me, that the same complaint had oc-
curred to them before, in the same extremity.*
* Dr. Denman asserts the possibility of the same woman being affected
with this disease more than once. Introd. to Midwifery, p. 622.
118
DEMA.
OF THE
CCCCLIII. The ædema puerperarum does not appear to
be confined to any particular temperament, form of body, or
habit of living. It has no connexion with the paucity, or abun-
dance of the lochial discharge, nor with the secretion of milk,
nor with the suppression of that secretion ; although some of
the French writers have asserted, that it sometimes appears
subsequently to weaning the child.* The disease never sup-
purates, nor does it leave any permanent induration or lame-
ness, although, in some cases, several weeks elapse before the
patient recovers the use of the limb entirely. .


distinguished from the iliac abscess; from the tumefaction, in-
incident to lying-in women; and from that inflammation of the
absorbent vessels which is attended with enlargement of the
whole limb, and which will be described in a subsequent part
of this chapter.
CCCCLV. There are no instances upon record in which
this form of the ædema hath proved directly fatal ; † nor are
we possessed of any satisfactory account of the state of the
limb, from an accurate anatomical examination of the parts
after death. The remote cause of the disease is likewise in-
volved in considerable obscurity. In some instances, I have
seen it apparently derived from imprudently exposing the limb
to cold; but in other cases, it has occurred without the evident
intervention of any assignable cause. There is no good rea-
a metastasis takes place.
SECTION VIII.
OF THE TREATMENT OF THE EDEMA PUERPERARUM.

CCCCLVI. The symptomatic inflammation may be re-
lieved by such medicines as promote a diaphoresis : e. g.
* Levret, &c.
† Dr. Denman is of opinion, that it does sometimes prove fatal. In-
trod. to Midwifery, p. 656.
# The account given by Zinn is far too imperfect to require any qualifi-
cation of this language.
Ś Upon the subject of the remote cause of the dema puerperarum, the
writings of Mr. White, Dr. Ferriar, Dr. Hull, Dr. Denman, and the au-
thors referred to by those gentlemen, may be consulted.
OF THE EDEMA.
119
James's powder--saline draught with volatile alkali-Minde-
rerus’ spirit-small doses of the pulvis ipecacuanhæ composi-
tus-camphor with opium, &c.
CCCCLVII. When the violence of the first symptoms
have somewhat abated, the free exhibition of purgatives, espe-
cially such as are combined with calomel and alkaline salt, are
highly beneficial. They should be repeated as frequently as the
strength of the system will permit.
On the intermediate days, when the es are not ex-
hibited, the Peruvian bark, cascarilla, myrrh, vitriolic acid, and
similar tonics may be administered
CCCCLVIII. Of the local treatment.
a. When the pain is very severe, leeches may be applied to
the upper part of the thigh, with advantage.
b. Anodyne fomentations. Camphorated oil, with tincture
of opium. Linimentum ammoniæ and linimentum saponis
compos—in equal quantities. A flannel bandage, as soon as
the tenderness of the limb will allow of its application...
c. Small blistering plasters have been recommended by the
most respectable practitioners.
d. When the limb can permit motion and pressure without
exciting great uneasiness, moderate exercise and the prudent
use of friction will be highly conducive to recovery.
Some degree of lameness may remain during many weeks
after all external appearances of the disease have vanished.


SECTION IX.
V. EDEMA CUM ERYTHEMATE.
CCCCLIX. This form of the ædema usually comes on
suddenly; the patient complains of shivering, pain in the loins,
nausea, head-ache, and the other symptoms which commonly
accompany the first attack of a fever. The violence of these
febrile symptoms seldom continues above twelve hours ; but
as they gradually remit, the patient has a sense of tingling in
the foot and calf of the leg, which ascends up the leg and thigh
to the groin. The whole of the lower extremity swells, be-
comes painful, and is almost universally red; there is a con-
siderable degree of tenderness in the skin, and all motion gives
120
OF THE EDEMA,
Noman who menstruate regularly are not
great uneasiness; at the same time, the absorbent glands in
the groin and upper part of the thigh, become considerably en-
larged. The redness and tumefaction commonly begin to
subside in three or four days, and leave the leg and foot in a
very ædematous state.
CCCCLX. This disease sometimes attacks young women
who do not menstruate regularly; and under this circumstance,
I have usually seen the tumefaction attended with more firm-
ness, than when women further advanced in years have been
afflicted with it. Women who menstruate reg
exempted from this form of the ædema, and it sometimes at-
tacks the lower extremities of men. It does not affect one
side of the body more frequently than the other ; but it will
sometimes attack each extremity successively, and a recur-
rence of the disease is by no means unfrequent.
CCCCLXI. When a patient has suffered many attacks of
the ædema cum erythemate, the leg will frequently remain
permanently enlarged; it will acquire a considerable degree of
hardness, and the skin will be immoveable over the muscles.
If an ulcer shall take place in this morbid state of the integu-
ments, it is often troublesome and difficult to heal, nor indeed
does it admit of a permanent cure, until the surrounding skin
has recovered somewhat of its natural softness and flexibility.
CCCCCLXII. The persons who are most liable to be at-
tacked by this form of the cedema, are those who are corpu-
lent; whose fibres are flaccid ; whose occupations require
much standing ; more especially when those persons drink im-
moderately of spirituous liquors.

SECTION X.
OF THE MODE OF TREATMENT.
CCCCLXIII. The general and local modes of treatment,
which were recommended for the cure of the ædema deutero-
pathicum, seu puerperarum, may be employed with success in
the removal of this disease.
OF THE EDEMA.
121
SECTION XI.
VI. EDEMA PURULENTUM.

CCCCLXIV. This form of the ædema is seen less fre-
quently than any of the former ; but it equals in severity of
pain, and in its effects on the general state of the health, any of
those described in the preceding sections. It would consti-
tute one specimen of the Edema Spurium of Callisen.* .
CCCCLXV. This disease commonly begins with shiver-
ing, increased heat, a more frequent pulse than natural, sense
of debility, with the other common symptoms of fever. Soon
after this attack, the patient complains of a pain in his groin,
and on exarnination, some of the absorbent glands there, are
found enlarged and tender, the thigh is preternaturally hot ;
but neither hard, swollen, nor discoloured. In the course of a
few days the knee becomes hot, tumefied, and violently pain-
ful on the least motion, while the leg and foot are affected with
the ædema simplex flaccidum. In about ten or fourteen days
from the commencement of the disease, two, or three, indura-
ted parts, of small dimensions, may be discovered in the ham
and inner part of the thigh, which may be regarded as indica-
tions of suppuration having taken place, and at this period, the
whole of the lower extremity is commonly highly edematous.
When one of these morbid parts gives way, a very large quan-
tity of pus, of an ash colour, and very much resembling the
inatter discharged by a psoas abscess, will be evacuated, and
the daily discharge will be very considerable; so profuse in-
deed, that I have at first suspected the existence of a lumbar
abscess; yet, on a more accurate examination, I observed that
the matter could be pressed, apparently, from all the interstices
of the muscles of the
CCCCLXVI. The ædema purulentum appears without
the intervention of any evident cause. I have hitherto seen it
only in young persons, under the age of twenty years, and who
had a well marked scrofulous habit of body.

* Principia Systemat: Chirurg : Vol. II.
16
122
OF THE CEDEMA,
SECTION XII.
OF THE MODE OF TREATMENT.
CCCCLXVII. I am doubtful whether a resolution of the
tumefaction, &c. ought to be attempted; no endeavours that I
have yet used have been successful, and it is more than proba-
ble, that the patient is rather injured than benefited by a steady
adherence to the antiphlogistic mode of treatment. During the
first period of the ædema purulentum, such medicines as deter-
mine to the skin, joined with opium to allay the pain, seem the
best adapted to relieve the distress of the sufferer.
CCCCLXVIII. As soon as the process of suppuration is
indicated, the patient must take Peruvian bark, with opium ;
this must be continued after the rupture of the abscess, with a
plentiful diet, and country or sea air. The diluted sulphuric
acid may be likewise administered with advantage. The pa-
tient generally recovers, and regains the use of his limb; but
he will seldom be found completely restored to his health in
less than three or four nionths.
CCCCLXIX. The local treatment.
No application to the diseased limb is attended with any pe-
culiar advantage, during the first stage of the disease ; when the
abscess has burst, the ulcer may be dressed with dry lint and
common digestive, washing the part with the Aqua Cainpho-
rata Bateana, at each time of renewing the dressing. As there
is generally a remarkable flaccidity of the limb, after the dis-
charge of the matter, the use of a flannel or calico roller will
be attended with many advantages.
The patient will be generally benefited by sea-bathing, dur-
ing the healing of the ulcer.

T
SURGICAL OBSERVATIONS
ON
THE CONSTITUTIONAL ORIGIN AND TREATMENT OF

LOCAL DISEASES;
AND ON
ANEURISMS.
BY JOHN ABERNETHY, F. R. S.
Honorary Member of the Royal Medical Society of Edinburgh, and of the Medical Societies
of Paris, Philadelphia, &c., Surgeon to Christ's Hospital, Assistant Surgeon
to St. Bartholomew's Hospital, Teacher of Anatomy and Surgery,
and Professor of Anatomy and Surgery to the Royal
College of Surgeons.

" Chirurgo necessariam esse cognitionem Physices, Chimiæ,
Logices, omnis (fere) ambitus Medicinæ ; neque solo manus
exercitio veros chirurgos fieri."
Herm. Boerhaav. Method.
Stud. Med, locupletata ab Alb. von Haller.

PREFACE.
The best mode of obtaining and extending medical and sur-
gical knowledge is, in my opinion, to pay that strict attention
to diseases, which qualifies us to note even the slightest shades
of difference that distinguish them from each other. Such dis-
crimination leads us to form some regular arrangement of them,
which, even if it be not correct, may ultimately enable us to
discover their natural series and order. This method I have
pursued from the beginning of my professional studies. When-
ever the opinions on subjects of importance, which an attention
to cases had impressed upon my mind, differed from those
which seemed to prevail amongst other practitioners, I pub-
lished the facts, and the inferences which I drew from
them; because I thought that the former at least deserved at-
tention, and that the latter would either be confirmed or con-
futed by the result of general experience.
It is more, however, on account of the cases, than of the
conclusions which they suggested, that I am desirous of repub-
lishing my surgical writings. Various advantages result even
from the publication of opinions ; for though we are very liable
to error in forming them, yet their promulgation, by exciting
investigation, and pointing out the deficiencies of our informa-
tion, cannot be otherwise than useful in the promotion of sci-
ence.
- The publication of the opinions which naturally arise
in the mind of the surgeon, from the cases submitted to his ob-
servation, possesses the further utility of rendering a prolix de-
tail of circumstances unnecessary. It would be almost impos-
sible to relate every minute occurrence, that tended to impress
certain conclusions on the mind of the observer; or to relate

126
PREFACE.
every trifling particular of treatment, by which the surgeon en-
deavored to accomplish his object. Such a dull and tedious
narrative, which would weary and disgust the reader, may in-
deed be well spared; because the practitioner may, and must,
repeatedly peruse the case at large in the book of nature.
The writer merely points out those signs by which any disease
may be discriminated from others, and identified as one of the
particular class to which he is desirous of exciting the public
attention.
With regard to the cases, which I consider as the valuable part
of the book, I may observe, that it is not to be expected that
the records of them will make so strong an impression on the
minds of the readers, as the observance of them has done on
that of the writer; but when the same occurrences are met
with in practice, then will the impression become more vivid,
and knowledge arise, as it usually does, from personal expe-
rience. If the facts contained in this volume occurred so
rarely, that others could not be expected to meet with them,
their relation would be of little value. They may, however,
not improperly be compared to certain species of plants, by no
means uncommon, which are liable to be confounded with oth-
ers by an inattentive observer; but when their discriminating
characters are once pointed out, they may be so readily dis-
tinguished, collected and examined, as to render a more minute
description of them unnecessary. If diseases could, like oth-
er objects which we mean to delineate, be placed in various
points of view, and illuminated at pleasure, so as to show dis-
tinctly their different parts, one accurate representation would
suffice; but we see them obscurely, and as knowledge increas-
es, it serves, like light shining from different places, to illumin-
ate the various parts of the objects of our examination.
For, as I have expressed it in the first edition of these wri-
tings, “in proportion as we advance in knowledge, we are led
to remark many circumstances in the progress of a disorder
which had before passed without notice; but which, if known

PREFACE.
127

and duly attended to, would clearly point out the nature of the
complaint. Hence the records of former cases are of much
less value ; as the symptoms about which we are now anxious to
inquire, have in them been entirely overlooked.” It, therefore,
becomes necessary that each writer should state those circum-
stances to which he has been particularly attentive ; nor need
he further delineate the case than by a general outline, so as to
render it intelligible.
The relation of cases may be compared to the representa-
tions which an artist gives of natural objects, and which are
valuable only inasmuch as they are correct or vivid deline-
ations of reality. Such portraits, sketched by a person of dull
perception, or by one whose optics are perverted by prejudice
and theory, are either valueless or deceptive; and hence, per-
haps, has arisen that objection to books of cases which I find
to be very prevalent. In the imperfect sketches which I have
laid before the public, my chief object has been to touch up
and bring into view some parts of the subjects which have not
been so clearly seen or strongly delineated by former drafts-
men.
When books of this kind are published, mutual forbearance
is requisite on the part both of the writer and the reader. The
former should not expect his work to be approved of, till the
latter has examined whether his representation of diseases be
correct, and his conclusions legitimately drawn from the facts
which he has observed and collected. Neither should the
reader condemn the work till he has examined the subject, and
is in consequence able to point out the errors of the premises
or conclusions. The author's view of a subject may indeed be
correctly formed from the facts which he himself has witnessed;
but it may differ from that which more extensive experience
would have suggested. For this difference no blame can prop-
erly be attached to him; he relates what has fallen under his
own observation, and invites others to attend to the same
facts.
128
PREFACE,
I have been induced thus to offer my sentiments respecting
the design, mode, and probable advantages of recording cases,
not with a view of vindicating the plan which I have pursued,
for that indeed cannot be necessary, since it is the same that
has been followed by the best authors on surgery. My object,
by these remarks, lias been to induce others to reflect how they
may most effectually promote medical knowledge. No one
can have thoroughly studied his profession without perceiving
how susceptible it is of improvement, without discerning how
inadequate the efforts of an individual must be towards the ac-

an earnest wish to engage general co-operation in this desirable
object.
In republishing my former writings, I have left out all that
part which relates to physiology. The surgical facts contained
in them, will now be found incorporated with my later publi-
cations, under the same general head of Surgical Observations.
I have also made those alterations and enlargements which a
greater share of experience has dictated. The subjects have
likewise been transposed. I have put at the beginning of the
book those cases which show how much local diseases depend
upon the general state of the patient's health, because I shall
have frequent occasion to refer to this subject in the succeeding
parts of the work.
I feel much gratified in finding, that, though a larger portion
of experience has enabled me to add some new and striking facts
to this edition, it has not shown me any thing that I ought to
retract or materially to alter. This, indeed, must be the case
in a book containing only facts, and opinions not incautiously
deduced from them. Several of the papers contained in this
volume met with very general and strong objection, which I
considered as the greatest compliment which could be paid to
them. For if the views which I had taken of various practical
ly found to be correct, the greater was the necessity for their
publication.
SURGICAL OBSERVATIONS.
ON THE

CONSTITUTIONAL ORIGIN AND TREATMENT
OF
LOCAL DISEASES.
An evil seems to me to have arisen from the artificial divi-
sion of the healing art into the medical and surgical departments.
This division has caused the attention of the physician and the
surgeon to be too exclusively directed to those diseases, which
custom has arbitrarily allotted to their care. The effects of lo-
cal disorders upon the constitution have, in consequence, been
too little attended to ; and indeed I know of no book, to which
I can refer a surgical student for a satisfactory account of those
febrile and nervous affections which local disease produces, ex-
cept that of Mr. Hunter.* The reciprocal operation of consti-
tutional disorders upon local diseases has obtained still less at-
tention. To investigate more particularly some parts of these
subjects, and to submit them to public notice, are the pro-
posed objects of the present paper.
No part of the animal body can in general be very consider-
ably disordered, without occasioning a correspondent derange-
ment in other parts of the system. Such disorder has been
considered by Mr. Hunter as the result of universal sympathy.
This consent of the whole constitution with its parts manifests
itself, in particular instances, by a greater disturbance of the
functions of some organs than of those of others; and from this
circumstance diseases have derived the appellations, by which
they are commonly distinguished. If the actions of the san-
guiferous system be principally disturbed, and the temperature
of the body subject to unusual variations, the disease is termed
WNIO
* Treatise on the Blood, Inflammation, &c.
17
130
ON THE CONSTITUTIONAL ORIGIN AND

fever : iſ the nervous system be chiefly affected, a state of vige
ilance or of delirium may be produced: convulsions and teta-
nus take place, when the functions of the muscular system are
more particularly deranged. Though the disorder of particular
organs thus gives a character and denomination to the disease,
it is sufficiently evident, in the instances adduced, that the
whole constitution is disturbed ; while certain parts are chiefly
affected, perhaps from unknown circumstances relative to the
nervous system, or froin a predisposition to disorder existing in
the affected parts. It seems to be ascertained, that persons of
particular constitutions are predisposed to those febrile actions
of the sanguiferous system, which constitute the inflammatory
fever ; that there is a propensity to convulsions in children;
and to tetanus in the inhabitants of warm climates.
It may be a fit subject for inquiry, whether it be possible
for particular organs to become affected otherwise, than through
the medium of the nervous system in general. Though some
instances of sympathy are strange, and perhaps inexplicable,
there are strong reasons for believing that the inflammatory fe-
ver, the state of vigilance and delirium, convulsions and tetanus,
which arise in consequence of injuries of the limbs, are pro-
duced by irritation imparted to the brain, which, by a kind of re-
flected operation, occasions a greater disorder of some of the
organs of the body than of others, and thus gives a character
and denomination to the disease. *
That the stomach and bowels are disordered by injuries and
diseases of parts of the body, has been remarked by various
persons; but the subject has never been extensively surveyed,
* Mr. Hunter, who, with that patience and industry for which he was
do remarkable, collected and examined all the facts which he had observed
relative to the subject of sympathy, has divided it into continuous, contis.
uous, and remote. It is the remote sympathies, according to his division, of
which I am now speaking.
The observations of Dr. Darwin on ocular spectra, and indeed the con.
sideration of the nervous functions in general, render it liighly probable that
sensation is not produced merely by impulses made on the nerves, but by
means of actions excited by such impulses, which actions are continued
to the sensorium. Nervous actions, then, may take place without the usual-
ly exciting causes; such actions may be continued through the medium
of the reticular communications of nerves, and thus physiologically we may
explain the continuous and contiguous sympathies. Action's also produc-
tive of sympathetic sensations may be supposed to take place through the
media of ganglia or plexuses. In remote sympathies, however, we must
suppose the actions which originate in an injured or diseased part of the
body to be continued to the sensorium, and there to excite the actions of
other nerves, &c.

TREATMENT OF LOCAL DISEASES.
131
nor viewed with that accuracy of observation which its high
importance merits. It has been observed that sprains of ten-
dinous or ligamentous parts produce sudden sickness; and
Mr. Hunter has attributed that shivering which is consequent
to accidents, and attendant on some diseases, to the state of
the stomach. It is known that, in some local injuries from ac-
cident or operations, the stomach has appeared to be the part
principally affected. But remarks on the affections thus induced
in the digestive organs have been made only in a cursory man-
ner; and it is my intention to examine the subject more partic-
ularly. It also appears to me that the connexion of local dis-
eases with the state of the constitution in general is either not
sufficiently understood, or not duly regarded by the generality
of practitioners; and I also mean to claim their particular atten-
tion to this subject. I shall in the first place select a case to
show how the stomach and bowels, or, to speak yet more exten-
sively, the digestive organs may be affected from local disorder.
SUDDEN AND VIOLENT LOCAL IRRITATION WILL SOMETIMES
PRODUCE AN EQUALLY SUDDEN AND VEHEMENT DISORDER
OF THE DIGESTIVE ORGANS.
CASE I.
A HEALTHY gentleman, about twenty-five years of age, was
induced to submit to an operation for the return of an adhe-
rent omental hernia, rather in order to remove the inconve-
nience and apprehension which the disorder occasioned, than
from any urgent necessity; for any increased exertion in walk-
ing or riding produced the descent of a portion of intestine
behind the thickened omentum, and obliged him to stop, and
replace it : and he frequently could not accomplish the reduc-
tion without considerable difficulty. The application of trus-
ses had been quite ineffectual in obviating these alarming in-
conveniences.
The patient's diet on the day preceding the operation was
scanty, and consisted of fluid substances. He took on the
morning of the operation some Epsom salts and manna,
which purged him twice and seemed to have emptied his bow-
els. A portion of the omentum was cut off, and the remainder
132
ON THE CONSTITUTIONAL ORIGIN AND

was returned, after two vessels had been tied. The operation
was followed by general disorder of the constitution, manifested
by a full and strong pulse, furred tongue, great anxiety, rest-
lessness, and total want of sleep. The stomach was part cu-
larly affected, being distended, uneasy on compression, and re-
jecting every thing that was swallowed. He was bled largely
in the evening, and took saline medicines, but could not be pre-
vailed on to swallow any thing else, except some toast and wa-
ter. The sickness had in some degree abated on the next day.
À solution of sulphate of magnesia in mint water was prescribed
in small occasional doses, in order to relieve the disorder and
distention of the stomach, by procuring some discharge from
the bowels.* In the course of the day he took an ounce of the
salts, which were not rejected by the stomach, yet he could
scarcely be prevailed upon to take any thing else. The tongue
was still covered by a thick yellow fur; the skin was hot and
dry, and the pulse frequent. As there was no particular tender-
ness about t]
was not again bled. The
second night passed without any sleep. As the salts had
produced no effect, the same medicine was ordered in an effu-
sion of senna, with the addition of some of the tincture, which,
by being given in very small doses, was retained. When,
however, it seemed likely that no effect would result from this
medicine, a grain of calomel was given at night, and repeated
on the following morning. Still the loathing of food continued.
The third night passed, like the former ones, without sleep, and
in great anxiety. On the next morning, two pills, containing
five grains of the pil. colocynth. and the same quantity of the
pil. aloet. cum myrrhâ, were given every fourth hour. These
procured no stool, nor produced any sensation which inclined
the patient to believe that they would operate. Again he pass-
* It is most probably the disorder of the brain which affects the stomach ;
but the reaction of the latter affection is liable to increase and maintain
the former, by which it had itself been produced. The effects that result
from the sympathy of the whole constitution with local disorder vary
greatly both in nature and degree. Sometimes the brain is the part chiefly
affected; on these occasions the nervous energy appears to be much
impaired; and in some instances of this description, the patient gradual-
ly sinks, little fever or reaction of the constitution being observed ; in
other instances, however, there is a low delirium, with a slight degree of fe-
brile action; and in others again, the delirium is more violent, and is ac
companied with a proportional increase of fever, subsultus of the muscles,
and convulsions. Sometimes other parts of the body or particular organs
seem to be principally affected; indeed the variety of effects produced un-
der the circumstances alluded to is such as to baffle description.

TREATMENT OF LOCAL DISEASES.
133
ed a sleepless night; but, towards the morning, he felt his bow-
els apparently filling, to use his own expression, and a profuse
discharge ensued. A dozen copious, fetid, and black evacua-
tions took place between five and ten o'clock, and he had sev-
eral others in the course of the day; after which his appetite
returned, bis tongue became clean, and a sound and continued
sleep succeeded.
That the chylopoietic organs were the parts chiefly affected
in this case, can scarcely be questioned. The sickness, the
tenderness of the parts in the epigastric region, the aversion to
food, and the state of the tongue, all indicate that the stomach
was much disordered. The insusceptibility of the bowels to
the action of medicines, which would ordinarily have produced
discharges from them, and the profuse evacuations which sub-
sequently relieved the patient, prove that these viscera partici-
pated in the affection. The black colour of the discharges
shows, I think, that the secretion of the bile was not healthy,
and that the liver was affected with the other chylopoietic
viscera.
It may be supposed, that the injury done to the omentum
might contribute to produce the disorder of these organs, rath-
er than of others. We do not, however, find that such effects
commonly succeed to similar operations. The consequences
in the present case were more severe than might have been ex-
pected, if it were not known, that an operation performed on
a healthy patient is more apt to produce considerable disorder,
than when performed on one whose constitution has previously
sustained the irritation of a disease, for which the operation
becomes necessary.
It is probable also that the restlessness and anxiety of the
patient were aggravated, if not principally caused, by the state
of the chylopoietic viscera; since the relief which took place in
those parts on the renewal of secretions into them, certainly re-
moved the nervous and febrile symptoms. That the discharges
were the effect of secretion is proved by the absence of alimen-
tary matter in the bowels, in consequence of the action of the
purgative administered on the morning of the operation, and
the abstinence both before and after that period.*
* Two instances are recorded in Mr. Pott's Works, of the operation for
the reduction of an hernia being performed where no strangulation exist.
ed. See Pott's Works, Vol. III. pp. 295, 299, edition of 1783.
The operation in the case just related was undertaken upon the authority
of these cases, which were both successful. I performed a similar operation
134
ON THE CONSTITUTIONAL ORIGIN AND

I could relate numerous cases in support of the inferences
which I have drawn from the preceding history; that local ir-
ritation acting on the nervous system may affect the digestive
organs in a very serious manner, and thereby create great gen-
eral disorder of the system, which is afterwards alleviated in
proportion to the amendment that ensues in the state of those
viscera. Such consequences of great local irritation must fre-
quently occur to every one; it is therefore unnecessary to ad-
duce more instances to support the opinions here delivered.
With respect to the treatment of cases of this description it
may be right to add, that the primary object should be to pro-
duce secretion from the irritable organs. In the case which
has been related, and in many others recorded in this volume,
the effect of secretions occurring from the disordered organs
in relieving their irritable state is very manifest. In many in-
stances opium will not prevent continual efforts to vomit, yet
when by magnes. sulphat, or purgatives administered in the
form of pills, and clysters, stools are procured, the vomiting
ceases, the stomach retains both food and medicine, and gene-
ral tranquillity of constitution is as suddenly restored.
VO
reo
A SLIGHTER DEGREE OF CONTINUED LOCAL IRRITATION WILL
PRODUCE A LESS VIOLENT DISORDER OF THE DIGESTIVE
ORGANS.
If then vehement local irritation can produce a violent dis-
turbance of the chylopoietic organs, it may be expected that a
less degree of a similar cause will produce slighter effects of the
same nature. Indeed, the foregoing case was related not mere-
ly because it seemed worthy of record by itself, but chiefly to
prepare the reader for the observations which are to follow.
The slighter degree of derangement occurs in the advanced
stages of lumbar abscess, diseased joints, compound fractures,
on a patient, whose life had been twice in imminent hazard from strangula-
tion in a case of adherent epiplocele, in which a truss did not keep up the
hernia, and the operation was followed by violent peritonitis, which could
only be subdued by such copious and repeated venesection as endangered
the patient's life. These two cases have made such an impression on my
mind, that I should be very averse in future to undertake similar experi-
ments.

TREATMENT OF LOCAL DISEASES.
135
and all kinds of local disease, which impart considerable and con-
tinued irritation to the whole constitution. We also find a less
important disease, as for instance, a fretful ulcer, keep up a
disorder of the system in general, and of the digestive organs
in particular, which subsides as the irritable state of the ulcer
diminishes. But as practitioners in general may not perhaps
have so attentively remarked these circumstances as to be
familiarly acquainted with them, it may be useful to mention a
very common occurrence, which cannot have escaped observa-
tion. I allude to the effects of the irritation of teething upon
the health of children. The brain is sometimes so affected as
to cause convulsions; the digestive organs are almost constantly
disordered. The appetite fails; the tongue is furred; the
secretions of the liver are either suspended, diminished, or vi-
tiated. The bowels are either purged or costive, and the fæces
fetid. The fæcal matter is often mixed with mucous and other
secretions. There is also frequently a very troublesome cough.
Such symptoms generally subside when the local irritation
ceases, but sometimes the disorder of the digestive organs, thus
excited, continues and disturbs the general health of the pa-
tient.
· If local irritation be capable of disordering the bowels, it
seems natural to conclude that it acts upon them through the me-
dium of the brain. If also the brain and nervous system should
be disordered, without any apparent local disease, similar
derangements may be expected to take place in the functions
of the digestive organs. In cases, where some morbific poison
has been absorbed, producing effects similar to those of syphilis,
we usually find the irritation of the constitution which ensues
to be accompanied with this slighter disorder of the chylopoie-
tic organs.
Whenever, also, the nervous energy and general powers of
the constitution have been weakened and disordered by any
violent disease, as fever, small pox, measles, hooping-cough,
&c. the digestive organs are frequently affected in consequence,
and such affection becomes, as will afterwards be explained, the
cause of many secondary diseases.
In persons, likewise, who have naturally a weak or irritable
state of the nervous system, we find the digestive organs dis-
ordered in a similar manner. Improprieties in diet will also
produce a similar state of irritation, weakness, and disorder of
the functions of the digestive organs.
136
ON THE CONSTITUTIONAL ORIGIN AND

This slighter disorder of the chylopoietic organs is, in gen-
eral, manifested by a diminution of the appetite and digestion,
flatulence, and unnatural colour and fætor of the excretions,
which are generally deficient in quantity. The tongue is dry,
whitish, or ſurred, particularly at the back part; this symptom
is most apparent in the morning. The fur is greatest at the back
part, and extends along the middle of the tongue to the tip, the
edges remaining clean. As the disease advances, a tenderness
is felt when the epigastric region is compressed, and the pa-
tient breathes more by the ribs, and less by the diaphragm than
in the healthy state. The urine is frequently turbid.
In this general enumeration of the symptoms, several circum-
stances are omitted which occur occasionally, and which may,
when the subject shall be better understood, denote peculiarities
in the disease, and require corresponding peculiarities in the
medical treatment. I shall here notice a few of them. The ap-
petite is sometimes moderately good, when the digestion is im-
perfect; and the latter may not be defective, although the dis-
ease still exists. In some ijstances, indeed, the appetite is in-
ordinate. Tenderness of the epigastric region on pressure,
is not always an attendant even in advanced stages of the dis-
ease. The bowels are alternately costive, and lax even to purg-
ing.* The urine is sometimes pale coloured and copious like
that of hysterical patients.
Patients affected in the manner above described, commonly
declare they are in good health, except that they feel disturbed
by their local complaints; yet they are found, on inquiry, to
have all the symptoms, which characterize a disordered state
of the digestive organs. The mind is also frequently irritable
and despondent; anxiety and languor are expressed in the
countenance. The pulse is frequent or feeble; and slight
exercise produces considerable perspiration and fatigue. The
patients are sometimes restless at night, but when they sleep
soundly they awaken' unrefreshed, with lassitude, and some-
times a sensation, as if they were incapable of moving. Slight
noises generally cause them to start, and they are, to use their
own expression, very nervous. These circumstances seem to me
to indicate weakness and irritability of the nervous and muscu-
* I have known persons whose bowels were ordinarily costive, and
whose general health was much deranged by diso der of the digestive
organs, though they were unconscious of its existence, feel pleased that
they resembled pitch in colour and appearance,

TREATMENT OF LOCAL DISEASES.
137
lar systems; which, in addition to the disorder of the digestive
organs, that has been described, are the chief circumstances ob-
servable relative to the general health of those patients, whose
cases are related in the following part of this paper. By cor-
recting the obvious errors in the state of the digestive organs,
the local disease, which had baffled all attempts at cure by lo-
cal means, has speedily been removed, and the patient has ac-
knowledged that such an alteration has taken place in his gen-
eral health, as excited his surprise.
A REVIEW OF THE NATURAL FUNCTIONS OF THE DIGESTIVE
ORGANS, AND AN INQUIRY INTO THE SIGNS WHICH DE-
NOTE THEM TO BE IN A HEALTHY OR DISORDERED STATE.
Before I proceed, I may be allowed to enter more fully in-
to a consideration of the symptoms which denote disorder of
the digestive organs; in order to induce surgeons to pay that
strict attention to them, which the importance of the subject so
well deserves. It would indeed be impossible for the reader
to understand, without such prefatory observations, my object
in the treatment of the cases which will presently be related, or
the opinions which I have formed, relative to their mode of cure.
The changes which the food undergoes in the digestive or-
gans of the more complicated animals are threefold; and dis-
tinct organs are allotted to each of the three processes. Di-
gestion takes place in the stomach; chylification in the small
intestines; and a third process, hitherto undenominated, is per-
formed in the large intestines. It is probable that in some ca-
ses, one set of organs may be more disordered than the others,
and of course one of these processes may fail more than
the rest. For instance, the stomach may digest the food in a
healthy manner, although the intestines do not perform their
share of the changes which they ought to effect. .
The food is converted in the stomach into a viscid semi-
transparent substance called chyme; and that this change is
effected by the agency of a succus gastricus, is a point as well
ascertained as any in physiology. In a state of health this con-
version takes place without any appearance of that natural de-
composition which animal and vegetable matter would ordinarily
undergo in a warm and moist place. When, however, diges-
tion is imperfect, gaseous fluids are extricated from the alimen-
18
138
ON THE CONSTITUTIONAL ORIGIN AND
tary matter. Vegetable food becomes acid, and oils become
rançid. Uneasy sensations are also felt, and undigested ali-
ment may be observed in the fæces.
Disorder of the stomach is however more readily perceived
by adverting to the state of the tongue, which often indicates
an irritable and unhealthy condition of the stomach, when no
manifest symptoms of indigestion occur. If there be no fever
to disturb the secrétions in general, the change which is visi-
ble in the tongue can be imputed to no other cause than local
disease, or a participation in a disorder of the stomach or lungs.
Local irritation or mental anxiety will cause a white and dry
tongue ; but does not this effect arise through the medium of
an affection of the stomach? For although the secretions of
the tongue must partake of the general disturbance which pre-
vails in fever, their especial disorder may be, in that case, also,
not improperly attributed to the state of the stomach.
The state of the tongue is, in general, an infallible criterion
of a disordered condition of the stomach; but it does not point
out the kind and degree of that disorder. In recent and con-
siderable affections, where the appetite is lost, and the diges-
tive powers are greatly impaired, the appearances of the tongue
are by no means so strikingly unhealthy as in more confirmed
çases, where neither the appetite nor digestion appear materi-
ally deficient. It is probable that a continuance of irritation in
the stomach may so affect the tongue, as to render unnatural
secretions habitual to the part, and that these exist independently
of the original cause, or may be reproduced by trivial degrees
of disorder. Nay, sometimes the cuticle of the tongue seems
to have lost its transparency, and to become permanently
white, in consequence of continued irritation.*
After making the allowances, which such circumstances re-
quire, we may in general be enabled to detect a disordered
state of the stomach by observation made on the tongue; and,
as it is of consequence to ascertain such disorder at an early
period, when the symptoms are probably slight, this organ
should be observed in the morning, when it will be found much
furred, particularly at the part next the throat. Its appearance
may vary in different parts of the day from varieties in the state
of the stomach, depending on the excitement which is derived

| * In hectic fever, although the stomach may be very weak, the tongue
is generally clean; it is therefore probable that the foulness of the tongue
denotes irritation of the stomach, and not mere weakness when accompa-
nied with tranquillity.

TREATMENT OF LOCAL DISEASES.
139
from food, or a state of irritation arising from too long fasting.
*The tongues of many persons with disorder of the stomach look
moderately healthy during the day, though they have been so
much furred in the morning, that it has been deemed necessary
to scrape them.
A disordered state of secretion, either as to quantity or
quality, will be the natural effect of irritation of a secreting or-
gan. This is evidently the case with the tongue; and we inay,
with great probability, conjecture that the same consequence
also takes place in the stomach. Since the juices of the stom-
ach are the immediate agents in digestion, that process must be
disturbed in proportion as its secretions are deficient or vi-
tiated.
If undigested matter pass from the stomach into the intes-
tines, it can scarcely be supposed that their powers are capa-
ble of converting it into chyle; and it may become irritating to
those organs in consequence of the chemical changes, which
it may then undergo. When digestion is imperfect, animal and
vegetable substances experience considerable chemical changes
before they leave the stomach; and similar changes may con-
tinue to take place during the time they are detained in the
bowels, unless counteracted by the powers of the digestive or-
gans; powers which seem chiefly to belong to the fluids which
are secreted into them.
The extent of the power which the intestines possess of con-
verting what they receive from the stomach into chyle, or of pre-
venting chemical changes, is unknown. It is probable that
much undigested matter is absorbed by the lacteals, when the
digestive powers fail in their functions. This is apparently the
case in diabetes, where the vegetable matter floats in the serum
of the blood, rendering it turbid, and afterwards combines so as
to form sugar in its passage through the kidneys. The strong
odour, which various kinds of food impart to the urine,
indicates that different substances are absorbed indiscriminately
from the intestines. It is probable that a turbid state of the
urine, and variations from the natural odour of healthy urine,
may very frequently arise from a similar cause, viz. from the
imperfect action of the digestive organs, in consequence of
which, unassimilated matter is taken up by the lacteals, and
afterwards separated from the blood in the kidneys. It may
be reasonably conjectured that the same powers, by which
the kidneys convert the old materials of our body into that pe-
140
ON THE CONSTITUTIONAL ORIGIN AND
OU
VOU
culiar modification of animal matter, which is dissolved in the
water of the urine, and which has been called by the French
chemists urée, may also enable it, in a healthy and vigorous
state, to dispose of much unassimilated substance in the same
way. The further consideration of this subject would, however,
lead to a discussion foreign to the purpose of the present paper.
It will be sufficient to remark at present, that the state of the
urine may afford assistance in ascertaining the existence of
disorder of the digestive organs, and in indicating its nature.
It has been already mentioned, in the brief account of the
symptoms, that the urine is frequently turbid. It should, how-
ever, also be observed, that the quality of the urine greatly de-
pends on the state of the nervous system. It is frequently, in
the disorders of which I am speaking, pale coloured and copi-
Qus; which is probably owing to a state of nervous irritation,
such as exists in hysteria. It is not improbable that disorders of
the digestive organs, by causing the frequent secretion of un-
natural urine, may produce irritation, and subsequent disease of
the kidneys, and other urinary organs.
Modern physiologists seem to agree in the opinion that the
succus gastricus is the agent, by which digestion is effected;
but they are not so unanimous as to the immediate cause of
chylification. It is not improbable that the succus intestinalis is
a principal agent, although its qualities have not yet been in-
quired into; for, indeed, the investigation would be attended
with difficulties almost insuperable.
Since the bile and pancreatic liquor are poured into the in-
testines at a small distance from the stomach, it is natural to
consider these fluids as useful in affecting the change, which
the alimentary matter undergoes in the small intestines, name-
ly, its conversion into chyle. The chyme, or aliment digested
by the stomach, being viscid, the pancreatic juice has been
considered as an useful and necessary diluent, and perhaps
this fluid may have other properties with which we are unac-
quainted.
The uses of the bile have of late much engaged the attention
of physiologists. Mr. Hunter observed that it did not seem to
incorporate with the chyle ; and it certainly cannot do so and
retain its own nature, since its colour and taste are so intense,
that it would impart these properties to the chyle, if mixed with
it in the smallest quantity. The difficulty of conceiving that
the two fluids can be agitated together by the peristaltic motion


TREATMENT OF LOCAL DISEASES.
141
of the intestines, without becoming incorporated, has led to an
opinion that the bile may combine with the alimentary matter,
and lose its original properties ; but nothing of this kind is as-
certained. Fourcroy thinks that the alkali and saline ingredi-
ents of the bile may combine with the chyle, and render it
more fluid, while the albumen and resin may combine with the
excrementitious matter. It is, indeed, evident that the bile
combines either totally or partially with something separated
from the chyle, and exists formally in it, and in a state of health
uniformly dyes it of its peculiar colour; and therefore it has of
late been supposed, that the bile may serve to purify the chyle,
by precipitating and combining with its feculent parts.*
It has been said in the brief and general recital that has been
given of the symptoms, which characterize disorder in the chy-
lopoietic organs, that the stools are of an unnatural colour and
odour. Medical men entertain various opinions respecting the
colour of the fæces: to me this property seems generally to
depend on the kind and quantity of the bile. All the secretions,
which are poured into the alimentary canal, except the bile,
are colourless or white; iſ, therefore, this fluid were wanting,
the residue of the aliment would be of the colour, which might
be expected to result from its undigested parts combined
together. When, for instance, the secretion of bile is stop-
ped by the irritation of teething in children, whose diet is
chiefly bread and milk, the fæces are white; when this secre-
tion is obstructed in adults, the stools are pale like whitish-brown
paper.
In cases of disease, however, coloured excretions may take
place from the bowels. There is great reason for ascribing
the discharges in the disease called melæna to a vitiated secre-
tion from the surface of the alimentary canal. I was intimate
ly acquainted with a patient who suffered repeated and increas-
ing attacks of constitutional irritation. When the disorder was
wrought up, as it were, to a crisis, he was forewarned, by a
sensation, as if his stomach was filling, of the occurrence that
was about to take place. In less than a quarter of an hour he
would vomit more than two quarts of a fluid resembling coffee-
grounds in colour and consistence. Shortly afterwards very
* In the inquiry into the probable uses of the bile, it ought to be observ-
ed, that in many persons, in whom that secretion is either for a considera-
ble time wholly suppressed, very deficient, or much depraved, it does not
appear that the nutrition of the body is defective,

142
ON THE CONSTITUTIONAL ORIGIN AND
copious discharges of a similar darker coloured and offensive
matter, took place from the bowels : but a green viscid bile,
appearing distinct and uncombined, was intermixed with this.
These evacuations ceased in a day or two, and the constitu-
tional irritation disappeared with them.
I examined the bodies of several persons, who died under
attacks of this nature, and found the villous coat of the alimen-
tary canal highly inflamed, swoln and pulpy. Bloody specks
were observed in various parts; and sphacelation had actually
taken place in one instance. The liver was healthy in some
cases, and diseased in others. I conclude therefore that these
diseases, which were termed hæmatemesis and melæna, arose
from a violent disorder, and consequent diseased secretion of
the internal coat of the bowels; and that the blood, discharged
when the affection was at its height, did not flow from any sin-
gle vessel, but from the various points of the diseased surface.
Indeed I think it probable, that the profuse discharges, which
sist of morbid secretions from the bowels themselves, and not
of the residue oſ alimentary matter detained in those organs.
Such evacuations, either occurring spontaneously, or excited
by medicine, frequently relieve irritation of the chylopoietic
viscera.
It seems probable that the stools which resemble pitch are
principally composed of diseased secretions from the internal
surface of the intestines, since they do not seem either like the
residue of the food or discharges from the liver. Can we sup-
pose that all the black and fetid matter which was discharged
from the bowels in the first case, was poured forth solely from
the liver ?
The subject of morbid secretions is however particularly illus-
trated by that well-known alvine discharge, which so much re-
sembles yeast in colour and consistence that it cannot be con-
founded with fæces, with blood, or with a vitiated secretion
from the liver. A medical man of my acquaintance took, for
some disorder in his stomach and bowels, an aperient medicine,
which apparently emptied those organs. He ate nothing but
a little bread in broth for his dinner, and a small quantity
siness in his bowels, and an inclination to evacuate them af-
ter he had gone to bed; but he resisted this desire till four
o'clock in the morning, when its urgency forced him to rise.
He then discharged, what he supposed to amount in quantity

TREATMENT OF LOCAL DISEASES.
143
to a gallon, of a matter exactly like yeast, unmixed with any
bile or fæces. When he arose in the morning, he had a simi-
lar evacuation of about a quart; and on the succeeding day
there was a solid stool, apparently of the same substance, col-
oured of a light green from an admixture of bile. He had a
natural stool the next day : his appetite returned, and the uneasy
sensation subsided.
An unhealthy colour of the fæces may further be attributed
to some degeneracy in the quality of the alimentary matter;
such as may be supposed to take place when the digestive organs
fail in the performance of their offices, and different alimenta-
ry substances are in consequence detained in the bowels,
where they may pass through chemical decompositions and
re-combinations. But, though I am inclined to allow the full
operation of these causes, the following reasons lead me to be-
lieve that the colour of the fæces generally depends on the
kind and quantity of the bile. In the natural state of the di-
gestive organs, when there is no peculiarity of diet, and no
medicine is taken, the bile alone colours the residue of the
food. The fæces voided during a state of disorder of the di-
gestive organs are sometimes partially coloured ; which cir-
cumstance cannot be well accounted for upon any other sup-
position than that of an irregular secretion of the bile. Fluids
secreted from the intestines do not usually enter into combina-
tion with the fæcal matter, but appear distinctly when excreted.
Thus we find mucus and jelly discharged from the bowels,
unmixed with the fæces. Medicines which affect the liver
produce a very sudden change in the colour of the fæcęs.
Small doses of mercury, without any alteration of diet, some-
times change the stools immediately from a blackish to a light
yellow colour, which indicates a healthy but deficient secre-
tion of bile.
The appearance of healthy bile in the human subject is that
of a deep brown, resembling a mass of powdered rhubarb
when just moistened with water. Yet if bile be dropped into
water, a single drop will dye a large quantity of water of a bright
yellow, so that the deep brown appearance is the effect of the
intensity of the yellow colour. In health there ought to be so
much bile poured into the bowels, as when commixed with the
residue of the food, to dye it of the peculiar colour of bile. It
is right, however, to say that the colour of the bile may vary
considerably without any apparent disorder of the organ which
prepares it, or of the health in general. Sometimes, indeed, we

144
ON THE CONSTITUTIONAL ORIGIN AND
find green bile in the gall bladder, when the liver is not diseased.
I cannot, however, but think that the natural colour is a yel-
low, so intense as to appear brown. Green bile is usually
poured out in circumstances where there is evident disorder
of the digestive organs; and we cannot well suppose that there
are two kinds of healthy bile. The quantity of this fluid should
be such as completely to tinge the excrement of its peculiar
colour. By attending, therefore, to the colour of the fæces,
the kind and quantity of bile, which the liver excretes, may in
general be ascertained.
The colour of the alvine excretions in disordered states of
the viscera is various. Sometimes they appear to consist of
the residue of the food, untinged by bile. Sometimes they
are of a light vellow colour, which denotes a very deficient
quantity of healthy biliary secretion; they may also be of a
deep olive, of a clay brown, and of a blackish brown; all
which show a vitiated state of the biliary secretion.
Any kind of brown, which dilution will not convert into yel-
low, I should consider as unhealthy, since the colour of heal-
thy bile is a bright yellow, which by concentration appears
brown.
Such are the circumstances which I have collected from my
own observation, and the reports of others, relative to the al-
vine excretions, in the disorders which have been described.
· I have dwelt thus particularly upon the subject of the biliary
secretion, from a belief that its quantity and quality can, in gen-
eral, be ascertained by inspection, and will therefore serve to
indicate the presence of disorder. Whether the foregoing opin-
ions be correct or not, it will, I think, be generally granted that
the excretions from the bowels commonly indicate the healthy
or disordered state of the digestive organs. By the state of
the fæces we may judge how far digestion has been effected ;
and gelatinous, mucous, and other matters being mixed with
them, denote irritation or disease of the bowels.
The effects, which medicine or diet may have upon the col-
our of the fæces, ought, however, to be considered. When
the food is coloured, and this colour is not altered by digestion,
it will, of course, appear in the fæces; hence, if it should be
thought desirable to know accurately the state of the biliary se-
cretion, it would be right to restrict patients to a diet that is
not likely to colour the fæces. The green colour of vegeta-
bles tinges the fæcal residue of the food. Steel also is known
to blacken the fæces. It should also be remarked that the ex-
posure of the fæces to air after their expulsion, will, in some

TREATMENT OF LOCAL DISEASES.
145
instances, cause a considerable alteration in their colour. In
our endeavours, therefore, to ascertain whether the liver is per-
forming its office rightly, by observing the colour of the fæces,
attention should be paid to these circumstances.
I conclude this review of the opinions entertained respecting
chylification, by observing that if the succus intestinalis be an
agent in this function, disorder of the intestines is likely to af-
fect its secretion, and thus impede this second important part of
the process of assimilation.
The residue of the alimentary matter, mixed with the bile,
passes from the small into the large intestines, and there under-
goes a sudden change; it acquires a peculiar fætor, and be-
comes what we denominate fæces. This change is so sudden,
that it cannot be ascribed to spontaneous chemical alterations,
(which would be gradual) but to some new animal agency.
If the contents of the small intestines at their termination, and
of the large at their commencement, be examined, they will be
found totally different, even within a line of each other; the
former being without fætor, and the latter being in all respects
what is denominated fæces. Though chemists then might
speak of the leculent matter of chyle as fæces, yet physiologists
would rather apply that term to the change in the residue of
the food, which takes place in the large intestines, and which
seems to be effected by the animal powers of those organs.
The fæces quickly suffer chemical decomposition out of the
body, although they often remain in the bowels without under-
going the same kind of change. Their chemical decomposi-
tion is attended with the sudden formation of ammonia ; yet if
they be examined when recent, they are found to contain acids
which ammonia would neutralize. The inference, therefore,
naturally arises, that this third process, I mean the conversion
of the residue of the aliment into fæces, may, amongst other
purposes, be designed so to modify that residue, as to prevent
it from undergoing those various chemical changes, which
might be stimulating to the containing organs, as well as injuri-
ous to the general health.
In a perfectly healthy state of the digestive organs, probably
no chemical decomposition, even of the fæces, takes place;
yet such changes happen, in some degree, without apparently
producing any injurious consequences. To chemical changes
we may probably attribute the extrication of inflamınable air,

19
146
ON THE CONSTITUTIONAL ORIGIN AND
and the various and unnatural odours of the fæcal matter, which
are observable in disordered states of the digestive viscera.
The means by which this modification of the residue of the
food, which takes place in the large intestines, is effected, are
but little known. Analogy leads us to refer it to the effects of
a secretion from the lining of those intestines in which it occurs.
Now if this secretion deviates from the healthy state, in conse-
quence of an irritated or disordered state of those organs, we
may reasonably expect a corresponding derangement of the
process, by which the residue of the food is converted into
fæces.

FURTHER INQUIRY INTO THE NATURE AND EFFECTS OF
THAT DISORDER OF THE DIGESTIVE ORGANS, THE SYMP-
TOMS OF WHICH HAVE BEEN RECITED AT PAGE 136.
Having taken this general view of the functions of the chy-
lopoietic viscera, in order to facilitate the forming a judgment
relative to those circumstances which indicate their derange-
ment, I return to speak more fully of that affection of them,
which I have described, as arising from causes recited at page
136. This subject, it must be acknowledged, is very important,
if it can be shown that disorders of the digestive organs are the
cause of a great number of other diseases. The inquiry would
then not only lead us to discover the source of many disturbances
of the constitution, which originate in those of the digestive or-
gans (for patients have no suspicion of any disorder existing
in them), but would also lead to the prevention and cure of
many secondary diseases of a more vexatious and sometimes
of a more fatal nature, than those from which they orig-
inated.
If the tongue be furred at its back part in the morning, when
there is no fever, it is reasonable to infer in general that the
state of the tongue is owing to its participating in the irritation
of the stomach. Such participation produces an alteration in
the secretions of the tongue: they are either deficient in quan-
tity, or vitiated in quality. A state of irritation in any secre-
ting surface is, indeed, likely to be attended with the same con-
sequences. It is, therefore, fair to infer that, when a general
disorder of the digestive organs takes place, those fluids, which
produce the changes that the food undergoes in them, are de-
ficient or depraved, and consequently that digestion and the

TREATMENT OF LOCAL DISEASES.
147
subsequent processes must be imperfectly performed. The
liver is likely to participate in the disorder, and the biliary se-
cretion to be diminished or vitiated. This circumstance ad-
mits of ocular demonstration; and I have, therefore, consid-
ered it as an evidence of a more or less general disorder of the
digestive organs. A very reasonable objection may, however,
be made to considering the derangement of the functions of
the liver as a criterion of those of the stomach and intestines;
since the liver is independent of the latter organs, and may be
the subject of a disorder confined to itself. In some cases, also,
the alimentary canal may be affected, without disturbing the
liver. Such circumstances may happen occasionally ; but
they are not ordinary occurrences, and should be considered as
exceptions to general rules, which do not militate against their
common operation. In general, affections of the former influ-
ence the functions of the latter ; and the state of the biliary
secretions affords a very useful evidence of a more or less gen-
eral derangement of the chylopoietic viscera, and should excite
our attention to investigate its kind and degree.
I have stated, in describing the symptoms which denote dis-
order of the digestive organs, that the fæces are generally de-
ficient in quantity. This circumstance may be accounted for
in various ways. It may be ascribed to diminished or unhealthy
secretion of bile, which does not precipitate the usual propor-
tion of feculent matter from the chyle. Persons whose bowels
are lax, and not inactive in carrying downwards the feculent
matter, void it daily in deficient quantities. It may be supposed
too that, either from the deficiency of bile, and consequent
want of excitement, or from the effects of disorder, a torpid
state of the bowels may exist, which causes them to carry
downwards the feculent matter in small quantities. This cir-
cumstance may produce a greater absorption of the fæces than
what is natural, or an accumulation of them in the colon.
That the digestive organs in general were affected in the
cases of local disease, which I am about to record, is most evi-
dent; but I am aware that many varieties of disorder may be
included in the general description of the symptoms, which I
have given. Future observations may lead to further distinc-
tions; but I see no impropriety at present in speaking of the
disordered state as general; since it is probable that no mate-
rial disorder can ordinarily take place in one of the digestive
organs without disturbing the functions of the others. When

148
ON THE CONSTITUTIONAL ORIGIN AND

digestion is imperfectly performed, the functions of the intesti-
nal canal will soon participate in the disorder of the stomach.
Under these circumstances, the secretion of bile will also
probably become irregular. Should disease commence in the
large intestines, as about the rectum, it disturbs the functions of
the stomach, and secretion of the liver, and becomes augment-
ed in its turn by its sympathy with these parts. Should the
liver be disordered in the first instance, the stomach and bow-
els may not immediately sympathize, although they will proba-
bly soon become affected.
I feel further warranted in considering the symptoms, which
have been recited in the former part of this paper, as arising
from a general disturbance of the functions of the digestive or-
gans, from contemplating the effects of blows on different parts
of the belly, which do not seem to have injured the structure
of any single abdominal viscus, but yet produce effects deno-
ting a general disorder of these organs. The symptoms have
varied in severity in proportion to the violence of the blow re-
ceived. In the cases which were the consequence of the more
forcible injuries, the symptoms were, a ſurred tongue; great
vomiting, so that the stomach could retain no food ; difficulty
of affecting the bowels by medicine ; great ſever; and even
delirium. Indeed, all those effects were produced, which I
have represented as arising from vehement local irritation of
remote parts of the body. The disorder bas generally termi-
nated by a profuse discharge of black and fetid stools, after
which the patient has perfectly recovered. On the contrary,
where the symptoms consequent on the blow have been less
violent, so as not to claim such strict attention, the disorder
has continued. Persons who had been previously in perfect
health, have become hypochondriacal, and have had all those
symptoms of disorder of the digestive organs, which have been
already enumerated as arising from a less degree of local irri-
tation, with such consequent diseases as originate from such dis-
order, and which will be mentioned in the subsequent part of
this paper.
In order to inquire more particularly into the nature of this
disorder of the digestive organs, I have exarnined the bodies
of a considerable number of persons who have died of diseased
joints, lumbar abscesses, and other great local diseases. I knew
that these patients had their digestive organs disordered in the
manner that I have described, and that in many of them the

TREATMENT OF LOCAL DISEASES.
149
secretion of bile had been suppressed for a great length of time,
and, when it was renewed, that it was very deficient in quantity,
and faulty in quality : yet, on dissection, no alteration was dis-
covered in the structure of the chylopoietic viscera, which could
be decidedly pronounced to be the effect of disease. It natu-
rally excites surprise, that such a state of irritation, and imperfect
performance of the natural functions of these parts, should ex-
ist for so long a time, as in many cases it is known to do, with-
out producing organic disease; still I believe it may be set
down as a truth, (which has been verified by every observa-
tion I have made,) that a state of irritation leads to those dis-
eased vascular actions, which produce an alteration of structure
in the irritated parts.
However, where the disordered state of the bowels had been
of longer duration, I have found the villous coat of the intestines
swoln, pulpy, turgid with blood, and apparently inflamed, and
sometimes ulcerated; and these appearances have been most
manifest in the large intestines. Having observed repeatedly
in dissections of these cases, that the large intestines were more
diseased than the small ones, it occurred to me, that the fact
might be accounted for in the following manner: If digestion
is incomplete, the undigested food must be liable to chemical
changes, and the products resulting from this cause are likely
to be most stimulating to the large intestines. Indeed, in ad-
vanced stages of this disorder, mucus and jelly tinged with
blood are discharged, and it seems probable that a kind of
chronic dysentery may be thus induced.
In some instances, where the disorder had existed for many
years, the bowels had been diseased throughout their substance;
the internal coat being ulcerated, and the peritoneal covering
inflamed, so that the convolutions of the intestines were a
tinated to each other. In these cases the liver, and sometimes
the spleen also, were much diseased, being tuberculated in
every part. Such is the result of the information which I have
obtained by dissection.
Accurate attention to the subject, especially in medical cases,
may lead to important subdivisions, which I have not yet been
able to make. But when I find that irritation of the nervous
system, however it may originate, deranges the chylopoietic or-
gans, and affects the stomach, bowels, and liver, apparently at
the same time, I think it fair to infer, that these organs are
equally operated on by the same cause. Disorders of the
150
ON THE CONSTITUTIONAL ORIGIN AND

brain may affect the chylopoietic organs; and it is well known
that this influence is reciprocal. The stomach is said to be
chiefly concerned in producing these effects; but the causes of
the sympathetic affection are probably niore general. A fit of
passion has produced jaundice; and the irritation of teething in
children frequently suspends the secretion of bile; so that the
stools are not in the least degree tinged with that fluid. If the
head can thus affect the liver, it is reasonable to infer, that the
liver may reciprocally affect the head. It is very difficult to
form an opinion relative to this subject; for, in the instances
which have been mentioned, the affection of the liver may take
place, only because it forms a part of the digestive organs, and
not from a direct sympathy existing between it and the head.

irritation of the other chylopoietic organs may, as well as that
of the stomach, disorder the source of sensation.
To display how much hepatic irritation may affect the senso-
rium, and consequently the whole nervous system, I insert the
following case :
CASE II.
A gentleman applied to me with a thickened and tender
state of the periosteum of his tibia. This disease had troub-
led him for more than a year, but became at last so extremely
painful that he declared he had not slept for three months, and
ihat his life was so intolerable that he resolved to undergo a
course of mercury, even though, in the opinion of those sur-
geons whom he had consulted, his disease was not venereal.
The duration of the disease, as it had made no greater pro-
gress, induced me to coincide in the opinion which had been
given him. His tongue was much furred, his appetite was
moderate, and he was not conscious that his digestion was other-
wise than good. His bowels were perfectly regular. I de-
sired him to take five grains of the pilul. hydrarg. every second
pight; but, before he took them, to remark the colour of the
discharges from his bowels, and to observe whether the medi-
cine produced any change of it. In a week's time he called
upon me, and said, I come to tell you the strangest thing that
perhaps you ever heard, which is, that I actually do not know
ihe precise spot where the lump on my shin was situated, and
doubtless these pills which you directed are a most wonderful
compound of opium. The first gave me sleep, which I had

TREATMENT OF LOCAL DISEASES.
151
not had for three months. After taking a second, I have
slept soundly all night, and feel myself alert in the day. Every
other preparation of opium, which I have taken, failed in produ-
cing sleep, and made me ill during the succeeding day. After
all, continued he, it cannot be the pills that have made me well,
for they have had no perceptible effect on me. I asked him,
had he, as I requested him, remarked the colour of the alvine
discharges? He replied, he had, and that before he took the
medicine they were (to use the patient's own words) as black as
his hat, and now they were of a colour of a ripe Seville oranges.
The great relief arising from the correction of the biliary secre-
tion was not to me so strange as the patient expected. It is
doubtless such remarks that have impressed some medical men
with the opinion, that the liver was the root of the evil in all
disorders of the digestive organs.
Cases like the present, (and several similar ones will be found
recorded in this work,) appear to me highly valuable on many
accounts. They show that hepatic disorder may disturb the
sensorium, either immediately or intermediately, by disordering
other organs concerned in digestion ; they show how disorders
of the abdominal viscera may become the cause of various
other diseases, by disturbing the source of sensation and nerv-
ous energy; and they further show that unirritating and unde-
bilitating doses of mercury have, probably by their local action
in the bowels, a great influence in correcting the secretion of
bile, and by this means of relieving hepatic irritation.*

* To show how stomachic irritation may induce or maintain a general
disturbed state of the nervous system, I shall briefly relate the chief cir-
cumstances of a disorder which occurred in my own person. Having, in
consequence of dissection, had some morbific animal matter imbibed from
a cut on my finger, 1 suffered at first from severe fever, which subsiding,
left me much indisposed. I then became subject, occasionally, to consid-
erable and painful ulcerations of my throat, and to severe rheumatic pains,
which almost prevented me from going about. These symptoms left me
in the summer, and returned in the winter, during three succeeding years.
In the second winter, when their recurrence seemed to have arisen in con-
sequence of catching cold, the rheumatic symptoms rendered me almost a
cripple for three months; nor were they mitigated by any medicine which
I took. Exercise on horseback relieved them in a very great degree. I
could not exercise on foot, for the plantar fasciæ were affected, as were
my ancles, knees, elbows, and the muscles of my back. During the whole
of this illness I had no appetite, yet I ate food when it was put on the ta-
ble. The want of appetite excited no surprise ; for I thought it was a
natural consequence of general indisposition. At the end of three months,
I one day felt sick at stomach, for about an hour, but not to that degree as
to induce vomiting, and whilst this sensation continued I had not the
slightest rheumatic pain about me. I now resolved not to eat till my appe-
152
ON THE CONSTITUTIONAL ORIGIN AND
Nothing in pathology is more generally admitted, than the
reciprocal operation of disorders of the head and of the digest-
ive organs on each other; yet the exceptions to this general
rule deserve to be remarked in a comprehensive examination
of the subject. Some persons have great disorder of the di-
gestive organs, without any apparent affection of the nervous
system; and even diseases of a fatal nature may take place in
the former organs, without affecting the latter. Indeed, if we
examine any of the most evidently sympathetic affections, we
shall find the same exceptions. The stomach generally sympa-
thizes with disorder of the uterus, but it does not invariably
do so.
Many of the symptoms recorded in the description of the
state of health of those persons who are affected by disorder
in the digestive organs, denote a disturbance of the nervous
and muscular powers. When we observe this compound dis-
order, we can seldom determine which were the primarily af-
fected organs. General nervous irritation may have preceded
the disorder of the stomach and bowels, or may have been
caused by it. The history will generally show, that the de-
rangement of the digestive organs is secondary. When it
arises from local irritation, it can be produced only through the
medium of the sensorium. When it is idiopathic, it frequently
originates in causes which affect the nervous system primarily ;
such as anxiety, too great exertion of mind or body, and im-
pure air. Sedentary habits and irregularities of diet are causes
which may be supposed to act locally on the organs them-
selves. Nervous irritability and weakness are not perhaps
susceptible of a direct cure by medicine; but the disorders of
the digestive organs are more corrigible by medical remedies.
In practice, these require our chief attention ; and if their dis-
orders be corrected, all nervous irritation frequently ceases,
and health is restored. In many instances the nervous irrita-
tion, which has induced the disease, is trivial, and would soon
cease, were it not kept up by the reaction of its secondary
symptoms.

tite returned, and even then I gratified it very sparingly, eating only veg-
etable food, and drinking only water. In one week my appetite became
keen, my digestion easy, my stomach tranquil, and I was as free from
rheumatism, (a disorder to which I never had been subject,) as at any pe-
riod of my life. It is also sufficiently manifest how much uncomfortable
feelings of the bowels affect the nervous system, and how immediately
and completely the general disorder is relieved by an alvine evacuation,

TREATMENT OF LOCAL DISEASES.
153
Whether this disorder of the digestive organs be primary or
secondary, it generally produces irritation in the brain; and
thus may cause in many instances actual disease of that organ,
as will be stated in the conclusion of this paper. But derange-
ment of the digestive organs arises, in many cases, from es-
tablished nervous disorder: indeed there is often reason to sup-
pose that it is dependent on, or connected with, actual disease
of the brain. In such cases, the correction of the disordered
functions of the digestive organs cannot be accomplished; and
even if it were practicable, it would not cure the nervous dis-
ease. It is however highly necessary and advantageous to at-
tend to the disorder of the digestive organs, where it is only a
symptom of nervous disease. The relief of the former will
often mitigate, though it cannot cure the latter. *
The connexion of local disease with general disorder has
been often remarked; it has been formerly attributed to impu-
rity of the fluids; a theory which is not irrational. Imperfect
digestion must influence the qualities of the blood, and all parts
of the body may be affected from this source. But in account-
ing for the reciprocal influence of disorders of the head and the
digestive organs on each other, the modern explanation of these
phenomena, by means of sympathies, is perhaps preferable.
Afflicting intelligence will destroy the appetite and produce a
white tongue in a healthy person; and a blow on the stomach
disorders the head. These phenomena take place indepen-
dently of the blood, and can only be explained by admitting
that disturbance of one organ immediately affects another.
* The ingenious Mr. John Bell has of late published an opinion, that
all nervous disorders depend on the circulation of blood in the brain. The
opinion is founded on this dogma; the brain being insensible, there can be
no such thing as nervous irritation. Believing similar opinions to be
prevalent in the profession, I think it worth inquiring, whether, if the
motion of a worm in the stomach produces temporary blindness or convul-
sions, there be not some nervous irritation? If a man has his leg amputa-
ted on account of a compound fracture, and afterwards becomes delirious
and dies,—I grant that fulness of the vessels of the head will be found on
dissection; but was not the vascular action caused by precoding nervous
irritation? The same fulness of vessels and signs of inflammation are found
in those who die of fevers; but do not the miasmata which cause them
affect the brain, and suddenly impair and disturb its energy, and is not
then the vascular action a consequence? I would ask too, practically,
does blood-letting cure disorders in which there is a fulness of the vessels
of the head? It must be granted, that in many instances it temporarily
alleviates them, but in others it fails to relieve and even aggravates them.
20
154
ON THE CONSTITUTIONAL ORIGIN AND
The writings of the ancients abound with passages, in which
local diseases are attributed to, affections of the abdominal
viscera, and the same fact has been noticed by several of the
moderns. The French surgeons appear to be very solicitous
to keep the bowels in a cool and tranquil state; and Dessault
ascribes the origin of erysipelas to a bilious cause. The Ger-
man surgeons, Richter and Schmucker, attribute many local
diseases to gastric affections; and in Italy, Scarpa views the
subject in the same light. The English practitioners seem to
have been less attentive to this class of disorders; insomuch
that Fischer, a German, who published an account of the state
of medicine in this country, expresses his surprise that the
English should be so little acquainted with gastric diseases. I
know not exactly what ideas these gentlemen may annex to
the terms gastric and bilious disorders, since they do not par-
ticularly describe them. I have represented the subject in the
foregoing pages, as it has appeared to me on the most attentive
examination.
There is also an excellent dissertation, in which the effects
and treatment of disorders of the digestive organs are particu-
larly described, inserted in the eighth volume of the Memoires
de la Société Royale de Medicine of Paris for the year 1806,
at page 310, entitled Reflections sur le Traitment de la Manie
atrabílaire comparé a celui de plusieurs autres Maladies chron-
iques, et sur les Avantages de la Methode evacuante, par M.
Hallé. After describing the discharges from the bowels in
atrabiliary mania, he observes, that a similar state of those or-
gans is found in other diseases, namely, dropsy, hypocondriasis,
accompanied with difficulty of breathing and palpitation, obsti-
nate coughs, and a great number of very different diseases; to
all of which the same treatment is applicable. That the ex-
tremely prejudical consequences of disorders of the stomach
and bowels have been noticed at all times by persons of obser-
vation, and particularly by those who are in the habit of judging
of their state by their excretions, is sufficiently evident. The
ancients sought to correct the error by purging with hellebore,
and the moderns by more compound purges, to use the words
of M. Hallé, par le mélange de purgatifs résineux et des mer-
curiaux. I have not, however, met with any physiological in-
vestigation of the nature of these diseases, nor of the rational
objects of cure. It is to promote such an investigation, that I
have laid before the public the facts which have come under

TREATMENT OF LOCAL DISEASES.
155

my observation, and the reflections to which they have given
rise.
In investigating the connexion between local diseases and
disorder of the health in general, I can perceive, that failure
in the functions and irritation of the digestive organs may act
prejudicially on the system in general in various ways. They
may produce weakness, for strength and vigour seem to arise
from the conversion of our food into perfect blood. They may
produce an impure state of that fluid, and they may produce
great irritation of the brain, and thus influence the whole
body. However, what I have to observe respecting the causes
and cure of local diseases will be most properly introduced and
best understood after the cases have been recorded, upon which
the opinions have been founded."
The result of all these observations, which I have been able
to make, relative to this subject, has induced me to believe
that the disorder of the digestive organs, caused by the various
circumstances which have been recited, consists in a weakness
and irritability of the affected parts, accompanied by a deficien-
cy or depravity of the fluids secreted by them, and upon the
healthy qualities of which the due performance of their functions
seems to depend. This opinion is deduced immediately from
the consideration of the symptoms, and confirmed by all the
collateral evidence, which we can collect. The duration of
the affection, without fatal consequences, shows that it is a dis-
order of functions, and not a disease of structure. Dissections
confirm the opinion. Blows which excite general irritation of
the digestive organs, produce also the symptoms which charac-
terize the like disorder, when it arises from nervous irritation,
or is excited by intemperance. I doubt not but every one will,
on reflection, consider the disorders of the digestive organs to
be of the first importance, and will perceive the propriety of
diligently inquiring into their nature, that we may know them
when they exist, and that our attempts to remedy them may
be conducted on rational principles. This consideration will, I
trust, vindicate me for employing so much time in an investiga-
tion which, perhaps, some may consider as tedious and unpro-
fitable.
156
ON THE CONSTITUTIONAL ORIGIN AND
OCCASIONAL EFFECTS OF DISORDER OF THE DIGESTIVE
ORGANS.
It is generally admitted, that disorders of the chylopoietic
viscera will affect the source of sensation, and consequently the
whole body; but the variety of diseases, which may result
from this cause, has not been duly weighed and reflected on.
It may produce in the nervous system a diminution of the
functions of the brain, or a state of excitation, causing delirium ;
partial nervous inactivity and insensibility, or the opposite state
of irritation and pain. It may produce in the muscular system,
weakness, tremors, and palsy; or the contrary affections of
spasm and convulsions. It may excite fever by disturbing the
actions of the sanguiſerous system ; and cause various local
diseases by the nervous irritation which it produces, and by the
weakness which is consequent on nervous disorder or imper-
fect chylification. Or if local diseases occur in a constitution
deranged in the manner which I have described, they will be-
come peculiar in their nature and progress, and difficult of cure.
Affections of all those parts which have a continuity of surface
with the stomach; as the throat, mouth, lips, skin, eyes, nose,
and ears, may be originally caused or aggravated by this com-
plaint. I must observe, before I proceed to the relation of
cases, that such a disorder of the digestive organs as I have
described existed in every instance. I do not take upon my-
self to say that it was the primary cause of the general derange-
ment of the constitution, with which the local disease appeared
to be connected; it might have been the consequence, as in-
deed has been stated in these preliminary observations.


TREATMENT.
I shall now proceed to mention the plan which I have pur-
sued in the treatment of these disorders, when they have been
connected with surgical diseases : with what degree of success,
the following cases will demonstrate. I do not feel altogether
competent to give full directions relative to this subject; be-
cause I have never attended to medical cases with that degree
of observation which would lead me properly to appreciate the
efficacy of different medicines, when adninistered either in
their simple or compounded forms. The subject is so impor-

TREATMENT OF LOCAL DISEASES.
157
{ant, that the public would be highly indebted to any practition-
er, who would point out the varieties of these diseases, and the
appropriate modes of cure. The method of treatment, which
I have adopted, is simple, and founded on the opinions I have
formed of the nature of the disease, and on physiological views
of the functions of the affected organs. Believing the disorder-
ed parts to be in a state of weakness and of irritability, my
object has been, to diminish the former and allay the latter.
Believing also that the secretions into the stomach and bowels,
upon the healthy state of which the due performance of their
functions depends, were, in consequence of such disorder,
either deficient in quantity or depraved in quality ; I have en-
deavoured to excite, by means of medicine, a more copious and
healthy secretion.
It is a principal object of medicine to give strength and tran-
quillity to the system at large, which must have a beneficial in-
fluence on all its parts, and greatly promote the well-doing of
every local disease. We cannot reasonably expect tranquilli-
ty of the nervous system whilst there is disorder of the diges-
tive organs. As we can perceive no permanent source of
strength but from the digestion of our food, it becomes impor-
tant on this account that we should attend to its quantity, qual-
ity, and the periods of taking it, with a view to ensure its per-
fect digestion.
First, With respect to quantity: There can be no advantage
in putting more food into the stomach than it is competent to
digest, for the surplus can never afford nourishment to the bo-
dy; on the contrary, it will be productive of various evils.
Being in a warm and moist place, the undigested food will un-
dergo those chemical changes natural to dead vegetable and
animal matter : The vegetable food will ferment and become
acid, the animal will grow rancid and putrid ; this is only ren-
dered evident occasionally, when a disordered stomach rejects
some of its contents; then the teeth are roughened and set on
edge by the corrosive qualities of the acid, and the throat feels
burnt by the acrimony of the rancid oil. These effectst, hough
occasionally made apparent, must constantly take place, unless
by the digestive powers of the stomach the food is converted
into a new substance which is not liable to these chemical
changes. Such new and irritating compounds may not indeed
materially injure a healthy stomach, but cannot fail to be detri-
mental to one that is weak and irritable, as well as to the whole



158
ON THE CONSTITUTIONAL ORIGIN AND

tract of the alimentary canal, and thus maintain and aggravate
its disorder. Part of the food thus changed will be imbibed
from the bowels, and render the blood impure, from which there
is no outlet for various kinds of matter but through the kid-
neys; and thus may prove a cause of foul urine, as well as of
the presence of many substances in that fluid not natural to it,
and be productive of serious diseases in the urinary organs.
Observing the evils resulting from undigested aliment, we sure-
ly ought cautiously to guard against them by proportioning the
quantity of our food to the digestive powers. Nature seems
to have formed animals to live and enjoy health upon a scanty
and precarious supply of food; but man in civilized society,
having food always at command, and finding gratification from
its taste, and a temporary hilarity and energy result from the
excitement of his stornach, which he can at pleasure produce,
eats and drinks an enormous deal more than is necessary for
his wants or wellare ; he fills his stomach and bowels with food
which actually putrifies in those organs; he fills also his blood
vessels till he oppresses them, and induces diseases in them as
well as in his heart. If his digestion be imperfect, he fills them
with unassimilated substances, from which nutriment cannot be
drawn, and which must be injurious. In proportion as the
powers of the stomach are weak, so ought we to diminish the
quantity of our food, and take care that it should be as nutritive
and easy of digestion as possible. By adopting an abstinent
plan of diet even to a degree that produces a sensation of want
in the system, we do that which is most likely to create appe-
tite and increase the powers of digestion. In how great a de-
gree want effects these objects, is evident in those who have
been obliged to fast from necessity, or have been much re-
duced by hæmorrhage.
Secondly, As to quality : It is not my intention to discuss
the question as to the nature of the food proper for mankind.
When the stomach is weak, it seems particularly necessary
that it should be nutritive and easy of digestion. I may fur-
ther observe, that its qualities should be adapted to the feelings
of the stomach. In proof of this proposition, numerous instan-
ces might be mentioned of apparently unfit substances agreeing
with the stomach, being digested and even quieting an irritable
state of stomach, merely because they were suitable to its feel-
ings. Instances might also be mentioned of changes in diet
producing a tranquil and healthy state of stomach in cases
TREATMENT OF LOCAL DISEASES.
159
where medicines had been tried in vain. Neither can such
occurrences excite surprise, for as digestion and the consequent
tranquillity of the stomach depends on a proper quantity of
healthy juices being secreted and commixed with the food,
such secretions are likely to be produced by whatever agree-
ably excites it, and obstructed by whatever has a contrary ten-
dency:
Thirdly, As to the times of taking food : It is evidently the
intention of nature that we should put into the stomach a cer-
tain portion of food, the excitement of which inducing a secre-
tion of gastric fluid, by its action becomes digested. This of-
fice of the stomach being effected, it should be left in a state
of repose till its powers are restored and accumulated, and this
return of energy would in health be denoted by a return of ap-
petite. It is probable that three hours may elapse in health
before the digestion of a moderate meal is effected, so that the
stomach is empty and in a state of repose. It is therefore rea-
sonable to allot the same portion of time for the same purpose
5 disordered, whilst we have diminished the
quantity of our food in order to proportion it to the diminished
powers of the organ; yet instead of pursuing this rational plan
of diet, many persons are taking food every third or fourth hour,
pleading in excuse for such conduct that they cannot do with-
out it. The truth is, that when the stomach is disordered, the
exertion of digesting a single meal after its excitement and ef-
forts have ceased, is productive of sensations of languor, sink-
ing and inquietude, which ought to be calmed or counteracted
by medicines, and not by food, for a second meal cannot be di-.
gested in this state of the stomach. We also often teaze and
disorder our stomachs by fasting for too long a period; and
when we have thus brought on what I may call a discontented
state of the organ, unfitting it for its office, we sit to a meal,
and fill it to its utmost, regardless of its powers or its feelings.
The rules then for diet may be thus summarily expressed :
We should proportion the quantity of food to the powers of the
stomach, adapt its quality to the feelings of the organ, and take
it at regular intervals of six or seven hours thrice during the
day. It would be well if the public would follow the advice
of Mr. Addison, given in the Spectator, of reading the writings
of L. Cornaro, who, having naturally a weak constitution, which
he seemed to have ruined by intemperance, so that he was ex-
pected to die at the age of thirty-five, did at that period adopt.


. 160
ON THE CONSTITUTIONAL ORIGIN AND
a strict regimen, allowing himself only twelve ounces of food
daily. By this plan of diet he lived to more than one hundred
years; and it is delightful to observe the tranquil, cheerful and
energetic state of mind accompanying his bodily health, and in a
great degree induced by it. Cornaro found that as the powers
of his stomach declined with the powers of life in general, that
it was necessary he should diminish the quantity of his food,
and by so doing he retained to the last the feelings of health.
Every thing which we take into the stomach, except food,
may be considered in two points of view ; either as a diluent or
a medicine. Water is the only diluent, and we are in the
habit of mixing alimentary matter and stimulants with it. Di-
luents probably ought not to be taken during or immediately
after our meals, since they would be likely to render the juices
of the stomach less efficacious in the digestion of our food.
Hunger and thirst seem to be incompatible sensations: an
hungry animal would eat to satiety, and the stimulus of the food
would bring on a discharge of the juices of the stomach, which
have the power of digesting the food ; and it is not probable
that the sensation of thirst would be experienced till this ope-
ration of the stomach is effected. If the sensation of thirst then
occurred, water would appease it, without frustrating the diges-
tive functions, and being absorbed; from the alimentary canal
a certain portion of it would be furnished to the blood, and the
surplus would pass off from the skin, lungs and kidneys. All
stimulants must be regarded as medicines; vinous liquors are
of this class, and being suitable to the feelings of the stomach,
are in many cases very efficacious, yet they are very liable
quickly to pass into a state of acetous fermentation, and to pro-
mote that change in the remaining quantity of the vegetable
matter contained in a disordered stomach, and thus produce a
strong and injurious acid. The rule for taking vinous liquors in
persons to whom habit has rendered them necessary, may be thus
briefly stated. They should not take them during their meals,
lest the temporary excitement they produce should induce them
to take more food than the powers of the stomach are capable
of digesting, but afterwards they may be allowed so much of
them as may be required to induce agreeable feelings, or to
express the fact more clearly, as is necessary to prevent those
uncomfortable sensations which the want of them may occasion;
and it may be added, the less they take the better. People
deceive themselves on this point. A disordered stomach will




TREATMENT OF LOCAL DISEASES.
161
feel uncomfortable after eating ; fermented liquors remove for
a time the unpleasant sensations. Potion after potion is swal-
lowed on this account, often without producing permanent tran-
quillity, and much to the injury of the stomach. Wine drink-
ers do not drink wine after every meal, which proves that wine
is not necessary to their digestion ; and many who confided in
this belief have been convinced of their error, by leaving it off
and finding that they digested their food as well when deprived
of it, and that such privation greatly contributed to their even-
tual restoration to health. When stimulants seem requisite, and
fermented liquors run into the acetous fermentation in the sto-
mach, spicy and aromatic vegetables should be substituted, such
as ginger, pepper, mustard, &c.
Stomachic medicines are given to strengthen a weak stomach.
to tranquillize an irritable one, or to counteract some morbid
peculiarity in the feelings and actions of that organ. There is
a time when stomachic medicines seem to be particularly re-
quired. About three hours after a meal, when the stomach is
exhausted by the labour of digestion, when its morbid propen-
sities are increased by the languor consequent to fatigue; at
this period, when persons are in the habit, through ignorance,
of taking food to appease their distress, they ought, as has been
said, to take these kinds of medicines.
Even our food must be considered as exerting a medicinal
influence in disorders of the stomach, when that organ is irrita-
ble. A vegetable diet and abstinence from fermented liquors
may tend to tranquillize it. On the contrary, when it is weak
as well as irritable, that aliment which is most readily digested
is to be preferred, and cordials are sometimes beneficial. The
effects of food and medicine can never be considered as result-
ing from their operation on the stomach solely, but from their
conjoint influence upon the nervous system in general. Irrita-
bility of the stomach may arise from that of the brain, and un-
stimulating diet may tend to tranquillize the latter organ, and
thereby alleviate the disorder of the former. On the contrary,
a more generous diet may, by exciting the nervous system,
produce that degree of energy in its actions, which invigorates
the stomach, and tranquillizes its disorder. It may further be ob-
served in some cases, that the kind of medicines or diet which is
serviceable to the stomach, may aggravate the nervous disorder;
and on the contrary, that those means which seem to tranquil-
lize nervous irritation tend to diminish the powers of the stomach.


21
162
ON THE CONSTITUTIONAL ORIGIN AND
LIIC
Bark and steel are not uncommonly given in these diseases
to increase the powers of the stomach : they ought, I think, to
be administered in small doses, and never when the tongue is
dry; as they seem to suppress those secretions, which in many
cases are already deficient; and the increase of which would
tend to relieve irritation in the affected organs. I mention this
opinion, however, rather to account to the reader for these
medicines not having been prescribed in the subsequent cases,
than from any other motive; as I do not feel perfectly compe-
tent to decide upon their degree or kind of utility.
Vegetable diet-drinks appear to me very useful in tranquil-
lizing and correcting disorders of the stomach and bowels, for
this is the manner in which they seem to be efficacious in t
cure of local diseases. The vegetables prescribed in the dif-
ferent formulæ are so dissimilar, that we can scarcely suppose
that they act specifically upon the local disease. Even sweet-
wort has obtained considerable celebrity. When diet-drinks
fail to correct the disorders of the digestive organs, they also
fail to produce any amendment on local diseases. Such ob-
servations have induced me to believe that they have the utility
which I have ascribed to them, of tranquillizing and correcting
disorders of the stomach and bowels. It is allowable to form
an opinion from such observations, though I am sensible of
their invalidity as argnments to prove its truth.
Whilst thus on the one hand, by endeavouring exactly to
proportion the quantity of food to the powers of digestion, by
adopting an abstinent system of diet, and taking medicines
suitable to the condition of the stomach, we endeavour to foster
the powers and ensure the tranquillity of this important organ,
we ought on the other most carefully to attend to the regulation
of the action of the bowels, with a view to insure their tranquil-
lity; for the state of one part of the canal will be regulated by
the state of health or disease in the other. To produce tran-
quillity of the bowels when they are in a disordered state, it is
necessary that the residue of the food be daily carried down
and discharged from those organs; this is their natural func-
tion, and if they fail in its performance, they should be excited
by appropriate medicines, yet without teazing them so as to
induce what is ordinarily called purging. Purging, occurring
spontaneously, shows that the bowels are irritable, and the
aqueous and other discharges which take place from them in
that condition often relieves their irritability. When purging
occurs in consequence of taking medicine, it shows that the


TREATMENT OF LOCAL DISEASES.
163
bowels have been irritated and have relieved themselves in their
usual manner. Persons may be purged without having their
bowels cleared of the fæcal matter which may be detained in
them; we should therefore endeavour to ascertain what kind
or combination of purgative medicines will excite a healthy ac-
tion of the bowels, without teazing them or producing discharges
from the organs themselves. The best mode of proportioning
the degree of excitenient to the end designed is to take a dose
of a suitable medicine at night, but short of that which may
prove irritating ; if it fails sufficiently to excite the organs, a
similar dose may be taken in the morning ; which also failing,
it may be repeated at an advanced period of the day..
Purging medicines sometimes relieve unpleasant sensations;
but they do not in general produce even this effect; and all ac-
tive purges seem to me to increase the disorder. It is natural
to suppose that strong stimuli will aggravate the unhealthy con-
dition of weak and irritable parts.
I have already expressed my opinion of the manner in which
the continuance of purgative medicines, in such doses as do
not immediately purge, relieve disorders of the digestive or-
gans, by producing morbid secretions which afford considerable
relief, either when they occur spontaneously or are thus in-
duced. This plan of practice is what Dr. Hamilton has sug-
gested, and the utility of which he has so successfully eluci-
dated. I am aware that laxative medicines may relieve irri-
tation merely by augmenting the natural secretions of the vis-
cera, and thus unloading their vessels; and also by determining
the fluids from the head, when the nervous symptoms are
aggravated by a plenitude of the vessels of the brain. As I
have found the lenient plan of treatment, (that of exciting the
peristaltic action of the bowels, so as to induce them to clear
out the whole of the residue of the food, without irritating
them, so as to produce what is ordinarily called purging,) par-
ticularly successful, I have rarely deviated from it. I am not,
therefore, warranted from experience in speaking decisively
respecting the more free use of purgative medicines.
It is difficult, in many cases, to regulate the actions of the
bowels either by diet or medicine. They are costive for a time,
and then fits of purging come on. The former state must be
obviated, in order to prevent the latter. Medicines which ex-
cite a healthy action of the bowels in one person, are either in-
ert or too active in another. Doses, which would have no
effect in a state of health, become purgative in this disorder ;

164
ON THE CONSTITUTIONAL ORIGIN AND
a circumstance which shows that the bowels are irritable.
There are some rare instances of the contrary, in which it is
exceedingly difficult to excite the actions and secretions of
these viscera.
I have found in some cases, that purgative medicines
and spices dissolved in spirit and water, have answered bet-
ter than anything else, in producing a sufficient, but not
too copious a discharge from the bowels. Equal parts of
compound tincture of rhubarb and senna is the formula to
which I allude. When irritation in the large intestines has
been denoted by the mixture of mucus and jelly with the
fæces, and sudden and urgent calls to void them, I have ad-
vised oily and mucilaginous medicines as aperients: as castor
oil, mixed with a large proportion of mucilage. My sole object,
however, has been to regulate the state of the bowels; and
when they have been regular without medicine, I have rarely
recommended any."
At the same time, I have not been inattentive to the error
in the biliary secretion, which exists in the greater number of
these cases. I have endeavoured to correct this error by the
administration of such small doses of mercury as do not
irritate the bowels, and are not likely to affect the constitution,
even though persevered in for a considerable time. In this
state of the digestive organs, calomel, in small quantities,
sometimes proves irritating. I have combined it, as in Plum-
mer's pill, and have given one grain every other night. Where
this dose produced uneasy sensations, or acted as an aperient,
five grains of the pil. hydrarg. were substituted in its place;
and even this quantity has been diminished in some cases.
When the bowels are very irritable, the hydrarg. cum cretâ has
been given.* When it appeared necessary, on account of
the biliary secretion, and when the calomel did not irritate the
bowels, I have increased the dose. The relief, which arises
from the increase or correction of the biliary secretion, in a
great number of these cases, shows how much the liver is con-
cerned in causing or aggravating the symptoms in these diseases.

* I have mentioned in the second part of these observations, that thie
pilul, hydrarg. are very uncertain in their effects. Some of the students
at the hospital, on examining them, and different parcels of the conserve
of roses, say, that sulphuric acid may be discovered in each. Nor is it im-
probable, that in making the conserve for sale, some of this acid may be
added to brighten its colour; and if so the pilul, hydrarg. which are made
from it may contain, in varying proportions, some of that highly deleteri-
ous compound, the sulphate of quicksilver.
TREATMENT OF LOCAL DISEASES.
165
There are numerous and undoubted proofs of the utility of
mercury, in correcting and augmenting the biliary secretion ;
but the mode of administering it has not, perhaps, been suffi-
ciently attended to. I have known patients, who had voided
nothing but blackish stools for some months, discharge fæces of
a light yellow colour, denoting a healthy, but deficient secretion
of bile, upon taking such small doses of mercury. The effect
of this change on the constitution and spirits has been surprising-
ly great ; though the state of the stomach did not appear to be
altered. The use of mercury by inunction, sometimes acts
beneficially, in correcting the biliary secretion ; but if the con-
stitution be irritated and weakened by that medicine, the ac-
tions of the liver are disturbed, and the digestive organs in
general become deranged. Mercury, in my opinion, acts
most certainly and efficaciously, when taken into the bowels;
and a much smaller quantity will suffice, when its application is
in this manner rendered chiefly local.
Facts are wanting, to enable us to ascertain, whether mer-
cury meliorates and augments the secretions of the other di-
gestive organs, as it does that of the liver. The stornach fre-
quently appears worse during its employment, whilst the stools
are considerably better: I have, in such cases, discontinued
the medicine, and returned to it again if the state of the liver
made it necessary. When benefit is obtained from a small
quantity of medicine, we naturally expect an increased advan-
tage from an augmented dose; this is so natural an error, that
an admonition against it appears necessary. I have observed
in some instances, where small doses of mercury have unex-
pectedly affected the mouth, that considerable benefit seemed
to arise from this circumstance. Yet it is wrong, in general,
to augment the dose of the medicine, so as to create even local
irritation in the bowels by it. The various effects of mercury
in disorders of the digestive organs cannot, I think, be under-
stood, but by considering, not merely its local operation on
these organs, but also its action on the constitution at large.
When we see the biliary secretion corrected by a few grains
of the pilul. hydrarg., as in the second case, we cannot but be-
lieve its action to be local. When the medicine is given in
larger doses, it exerts an influence on the whole constitution,
and alters the state of the nervous system. It thus controls
diseases dependent on an irritable and disturbed state of the
nervous functions: this I think I shall be able to show by ca-
ses related in that part of this book which treats on diseases



166
ON THE CONSTITUTIONAL ORIGIN AND
induced by the absorption of morbific animal poisons; and
thus mercury may relieve disorders of the digestive organs by
relieving the nervous disorder which caused them. But when
mercury is given in still larger doses, as it is for the cure of
syphilis, it never fails to irritate and weaken the constitution,
and thus to disorder the digestive organs. Persons who are
salivated have, as far as I have remarked, the functions of the
liver and digestive organs constantly disturbed by that process.
I cannot, therefore, but think that it is wrong to use mercury
in hepatic affections to that extent, which would disorder the
functions of the liver, if they were previously healthy. In the
majority of cases the disorder has existed for a long time, and
has become habitual; therefore it is not likely to be cured sud-
denly. For this reason, we should adapt our treatment to the
more rational expectation of effecting a gradual recovery than
a sudden cure. The most judicious treatment will not remedy
the disease, if the exciting causes continue to operate; such
as improprieties of diet, agitation of mind, sedentary habits, or
impure air.
Although experience has made me think very highly of the
efficacy of small doses of mercury, in exciting and correcting
the biliary secretion ; yet it ought to be mentioned, that in
some few cases, this medicine fails to produce its usual effects,
and that the biliary secretion becomes healthy without its ad-
ministration. Nor is this surprising, for in general disorders of
the digestive organs, one organ is more disordered than the
rest, and appears to have been the cause of the whole affection.
Thus the liver may disturb the functions of the stomach and
bowels, or it may be disturbed by them. A .
The following cases will afford sufficient testimony of the
efficacy of such simple treatment as I have recommended, and
which appears to be well adapted to gradually restoring the
healthy actions of the digestive organs in cases of chronic dis-
order and disease. The treatment must be considered very
deficient, as a general account of what can be effected by med-
icine. In acute disorders of the digestive organs, we know that
nauseating medicines by exciting the secretions, often relieve
stomachic irritation, and that emetics and other remedies which
suddenly and powerfully affect the stomach, produce great
changes in the state of that organ and of the nervous system,
as well as correspondent alterations in local diseases. In
some inveterate cases, apparently depending on established
nervous disorder, this simple treatment has been ineffectual.



TREATMENT OF LOCAL DISEASES.
167
Under such circumstances, the nervous affection appears to re-
quire the principal attention.
In investigating the treatment of these disorders, it is neces-
sary to ascertain, not only what medicine is beneficial, but also
what change it produces in the circumstances of the disorder.
The administration of a medicine may in one case be succeed-
ed by a discharge of bile, and a striking relief from long con-
tinued and distressful feelings; yet the same medicine may be
given in many other instances without the same consequence.
Was the change, then, in this instance accidental? or must it
be attributed to some unnoticed peculiarity in the disease or
constitution ?
I have generally explained to the patients the objects which
I had in view, in correcting disorders of the digestive organs,
by saying that there are three things which I consider as right
and necessary to the cure of disorder. First, that the stomach
should thoroughly digest all the food that is put into it. The
patient, perceiving the necessity of obtaining this end, becomes
attentive to his diet, and observes the effect which the quantity
and quality of his food and medicines have upon his feelings,
and the apparent powers of his stomach. Secondly, that the
residue of the food should be daily discharged from the bow-
els : here too, the patient, apprized of the design, notes wha
kind and dose of purgative medicine best effects the intention ;
and whether it answers better if taken at once, or at intervals.
Thirdly, that the secretion of bile should be right, both with
respect to quantity and quality. In cases wherein the secre-
tion of bile has been for a long time deficient or faulty, I re-
commend, as I have said, unirritating and undebilitating doses
of mercury to be taken every second or third night, till the stools
become of the wet-rhubarb colour. This mode of exhibiting
the medicine has at least the advantage of being innocent, and
if months elapse before the object is accomplished, we cannot
wonder at the tardiness of the cure, when we consider the
probable duration of the disorder, prior to our attempts to cor-
rect it. The patient is relieved in proportion as the end is ac-
complished, which feelingly induces him to persevere in such
innocent measures. By thus engaging the co-operation of the
patient, the practitioner will, in my opinion, derive considerable
advantage in the treatment of the case.
Whenever circumstances would permit, I have recommended
the patients to take as much exercise as they could, short of pro-
ducing fatigue; to live much in the open air; and, if possible,


168
ON THE CONSTITUTIONAL ORIGIN AND
not to suffer their minds to be agitated by anxiety, or fatigued by
exertion. The advantages of exercise in nervous disorders, upon
which those of the digestive organs in general so greatly depende
appear to me very striking. It were to be wished that we had
some index to denote the strength and irritability of the ner-
vous system, serving as the pulse does with regard to the san-
guiferous organs. Perhaps the strength, agility, and indefatiga-
bility of the muscles may be regarded as the surest evidence of
energy of nervous power and bodily vigour. If this were
granted, however, it would follow that many persons, possess-
ing great nervous power, have nevertheless great nervous irrita-
bility. Many people, who are extremely irritable and hypo-
condriacal, and are constantly obliged to take medicines to regu-
late their bowels whilst they live an inactive life, no longer suffer
from nervous irritation, or require aperient medicines, when
they use exercise to a degree that would be excessive in ordi-
nary constitutions. The inference which I draw from cases of
this description is, that nervous tranquillity is restored in con-
sequence of the superfluous energy being exhausted by its
proper channels, the muscles. When, on the contrary, the
nervous system is weak and irritable, exercise seems equally
beneficial; but caution is here requisite as to the degree in
which it should be taken. A weak and irritable patient may
not be able to walk more than half a mile without nearly faint-
· ing with fatigue on the first day of the experiment; but
: persevering in the effort, he will be able to undergo consider-
able muscular exertion without weariness. Does not this im-
ply a considerable increase of bodily strength ? and is not the
acquisition of strength the chief desideratum in the cure of many
disorders? The nervous irritability also, when dependent on
weakness alone, will proportionably diminish with its cause.
In the latter case, the nervous energy seems to be augmented
in consequence of our increasing the demand for it. I am in-
duced to make these observations, from a belief that exercise is
not employed, as a medical agent, to the extent that its efficacy
seems to deserye : of its medical effects I entertain a high
opinion. It is however right to direct patients with regard to its
use, not to exert themselves for some time previous to a meal,
nor for three hours after. I would prescribe to my patients
the following rules : They should rise early, when their powers
have been refreshed by sleep, and actively exercise themselves
in the open air till they feel a slight degree of fatigue; they
should rest one hour, then breakfast, and rest three hours, in




TREATMENT OF LOCAL DISEASES.
169
order that the energies of the constitution should be concentered
in the work of digestion; then take active exercise again for
two hours, rest one, then taking their dinner they should rest
for three hours, exercise two, rest one, and take their third
slight meal. I do not allow the state of the weather to be
urged as an objection to the prosecution of measures so essen-
tial to health, since it is in the power of every one to protect
themselves from cold by clothing, and the exercise may be ta-
ken in a chamber, with the windows thrown open, by walking
actively backwards and forwards as sailors do on ship-board.
I also caution patients against sleeping too much; waking from
sleep indicates that the bodily powers are refreshed; many
persons upon first waking feel alert and disposed to rise, when
upon taking a second sleep they become lethargic, can scarcely
be awakened, and feel oppressed and indisposed to exertion
for some time after they have risen. When the disorders which
have been the subject of this paper, have been long continued,
they do not admit of a speedy cure; hence attention to diet, air,
exercise, and mental tranquillity, are more decidedly beneficial
than medicines. Surgeons in London meet with frequent and
convincing instances of the efficacy of pure air. Patients under
the irritation of a local disease, who scarcely eat or sleep in town,
recover their appetite, digestion, and sleep, so suddenly on
their removal into the country, as to leave no room for doubt-
ing, that the change of air has produced this beneficial alteration
in their health. The whole of the plan of treatment which is
bere recommended is so simple, and apparently so inefficient,
that its power might reasonably be doubted, did not facts at-
test its utility. I should not have thought it right to have thus
related it in detail, but for the purpose of avoiding repetition in
the recital of the cases which are to follow; and also because
it seemed right to state as explicitly as possible to the younger
part of the profession what are the curative intentions in disor-
ders of this nature.*


* After I had written the above account of the treatment, which I had
found the most succcessful in the correction of disordered states of the di-
gestive organs, I was much gratified by the perusal of Dr. Hamilton's
publication on the Effects of Purgative Medicines. I think there is a great
coincidence in the mode of treatment which I have described, and that
which is sanctioned by his more extensive experience. He prescribes
purgative medicines to act as eccoprotics, to excite but not to stimulate the
bowels; and he combines with them generally unirritating doses of mer-
cury. Dr. Hamilton's plan of treating these diseases also accords very
much with that of Mr. Hallé, to whose Memoir I have referred the reader.
22
170
ON THE CONSTITUTIONAL ORIGIN AND
CASES.
S.
SECTION I.
ON NERVOUS AND MUSCULAR DISORDERS.
Long before my attention was excited to disorders of the di-
gestive organs, I had remarked that there was a paralytic affec-
tion of the lower extremities, resembling that which is produced
by a disorder of the medulla spinalis, in consequence of dis-
ease of the bodies of the vertebræ. This paralytic affection
also appeared to me to vary with the state of the patient's health,
These observations led me to propose a method of treatment,
which proved successful in the cases of two young ladies, who
were affected in this manner. The issues, which had been
ineffectually kept open in the back, were healed ; and the state
of the health in general was amended by country air, exercise,
attention to diet, and a few simple medicines. The use of the
limbs returned in proportion as the health became established.
Such were the observations which I had made relative to this
subject, when I met with the following cases.

an
CASE 111.
A young lady, whose stomach and bowels were disordered
in the manner already described, became gradually affected
with weakness of the lower extremities, and pain in the loins.
The pain became at length very severe, and was aggravated in
a manner almost insupportable by the agitation of a carriage.
This lady could scarcely walk, and gave a description of the
state of her limbs, so exactly resembling that which is some-
times consequent to diseases of the vertebræ, that I thought it
right to examine the spine. I struck with my finger the spinous
process of each lumbar vertebra, and upon touching one in
particular, the patient complained of great pain ; but pressure
on the contiguous vertebræ also caused much uneasiness. Un-
der these circumstances I placed a blister on each side of the
spine, and kept up a discharge from the surface by dressing it
with savine cerate. These means, with rest, relieved her suf-
TREATMENT OF LOCAL DISEASES.
171
TE
ferings; but, as her health declined, she went into the country,
where she soon became much better. The blisters were now
suffered to heal, and she shortly afterwards had recovered so
much, as to take long rides on a rough-going horse. She re-
turned from the country in good health, and was both muscu-
lar and fat. About a year afterwards she was so ill, in the
same way, that she wished to have issues made in the back:
but I would not consent to this, from knowing that the bone
could not be diseased. Of this return of pain in the back, and
weakness in the lower extremities, she again got well, upon
amendment of her health in general. Since that period, now
five years ago, she has been, sometimes, very well, at others,
pale and emaciated ; and these changes have corresponded
with the natural or deranged state of her bowels.

CASE IV.
I was consulted on the case of a young lady, who had been
blistered severely for a pain at the bottom of her back, which
was chiefly felt at the junction of the ilium and sacrum. It was
supposed, that disease had taken place in the bone froin some
injury, and had affected the sacral nerves: for she could not
stand without support, so great was the weakness in the front
of the thighs. There was no projection of the vertebræ. If
the sacral nerves had been affected, the leg ought to have suf-
fered the greatest share of pain and weakness; but that was
not the case. She had no appetite; her tongue was greatly
furred; her bowels costive ; and pulse generally 110. I strong-
ly objected to making issues in this case; but as the patient's
sufferings increased, it was done. She went into the country,
and died in four or five months. The bone was found, upon
examination, to be perfecily healthy; but the mesenteric glands
and lungs were diseased, and it was concluded that she died of
consumption. I could not learn the state of the liver, nor do I
know whether its appearances were particularly attended to.

CASE V.
A young lady had been confined about six months to her
chamber, on account of pain in the loins, and weakness of the
lower extremities, which prevented her from standing or walk-
ing. The weakness of her limbs had been gradually increasing
for a year and a half, before it became so bad as to make her
incapable of moving about. Issues had been kept open, during

172
ON THE CONSTITUTIONAL ORIGIN AND
that time, on cach side of the spine ; but as the patient received
no benefit, my opinion was asked respecting the seat of the dis-
ease of the bone: for it was concluded, that the issues had only
failed from not having been made in the right place. I found,
upon inquiry, that the chief seat of her pain was in the posterior
edge of the liver. Indeed, that viscus was enlarged, so as to
be felt in the epigastric region, and was so tender as to cause
much pain on being compressed, at any part, along the cartila-
ges of the ribs. Her tongue was furred; her appetite deficient;
digestion bad ; bowels costive ; and stools black, or else un-
tinged with bile. I had no hesitation in advising, that the issues
should be discontinued; and that attention should be chiefly
directed to rectify the disorder of the chylopoietic viscera.
Mild mercurials and aperients were given, by which, with other
means, she got materially better in health, and was able to
walk about as well as ever. The gentleman who attended this
patient, met me accidentally, two months afterwards, and in-
formed me that she was quite well. I said, that as her disease
had been a long time in forming, it could hardly be expected
that she should recover so suddenly. He considered this ex-
pression as implying some doubt of his accuracy, and, therefore,
sent the patient to me in the morning. She came from Lam-
beth, in a hackney coach, and looked very well : she observed,
that long before her confinement, she could not have borne the
agitation of a carriage ; but that now, she did not feel it. I
have been informed, by several intelligent students, that similar
cases have occurred in the hospital : as I was not a witness of
these, I shall not relate them. I shall, however, mention one,
which I saw, and superintended myself; although it is, in some
measure, imperfect, as the patient quitted the hospital sud-
denly, without our knowing where he went to.

CASE VI.
Thomas Crighton, aged twenty-three, was admitted into St.
Bartholomew's Hospital, on account of a palsy of his limbs.
About a year before, while the use of his limbs was yet unim-
paired, he was attacked repeatedly with violent pain in the
bowels; uniformly preceded by costiveness, and, generally,
terminated by a copious discharge of loose, fetid, black stools.
The relief afforded by the diarrhea was speedy and uniform.
In the course of six months his lower extremities became
affected with occasional twitchings, and he found that he could
TREATMENT OF LOCAL DISEASES.
173
not regulate their motions in walking : this increased to such a
degree as to make him incapable of taking any exercise. He
had, at the commencement of his illness, a confusion of vision ;
and a constant and violent pain in the head. The former symp-
tom increased so much that he could discern no object distinct-
ly; a candle, for instance, although held near hini, appeared
as large as the moon. The sensation of his lower extremities
continued perfect; but the actions of the bladder were no long-
er under the control of the will; the urine sometimes flowed
involuntarily; and, at others, being retained for some hours,
with considerable pain. He afterwards, began to lose the use
of his upper extremities : the left hand and arm were more
affected than the right; but there was no difference in the af-
fection of the leg on the same side. His speech, also, became
much impaired; he hesitated and faltered considerably, and
the tones of his voice were irregular, so that at length he could
scarcely make himself understood. At the time of his admis-
sion into the hospital, there was an entire loss of voluntary mo-
tion of the lower extremities, and a great diminution of that of
the upper. The bowels were deranged; there was constant
head-ache; the speech was very indistinct; and vision so im-
perfect, that he could not read the largest print. An issue was
made in the neck, and some medicines were prescribed, under
the direction of the physician. As the treatment did not prove
beneficial, I was desired to examine the spine, and found such
a curvature and projection of the spinous processes of the upper
lumbar and lower dorsal vertebræ, that I thought the bodies of
those bones must be diseased. I was, therefore, inclined to
attribute the paralysis of the lower extremities to this disease of
the spine; and, consequently, directed that issues should be
made on each side of the projecting vertebræ. As this suppo-
sition would not account for the paralytic affection of the parts
above, and as the bowels were deranged, I ordered two grains
of calomel with eight of rhubarb, to be taken twice a week, and
some infusion of gentian with senna, occasionally. After using
these medicines, for about three weeks, his bowels became
regular, the biliary secretion healthy, and his appetite good.
He could move his hands and arms nearly as well as ever ;
and his eye-sight was so much improved that he could read a
newspaper; indeed, it was nearly well. The functions of the

174
ON THE CONSTITUTIONAL ORIGIN AND
bladder were completely restored ; * his speech became articu-
late ; and his general health, in every respect, much improved.
He remained in the hospital about two months, but with very
little amendment in the state of the lower extremities, when his
friends suddenly removed him, on account of some disagree-
ment with the nurses, and I was unable to learn whither they
had conveyed him.
The history of the preceding case was taken by Mr. Crutt-
well, now practising as a surgeon in Bath, who had been for
several years a most industrious student at the hospital, and
whose accurate observation and extensive information induce
ne to place entire confidence in any statement of a case which
I received from him. To that gentleman I am also indebted
for the following particulars, relating to a patient who died some
little time ago in the hospital, and whose body was examined.
The dissection serves still further to elucidate my present subject.
CASE VII.
Elizabeth Griffin, twenty years of age, was admitted into St.
Bartholomew's hospital in August, 1785, on account of an in-
ability to move her lower limbs; which was supposed to origi-
nate from a disease of the spine. On examination, however,
there were no appearances, which indicated caries of the ver-
tebræ. Her voice was, at times, considerably affected : and
she was subject to occasional attacks, resembling, in some de-
gree, epileptic paroxysms. The affection of the limbs was lia-
ble to considerable variations. At times, as she assured me,
she could walk across the ward with very little difficulty ; at
others, she could not even stand without assistance. Her tongue
was extremely, and, I believe, constantly white; her pulse
natural. Her bowels were generally costive, and it was ne-
cessary to employ active medicines in order to procure stools,
which were always of a dark colour. A slight temporary diar-
rhæa sometimes happened, and she invariably remarked, that the
ease or difficulty with which she could walk, and the pain in
her head, with which she was troubled, were in exact conform-
ity to the state of the bowels; all the symptoms being relieved
by the diarrhea, and returning as the bowels became again cos-


* I have seen several cases which induce me to believe that the weak.
ness of the sphincter vesicæ, which occasions young persons to void their
urine during sleep, very frequently arises from the same cause.
TREATMENT OF LOCAL DISEASES.
175
tive. There was an appearance of irritability and languor in the
eye, which I have before observed in these cases, and the pu-
pils were generally much dilated. After the patient had con-
tinued in the hospital about seven weeks, she was attacked with
fever, and died. To this brief account of the symptoms, I now
subjoin the dissection.
No diseased appearances were observed in the brain, though
it was examined with the most particular attention : neither
was there any disease of the vertebræ. No disease, in short,
was observed except in the abdominal viscera. The chief mor-
bid appearance, in them, consisted in an ulcerated state of the
villous coat of the ilium near to its termination in the cæcum.
The ulcers were numerous, and situated where the mucous
glands are chiefly found. The internal coat of the large intes-
tines, also, appeared inflamed.
The liver was healthy in its structure. In the gall bladder
about one ounce and a half of a light green serous fluid was
found, which had not in the least degree the soapy, or muci-
laginous feeling of bile.
Cases, like those which have been related, are not, if I may
judge from my own experience, at all uncommon. They suf-
ficiently prove, in my opinion, that local nervous disorders and
muscular debility may arise from a general disorder of the
health, in which the digestive organs are chiefly affected. This
disorder, as has been stated in the preliminary observations,
may, sometimes, be the cause, and sometimes the effect, of the
nervous affection. In either case, however, its correction is
of high importance in the medical treatment of the disease. In
the fifth and sixth cases; a disorder of the digestive organs
must, I think, be allowed to be the cause of the nervous affec-
tion, from the sudden and complete cessation of the latter,
when the cure of the former was accomplished. Decisive in-
stances like these are particularly valuable ; they show what
great nervous disorder may be produced by that of the diges-
tive organs, and consequently how much the latter disorder is
likely to aggravate the former, when it occurs even secondarily
as its effect. I have seen a considerable number of such cases,
which I cannot relate with precision, because I had not sufficient
opportunities of observing the patients, to enable me to note
the progress of the disease with accuracy.
Of these I can only observe, in general terms, that I have
seen several instances of pain, imbecility, and wasting of the


dse
176
S ON THE CONSTITUTIONAL ORIGIN AND

IO
muscles in one of the lower extremities, which were considered
as the effect of disease about the hip joint; yet the event proved
that there was no organic affection of that part. The complaint
was connected with that state of constitution which I have de-
scribed, and was amended as the health in general improved. I
have also seen several instances of wasting of the muscles of
one of the upper extremities in children ; so much indeed were
the muscles shrunk, that the bones and joints could be as dis-
tinctly examined as in a skeleton. The local affection in these
cases came on suddenly. I lately saw a little boy, who had
an attack of this kind in his left arm several years ago, and
on whose case I was at that time consulted. The bowels had
been violently disordered previous to the paralytic affection, and
were, at the time I saw him, in an extremely unhealthy state.
I recommended that the chief attention should be paid to cor-
rect the disorder of these organs, and that the arm should be
supported by a sling. The limb gradually recovered, and
though it is not at present quite so large and strong as the oth-
er, yet the difference is so slight, that it would not attract the
attention of a common observer. About six months ago I saw
a little boy in very similar circumstances, and in his case, the
arm quickly recovered its powers of motion, as the state of the
digestive organs became healthy.
I have also seen cases in children, in whom, after some gen-
eral disorder of the health, accompanied by derangement of
the stomach and bowels, an affection of the muscles of the ex-
tremities has taken place, like that which produces the varus
and valgus: I mean a predominance of the actions of some
muscles over others, producing distortion of the limb. I have
seen this happen sometimes in one, sometimes in both the
lower extremities. I have also seen the arm similarly affect-

ed.
That the local symptoms in these cases, as well as in those
which have been more fully detailed, arise from a nervous affec-
tion of the brain, and not from any cause acting locally on the
nerves of the affected part, will, I believe, on due consideration
be granted. I suspect however that some persons may hesitate
to admit such an opinion, from the belief that disorder of the
brain must operate generally, and not partially, on the ner-
vous system. Perhaps the contemplation of the consequences
of slight apoplectic effusions in the brain, may assist us in form-
ing just notions on this subject. Such slight effusions of blood,
TREATMENT OF LOCAL DISEASES.
177
occurring in various parts of the brain, have been known to par-
alyze one leg or one arm, or the muscles of the tongue, or of
one half of the face, without affecting the rest of the nervous
or muscular system.
Another opinion which I wish to be considered is, whether,
when there is considerable and continued paralysis, there must
necessarily exist some pressure or organic disease in the brain.
That this exists in many instances is undoubted; but the num-
ber of cases in which the paralytic affection is merely ner-
vous, and independent of visible disease, is in my opinion very
considerable. The instances which have been related war-
rant this conclusion, and show such cases to be more frequent
than is generally supposed. When there is organic disease
of the brain, the case is very hopeless; and probably no con-
siderable alleviation of the symptoms will take place, by that
attention to the state of the digestive organs which I have re-
commended. In dubious cases, (and such, on the first exami-
nation of them, the majority of these instances will probably be,)
it seems right to try the effect of correcting disorder of the
digestive organs, with a view to alleviate nervous irritation, be-
fore we proceed to those severer methods, which the belief of
the existence of organic or vascular disease in the brain would
induce us to institute. For if blood-letting and counter-irrita-
tion be employed, in order to diminish vascular action; or if
mercury be employed to some extent in order to induce the
absorption of deposited substance; these measures must ag.
gravate that disorder of the general health, upon which, in many
instances, the nervous affection depends.
My object, in the recital of the foregoing cases, is to point
out a cause of paralysis in particular muscles, which from its
locality would, I suspect, be generally attributed to some local
disorder of the nerves of the affected part, and therefore be
treated erroneously. If my opinion of the nature of these
cases be correct, they can only be successfully treated by means
which operate upon the constitution in general. I have partic-
ularly recommended that our efforts should be directed to cor-
rect any errors that may exist in the functions of the primæ viæ,
for reasons that have been stated in the preliminary observa-
tions. Of the efficacy of such endeavours I have seen many
more instances than I have brought forward ; indeed the pro-
priety of such attempts seems so obvious, that I doubt not but
they will be made, and the effect of them will, by that means,



23
178
ON THE CONSTITUTIONAL ORIGIN AND
be generally demonstrated. It is right, however, to mention,
that in some cases to which I have attended, I have been foiled
in my endeavours to correct, by the simple measures which I
have related in the introductory remarks, the disorders of the
digestive organs; probably because their derangement de-
pended on some established disease in the brain.
In other cases, when the functions of the digestive organs
had been partially restored, the nervous and muscular affections
were mitigated but not cured. I have also met with one in-
stance, in which the bowels became moderately correct in their
functions, without any evident amendment in the state of the
limbs; and I have known two instances of persons, who were
suddenly seized with paralysis of the lower extremities, appa-
rently dependent on general nervous disorders, in which the
digestive organs scarcely seemed affected.
In several of the cases which I have related, there were ner-
vous pains in the affected limbs. That this symptom may arise
from general nervous disorder seems to me very probable; at
least, I can affirm, that I have known such pains cured by cor-
recting the state of the digestive organs. In the cases of tic
doloureux, which have fallen under my observation, these
parts have been greatly deranged; and I have cured patients of
such complaints, by correcting this disturbance.
I wish finally to excite the attention of Surgeons to the state
of the bowels in tetanus. The occurrence of this disorder oc-
casionally, when the wound which produced it is healing,
seems to indicate that the effects, which have been produced by
its irritation, continue. It has been, I think, fully shown, that
local irritation may disorder the digestive organs; which disor-
der continuing, and aggravating the affection of the sensorium,
may possibly lead to the production of tetanus, at a time when
the wound is no longer irritable. In four cases of tetanus, in
which I had an opportunity of inquiring into the state of the
bowels, the evacuations from them were not like fæces. I wish
to propose, in investigating the cause of tetanus, as a question,
What is the state of the bowels between the infliction of the in-
jury and the occurrence of that dreadful malady ? *

* Such cases as I have related, with others that it would be foreign to my
present purpose to mention, have impressed the opinion on my mind, that
disorders of the digestive organs may originally cause, or may secondari-
ly aggravate, a nervous disorder; and produce, as has been “mention-
ed, in the nervous system, a diminution of the functions of the brain; or a
TREATMENT OF LOCAL DISEASES.
179
CASES.
SECTION II.
ON THE EFFECTS OF DISORDERS OF THE DIGESTIVE ORGANS
ATTENDING INJURIES OF THE HEAD.
I SHALL next speak of those cases, in which local disorders
of the head, produced by blows, are kept up and aggravated
by affections of the digestive organs. After what has been
observed respecting the reciprocal influence of the diseases of
the brain, and the chylopoietic viscera, it will readily be admit-
ted, that an injury of the former may disturb the functions of
the latter. Thus, concussion of the brain occasions vomiting
as one of its immediate consequences, and will also be found
to produce, almost constantly, at a more remote period, that
disturbance of the digestive organs, which I have described in
this paper. If the disturbance be only moderate in degree,
but continued, it will often re-act upon the head, so as to occa-
sion an irritable state of the injured parts, and impede their
recovery.
In many cases of blows upon the head, a slow inflammatory
affection continues in the parts chiefly injured, and ultimately
produces destructive diseases. The bone sometimes becomes
diseased, or an exostosis grows from its internal table; the du-
ra mater becomes thickened, or matter slowly collects on its
surface. Such local disorders produce others of a more gen-
eral nature, and destroy the patient. These occurrences are
however, in my opinion, rare in comparison with the cases
first described; in which a painful state of the injured parts is


state of excitation causing delirium, partial nervous inactivity, and insensi-
bility; or the opposite state of irritation and pain : in the muscular system,
weakness, tremors, and palsy; or the contrary affections of spasms and con-
vulsions."! Could these circumstances be proved, it would be scarcely
necessary to add, that those painful affections of parts, to which perhaps
some predisposition exists, may be excited in a similar manner; such as
gout and rheumatism. Indeed rheumatic pains are very usually concom-
itant upon that state of constitution, which existed in the patients, whose
cases I am relating.
180
ON THE CONSTITUTIONAL ORIGIN AND
kept up by means of disorder existing in the digestive organs.
The necessity for an accurate discrimination between these
disorders, must strike us on the most superficial view of the
subject; for the lowering treatment, which is necessary in the
first and rarer case, would be detrimental in the second and
more frequent ones. By attending to the state of the digestive
organs in these dubious cases, we may be enabled to form a
probable opinion of the nature of the local complaint; for, if
there be nothing wrong in the general health to excite or main-
tain it, we may reasonably conclude that it was merely local;
on the other hand, the inefficacy of evacuations in curing the
local disease would naturally suggest the opinion, that it pro-
ceeds from irritation, and is dependent on a disorder of the
health in general. It should be further observed, that when
the local disease is of an inflammatory nature, and likely to in-
duce morbid alterations in the structure of the affected parts,
still it may be maintained and aggravated by disorder of the
digestive organs. I have very frequently seen patients suffer
so severely as to warrant a suspicion, that local disease of the
most formidable nature existed; in these the usual methods of
treatment were ineffectual; and they recovered suddenly or
slowly, in proportion as the state of the digestive organs was
corrected. I shall relate some examples of the disease under
consideration, which will enable the reader to identify the case,
when it occurs in practice.


CASE VIII.
A young gentleman, about ten years of age, feil out of a
window, six feet high, and struck the back part of his head
against some stones. He was stunned by the blow, but per-
fectly recovered from the effects of the accident by bleeding,
purging, and a low diet. He caught the scarlet fever about
six weeks afterwards, and recovered from that also. But,
whilst he was convalescent, the pains returned in that part of
the head which had been struck, with so much violence, as to
induce the belief that some serious local mischief would ensue.
After they had continued without abatement for a few days, I
was desired to see him. He was lying in bed, and could
scarcely be prevailed on to lift his head from the pillow. The
integuments of the occiput were so tender, that he would hard-
ly allow me to examine the part; I ascertained, however, that
there was no fluid under the scalp, nor any inequality in the
TREATMENT OF LOCAL DISEASES.
181
I
bone. He dozed a good deal, and lay in a comatose state, but
was occasionally restless. His pulse was very frequent, his
skin hot and dry, and his tongue covered with a thick yellow
fur. He breathed almost without moving the diaphragm, and
complained much if the epigastric region was compressed. He
loathed food; his bowels were costive, and his stools of a
blackish colour. He was ordered to take small doses of calomel
at night, and draughts with rhubarb and kali vitriolatum in the
morning. The tongue soon became clean, and the stools nat-
ural ; his appetite and spirits returned, and he no longer com-
plained of any uneasiness in the head.
This case presents us with a striking example of what I be-
lieve to be a common occurrence; I mean, a disordered state
of the digestive organs taking place subsequently to a consider-
able febrile affection. Indeed, when we reflect in how weak
and irritable a state the brain must be left upon the subsidence
of such a disorder, and how much the chylopoietic viscera must
suffer from the impaired and disordered energy of the brain,
we might naturally expect such a derangement of the functions of
the digestive organs to ensue. When such disorder happens
in this manner, it frequently produces many local diseases, to
which the constitution may perhaps be predisposed; a circum-
stance I shall speak of in a future part of this paper. In the
present case, it brought on a painful state of parts recently in-
jured, with a considerable degree of fever. That the morbid
state of the stomach and bowels was the cause of both, is fairly
to be inferred from their ceasing so immediately, when the
disorder of the digestive organs was corrected. A case of this
kind, presenting an example of sudden recovery, is particularly
valuable, because it clearly demonstrates the cause and the ef-
fect in such diseases. The cause can indeed be seldom so
suddenly removed ; and the gradual cessation of it under any
plan of treatment leaves room for a variety of conjectures, as
to the mode of cure or of recovery from those disorders which
I have considered as effects. I could relate many cases of simi-
lar but less severe symptoms, produced by the same cause,
which gradually got well, in proportion as the disorders of the
digestive organs were corrected. As it does not, however,
appear to me necessary to accumulate instances to prove so
obvious a fact, I shall content myself with adducing two more
cases, to exhibit such effects in different points of view.



Ve
182
ON THE CONSTITUTIONAL ORIGIN AND
CASE IX.
A lady fell down in frosty weather, in consequence of her
feet slipping from under her, and the occiput struck against a
smooth stone pavenient. She was stunned by the fall, but
soon recovered; nor had she for some weeks the severe symp-
toms, which appeared in the sequel. This circumstance shows
that there was nothing produced by the blow that necessarily
caused the subsequent symptoms; which must therefore be at-
tributed to inflammation or irritation taking place afterwards.
When some weeks had elapsed from the time of the accident,
the parts which had been struck became extremely painful ;
and the pain extended forwards over the scalp to the right eye,
the sight of which became imperfect. The integuments upon
which the blow had been received were extremely tender, and
the patient became faint when they were examined even slight-
ly. These circumstances naturally induced a belief that some
disease was taking place; and bleeding and purging were em-
ployed to prevent its progress. The symptoms were mitigated
for a time by these means, but they quickly returned with as
much severity as before. After three inonths the patient care
to London, fully persuaded that nothing but an operation would
be of permanent benefit. When I first saw her, she tottered
in moving from one chair to another, and replied to questions
with hesitation and effort. Her eyesight was so much affect-
ed, that she could not read; and she entertained an apprehen-
sion that she should lose her senses. Her tongue was but
slightly furred; her bowels were habitually costive, and the
stools dark-coloured. It was evident where the injury had
been received ; for the aponeurosis had been separated from
the pericranium by an effusion of blood; and, though this
blood had been absorbed, the detachment of the scalp was dis-
tinguishable by the touch. No inequality was perceptible in
the surface of the bone. When I mentioned my suspicion that
these symptoms were rather the effect of irritability of consti-
tution, dependent on the state of the stomach and bowels, than
of local mischief, she gave not the least credit to the opinion ;
but said she was persuaded that the bone was starred, and that
three fissures extended in different directions. I ordered her
to take five grains of the pilul. hydrarg. every second night,
and a draught twice a day, containing one ounce of the com-
pound infusion of gentian, two drams of the infusion of senna,
and one dram of the compound tincture of cardamoms. These


100
TREATMENT OF LOCAL DISEASES.
183
medicines produced a considerable purgative effect. On the
second day there was but little pain in the head; the patient
walked about the room very steadily, and had read a newspa-
per in the morning. When I asked her opinion of this sur-
prising alteration, she imputed it to the evacuations which had
taken place ; but she was still persuaded that the bone was in-
jured, and still apprehensive that, without some operation, she
should ultimately lose her senses. The medicines were con-
tinued in such quantity as to procure only one alvine evacua-
tion daily. A fortnight elapsed under this plan of treatment,
during which the stools became nearly of a natural colour, and
the patient's health was considerably amended. There were
times when no uneasiness was felt in the head ; and, during
some nights, the pain was so trivial as to give but little inter-
ruption to her sleep. It was, however, occasionally disturbed
by pains, which were, in her opinion, as intense as at any for-
mer period of the complaint. Her pulse was good, and the
muscular strength greatly improved. The occurrence of the
pain in paroxysms strongly impressed me with the belief that
it was nervous, rather than depending upon local disease. Un-
der these circumstances all ideas of an operation were dismis-
sed from my mind, but it was far otherwise with respect to the
patient. Being obliged to return into the country, she consid-
ered the possibility of a relapse with horror; and was so con-
vinced that the bone had been injured, that she earnestly re-
quested it might be examined, were it merely to ascertain what
was the fact. I saw no objection to this examination, but
thought, on the contrary, that advantage might possibly arise
from an incision, which would loosen the tension of the scalp,
and produce a discharge that might relieve the irritation of the
part. I accordingly made an incision of a semicircular form,
extending farther back than the part which had been struck,
and turned up a portion of the scalp, so as to see the bone,
covered by its pericranium, to the extent of a crown piece.
The bone was uninjured, and together with the pericranium,
appeared perfectly natural. The scalp being replaced, the
wound was dressed superficially,without any attempt to favour
the union of the parts. If they united under these circumstan-
ces, there would be an additional reason for believing that
neither the bone nor the subjacent parts were diseased. The
pain was as severe for the first two days and nights after this
examination as it had been at any former period: it abated


184
ON THE CONSTITUTIONAL ORIGIN AND
when the wound began to discharge, and had entirely ceased
on the fifth day. This state of tranquillity continued as long
as the patient remained in town, which was about three weeks
after the division of the scalp. The wound at that time had
nearly healed. She has since had occasional returns of pain
in the head when her general health has been disordered, but
never to that degree as to induce a suspicion that any local
vascular disease existed.
To exhibit the effects of the reaction of disorders of the di-
gestive organs upon those of the head in another point of view,
1 subjoin the following case.

CASE X.
May 29, 1805, a labouring man, aged forty-five, fell from a
considerable height upon his head, and was immediately brought
to St. Bartholomew's hospital. No fracture of the skull could
be discerned; and the patient seemed to labour under the ef-
fects of violent concussion of the brain. By venesection, and
other antiphlogistic means, he soon recovered his senses. Ev-
ery thing went on very favourably for three days, when he was
attacked with shivering, nausea, pain in the head, impatience
of light, and other symptoms, which usually are considered as de-
noting inflammation of the membranes of the brain. He was
consequently bled, and had a blister applied on the head. He
was suddenly seized in the evening with a more excruciating
pain in the head, which, after lasting half an hour, was succeed-
ed by convulsions, so violent that three men could scarcely hold
him. When the fit abated, he expressed himself much re-
lieved, and said that he was easier than before its accession.
Some calomel and rhubarb were given to obviate a costive state
of his bowels. On the next morning (June 2d) he had a re-
turn of the pain and convulsions ; and the symptoms were so
violent, that he was bled four times in the course of the day.
This treatment, however, had no effect in diminishing the pain
and other symptoms, and another fit of convulsions took place
in the evening. The purgative operated on the succeeding
night, and brought away a large quantity of highly offensive fe-
culent matter of a light greenish-yellow colour. On the 3d
of June his breath was extremely offensive ; his skin hot and
dry; his pulse quick; his tongue thickly furred; and he had
great tenderness in the epigastric region, and right hypochon-
drium. He was ordered to take two grains of calomel imme-

TREATMENT OF LOCAL DISEASES.
185
diately, and a saline medicine at intervals; this produced two
motions in the course of the day. By pursuing this plan for å
few days, the state of his bowels was rendered more regular,
and the discharges acquired a healthy colour; in proportion
as this was effected, the tenderness of the abdomen was re-
moved, and the tongue became clean. He had no return of
convulsions, the pain and other symptoms subsided, and in a
short time, when the digestive organs had been restored to a
natural state, he went out of the hospital perfectly well.
Cases of this description have been noted from the earliest
ages. Many passages in the works of Galen show that he
was well acquainted with the circumstances that have been
stated in this section. Bertrandi* has related instances of
abscesses taking place in the liver, consequent to injuries of
the head. Andouillé f: relates additional cases, and makes
further observations on the same subject. Of late, Richter I
has delivered similar opinions, and has directed the practice
which should be pursued, when the head is disordered by the
re-action of affections of the digestive organs. Still, however,
these circumstances seem to me to be stated rather as occasion-
al, than as occurrences which are common and naturally to be
expected ; and I therefore think myself warranted in supposing,
that they have not made a sufficient impression on the minds of
surgeons, in this country at least.s
I beg leave, in the conclusion of this section, to repeat what
was said in the former one, viz. that I consider the disease as
depending on nervous irritation in the parts affected, which is
either caused, maintained, or aggravated by disorders of the
digestive organs. Yet as the local disease must be regarded
as chiefly nervous, it might, in some rare instances, exist in-
dependently of any manifest disorder of those organs. I may
further add, that much nervous irritation in any part generally
excites vascular action. It becomes therefore highly impor-
tant to attend to the nature and cure of such disorder, as it
might ultimately lead to the production of organic disease,
which would destroy the patient.

* Mémoires de l'Academie de Chirurgie, tom. iii. p. 484.
† Ibid. p. 506.
# Chirurg. Biblioth. b. viii. p. 538.
$ In Dr. Cheston's Pathological Observations, however, cases of this de-
scription are noticed.
24
186
ON THE CONSTITUTIONAL ORIGIN AND
SECTION III.
ON UNDEFINED AND UNDENOMINATED DISEASES ARISING
FROM DISORDER OF THE CONSTITUTION.
The next class of cases, to which I shall call the reader's at-
tention, is that of unhealthy indurations, abscesses, and sores.
Sometimes but one local disease of this description exists, but
in general they break out in succession in different parts of the
body. The circumstance of their successive formation is,
I think, a proof that they depend upon some error in the
health in general; and I have accordingly observed that they
are seldom, if ever, unattended with disorder of the digestive
organs. The imperfect history which the patients generally
give of their previous state of health, will not enable us to de-
termine with certainty that the disorder of the bowels was the
cause of their ill health, and subsequent local diseases; but I
can confidently affirm, that those diseases in general become
tractable, in proportion as the disorder of the viscera is correct-
ed; and that frequently no new local symptoms occur, after some
attention has been paid to the state of the digestive organs. The
diseases to which I allude, have not been described in books
of surgery ; and indeed it is scarcely possible to delineate with
precision their various appearances. It would be quite imprac-
ticable to describe all the diseases, which make the subject of
the present section; namely, unhealthy indurations, abscesses,
and sores. They may be compared, not improperly, in varie-
ty and number, with the infinitely diversified combinations and
shades of colour. Yet a brief and general description of them
will assist to recall them to the remembrance of the experienced
surgeon; and to enable the inexperienced practitioner to re-
cognize them, when they occur.
Some of these affections are quite superficial, occupying
merely the skin. The first that I shall describe is, I believe,
well known to surgeons, as a disease, which is frequently,
though not constantly, cured by giving mercury to such an ex-
tent as slightly to affect the constitution. A small induration
or tubercle takes place in the skin, and this is followed by the
successive formation of others at small distances from the origi-
nal one. The skin between these tubercles becomes thickened.

TREATMENT OF LOCAL DISEASES.
187
Chord-like substances, which are probably indurated absorbents,
may sometimes be felt, extended along the thickened skin.
The tubercles ulcerate, and form foul ulcers, which heal slow-
ly and break out again. .
Another species of superficial or cutaneous ulcer begins gen-
erally in one point, and extends in every direction. The chasm
of the ulcer is formed either by a very sudden ulceration, or by
sloughing. A sore is left, which first secretes a sanious, and
then an ichorous fluid. Granulations afterwards arise, and the
sore heals. The granulations are however indurated and un-
sound; and when the patient supposes that the sore is cured, it
is suddenly reproduced by a process similar to that by which it
was originally occasioned. After some time the ulcer again
heals, and again breaks out. Whilst these processes are going
on in the middle, the sore enlarges in its circumference; the
edges, which are thickened, become at times highly inflamed,
and either ulcerate or slough. The disposition to disease is
aggravated by fits, and there are intervals when it is apparently
tranquil. When this sore has enlarged to a considerable ex-
tent, in the manner already described, the central parts, which
have healed unsoundly, break out into separate ulcers; and
thus present an appearance of several sores, connected with
each other by indurated skin or newly-formed substance.
I shall briefly mention some of the principal circumstances
relating to the last sore of this description which came under
my care. The patient, who had been ill for more than two
years, and had taken a great deal of mercury, came from the
country in very bad health, and with his digestive organs much
disordered. The sore was so painful, particularly at night, that
he was in the habit of taking large doses of opium to procure
rest. It occupied the back of the hand and wrist. He
had had somewhat similar sores on his head and face; but
they were nearly healed, though disposed to ulcerate again.
By that attention to the state of the bowels which I have de-
scribed, and by dressing the sore with an aqueous solution of
opium, the greater part of it was healed in the space of three
weeks ; and the remainder was so much amended, and so little
painful, that he had left off his opium shortly after the com-
mencement of this treatment. As the patient's circumstances
made it inconvenient to him to remain in town, he went into the
country, where the sore broke out again. He then applied to
a person who sold a famous diet-drink; and before he had


188
ON THE CONSTITUTIONAL ORIGIN AND

taken twelve bottles, the sore was perfectly healed, and has not
since broken out. The diet-drink, he says, had no sensible
operation; but his bowels became regular and comfortable, and
his appetite amended by taking it.
Another variety of these sores originates in a more deeply
seated disease. The cellular substance under the skin becomes
thickened, and an unhealthy abscess follows; after the bursting
of which, a foul sore is formed. In consequence of this pro-
cess, the fascia of the limb is sometimes exposed to view, and
seems to have sloughed : when the slough has separated, the
disease may get well slowly. In many cases, however, there is
no exposure, nor separation of the fascia. Sometimes the sore
does not extend beyond the limits of the original induration,
but heals slowly, while other diseases of the same kind occur
in succession in various parts of the body. In other cases, the
ulceration of the original sore spreads along the contiguous parts,
whilst those which were first affected get well; and thus the
sore assumes an herpetic character. In many cases, the ulcer-
ation extends from the whole circumference of the sore, and
thus the scar and ulcerated edges have a circular or oval form ;
in others, the disease is propagated in particular directions, so
that the ulcerated surface presents the most irregular and sin-
gular figures.
These diseases sometimes are smail in extent in the begin-
ning, but enlarge considerably before the skin gives way ; and,
when this happens, it proves a kind of crisis to the disease,
which afterwards heals slowly. In these cases it becomes the
object of surgery to bring the disease to a crisis, whilst it is yet
of small extent; which may be effected by producing ulceration
of the skin by means of caustic.
Some of these sores are formed from diseases beginning
in the absorbent glands ; in which case the gland, having first
been indurated, suppurates and bursts, and ulceration ensues.
When this circumstance has taken place, in an absorbent gland
of the neck for instance, another ulcer may form, in the man-
ner above stated, in the skin and subjacent parts, without any
gland being involved in it. A third ulcer, having a diseased
gland for its cause, may form in the vicinity ; and thus the
disease proceeds without any regularity.
I once thought it a necessary but most difficult task for a
surgeon to remark the varieties of these diseases, in order to
understand his profession, and contribute to its improvement.
TREATMENT OF LOCAL DISEASES.
189

But, since I have found that these diseases indicate some dis-
order of the health in general, the correction of which is the
great object in their cure and prevention, I have perceived
that there is less necessity for undertaking this most arduous
investigation ; which, indeed, could never be accomplished
without very extensive opportunities and indefatigable dili-
igence.
It will be found in the majority of these peculiar diseases,
that the patient had been indisposed for some time before the
occurrence of the complaint, and that afterwards the health
had become more evidently deranged. The digestive organs
are disordered. The tongue is furred at the back part,
chiefly in the morning; and the biliary secretion is deficient
or depraved. My attention has been directed to the correction
of this disorder; and the most beneficial effects have result-
ed from this attention. The sores have healed readily in
some instances; and, in those cases where many had previous-
ly formed in succession, no new disease has in general taken
place. In some few instances, new sores have formed after
the medical treatinent of the disorder had commenced, and
even after it had been for some time continued. This proba-
bly arises from the difficulty which is experienced in correct-
ing an habitual and long-continued constitutional disorder. In
some still rarer cases I have found similar but much milder dis-
eases arise, after the disorder of the digestive organs had been
in a great degree corrected.
Whilst I am writing this, there are four patients, whom I
have attended in St. Bartholomew's hospital, with these dis-
eases ; which I mention, to show the younger part of the
profession how frequent they are. The health of these pa-
tients has been surprisingly amended in a very short period,
by employing the means which I have described ; and the
sorės have healed rapidly, although nothing but simple dress-
ings have been applied to them.
It is not meant by these observations to depreciate the utility
of topical applications to unhealthy ulcers, but merely to show
how much they depend on the state of the health in general ;
for some of them, which have remained uncorrected by a great
variety of local applications, will get well under simple dress-
ings, when the state of the constitution is amended. It is not,
however, to be expected that this will generally happen; for
local diseasedaction having been excited, becomes established,

190
ON THE CONSTITUTIONAL ORIGIN AND
and may continue, independently of the cause which produced
it. Topical remedies will, under these circumstances, be em-
ployed with the greatest advantage. Again, topical applica-
tions are of the highest utility in general practice, because an
irritable sore affects the whole constitution, and aggravates and
maintains that disorder by which it might have been originally
caused. The disorder of the digestive organs cannot in many
instances be corrected, till the fretful state of the local disease
is diminished. I may further mention, with relation to this
subject, that I have seen patients, who scarcely ever slept from
the pain of the local disease, whose stomachs were greatly dis-
ordered, and who had a distressing purging, which could only
be controlled by opium, sleep without interruption during the
night, regain their appetite, and have their bowels become
tranquil and regular, when, after various trials, a dressing has
at last been applied, which quieted the irritable state of the
sore. It is right, however, to mention, that the effects of such
an application are not, in general, permanent; but after a time
the sore becomes again fretful, and requires some new dressing
to soothe or control its irritability.
I have seen some cases of such diseased sores as I have
described, in consultation with other surgeons, who have be-
come convinced that my opinions are well founded. Others
have occurred, even in the persons of medical men, whose feel-
ings co-operated to render their conviction more strong.
Having thus, from general observation, acquired the opinion
that the peculiarities of local disease depend chiefly on the
state of the constitution, I shall relate some cases, which were
treated in conformity with the principles which such an opinion
would naturally suggest. I must, however, previously caution
the reader against inferring, that I attribute all local diseases to
some general error in the state of the health. I have seen local
diseases, which could not be deduced from any general indis-
position, nor corrected by remedies which act simply on the
constitution at large. I wish to guard against the suspicion of
being inclined to make general assertions; while I avow, at the
same time, that my observations induce me to believe, that the
peculiarities of local disease generally depend upon constitu-
tional causes. Reason also suggests the same opinion ; for if
sores of the same character break out in succession in different
parts of the body, can we doubt that they arise from the state of
the health in general ?



TREATMENT OF LOCAL DISEASES..
191
There appears to me a combination of nervous irritability
and weakness, and to such a combination I am inclined to attri-
bute the peculiarities of these variable and unclassed local
diseases. Perhaps I may explain my meaning further, by ad-
verting to what happens not unfrequently in cases of venereal
and other buboes. The part and the constitution have been
both weakened by the disease that has occurred; they have
been further debilitated by the mercury employed for its cor-
rection. The disease subsides, but a new disease and action
commences; a trivial wound frets out into a phagedænic sore,
which is very difficult of cure. The sores, in different cases,
are nearly as various in appearance, as those of which I have
been speaking. To what are we to attribute these dissimilar,
perplexing, peculiar sores, if not to irritation occurring in weak
and irritable parts ? As the peculiar diseased actions of these
sores originate chiefly from the weakness and irritability of the
parts, induced by the previous disorder which they have un-
dergone; so in their advanced stages they frequently present
the best instance that can perhaps be adduced, of a peculiar
local disease existing independently of constitutional disorder.
It is true they affect the health in general; but it may, by atten-
tion, be kept in a moderately right state, and yet the sore
remains unamended. The diseased actions of these sores
sometimes gradually, and sometimes suddenly cease ; when
healthy actions succeeding, the sore heals. I remember a
sore of this description, to which almost every variety of
dressing had been tried without benefit. It was very extensive,
and had burrowed in various directions beneath the skin. The
ulceration at length became stationary ; but after nine months
the sore still remained as foul and fretful as it had been for a
considerable time; when in the course of one week it perfectly
cicatrized, leaving the hollows which I have described; for it
had thrown out no granulations to fill these chasms.
Having thus stated the opinions, which I have formed, rela-
tive to these kinds of local diseases, and which have been de-
duced from cases too numerous to record, of which I have
preserved no accurate accounts,---I proceed to relate some cases
treated in conformity to these opinions, which will, I trust, be
sufficient to exemplify, and illustrate the present subject.

CASE XI.
A gentleman's servant, between thirty and forty years of age,
was sent to me with a bad ulcer in his cheek, situated between
192
ON THE CONSTITUTIONAL ORIGIN AND
1
the nose and under eyelid. The surrounding parts were in-
flamed, swoln, and indurated, so as to rise ſully half an inch
above their natural level. The sore was of an oval figure :
measuring about an inch and a half in length, and half an inch
in breadth and depth; indeed I could scarcely see its bottom.
The surface was covered by adhering matter of a greenish hue.
The cuticle round the margin was thickened, and had in some
parts scaled off. The patient had been rubbing in the mer-
curial ointment for this complaint. He declared that he had
had no chancre for many years, but had contracted a gonor-
rhæa about a year before his present disorder. His health was
much disturbed; he had no appetite ; his tongue was much
furred and tremulous; his bowels alternately costive and lax;
his fæces blackish. I advised him to take five grains of rhu-
barb about an hour before dinner, and five grains of the pil.
hydrarg. every second night, with castor oil or senna tea oc-
casionally, so as to procure a motion daily. The sore was
dressed with spermaceti cerate. I saw him again in three days;
when he said that he felt himself under the greatest obligations
to me. He had been entirely free from pain and distressful
sensations, since he began to take the medicines; although he
declared, that before that time, he should have been thankful to
any one who would have destroyed him. I mention this, because
I have often remarked in these cases, the surprisingly great re-
lief and comfort which have arisen from a change, produced
by means apparently insignificant and inadequate. The bowels
now acted regularly, and the stools were more copious and of
a more natural colour; and to this correction of the biliary
secretion I am inclined to impute that relief, which he so forci-
bly depicted. The sore had discharged profusely; the sur-
rounding swelling and inflammation were much lessened. He
pursued the same plan of treatment for a month, during which
time he recovered his appetite ; his tongue became clean; his
bowels regular, and the biliary secretion natural. The sore
had contracted into a small compass, but without the appear-
ance of granulations, and the surrounding parts were not swoln,
though still red. His health became at this time again much
disordered, in consequence of his catching cold, from exposure
to rain. He had pain in his bowels, with a slight purging ; his
appetite failed; his tongue was furred; and he had a severe
cough, attended with copious expectoration. The sore on the
cheek also enlarged to about one half of its former size : and


« TREATMENT OF LOCAL DISEASES.
193
the surrounding parts became tumid. I had the patient admit-
ted into St. Bartholomew's Hospital, where he took the decoc-
tion of cascarilla with squills. His cough became materially
better in a short time: the state of his stomach and bowels
also greatly improved. The sore again diminished in size.
About a fortnight after his admission into the hospital, an erup-
tion came out over his whole body. The spots were of a
copperish hue, but rather smaller and inore elevated than
venereal eruptions generally are.* Some of the eruptions
gradually disappeared ; and, in about a fortnight, it was cer-
tain that many were entirely gone. About this time he began
to complain of his throat; and an ulcer, of the size of a shil-
ling, formed in each tonsil. The edges of these sores were
elevated and uneven, without any appearance of granulations ;
the surface was covered with yellow adhering matter. The
patient now again caught cold : he was attacked with pain in
the bowels, and purging, which obliged him to get up frequent-
ly in the night, and to remain for some time out of bed. The
cough and expectoration returned : he lost his appetite ; and
he had a furred tongue. Dr. Roberts, whom I met at the
hospital, did me the favour to prescribe for him. In a day or
two afterwards, an erysipelatous inflammation appeared on the
right side of his face, opposite to the situation of the sore. The
eyelids were so tumid that he could not open them: the ery-
sipelas spread to the other side of the face; and the other eye
was equally closed. The fever also ran very high, and the
patient became delirious; so that he was obliged, for many
days, to be confined by a strait waistcoat. These symptoms
gradually abated, and he recovered, so as to be in better health
than I had ever seen him. He was discharged in about six
weeks, in a state of convalescence; and attended Dr. Roberts
as an out-patient. The eruption and sore throat had entirely
disappeared ; the original ulcer was firmly healed.; and the
contiguous skin had become soft and natural, though it was still
discoloured. A year has since elapsed, and he has had no
return of his complaints.
It is, I think, sufficiently evident, in the present instance,
that the peculiarities of the local diseases had their origin in the
state of the constitution.

* Many persons who saw the patient, did not entertain a doubt but that all the
symptoms arose from syphilis; it was their progress alone which evinced the
contrary.
25
194
ON THE CONSTITUTIONAL ORIGIN AND
CASE XII.
I was consulted, by a medical gentlemen in my neighbour-
hood, on the case of a lady about forty years of age, who had
been long subject to dyspepsia, and severe headaches. Her
present and chief complaint had been of about three months'
duration. It began with weakness, and an apparent irregular-
ity in the motions of the lower extremities, attended with con-
siderable pains resembling rheumatism, and rigidity of the
calves of the legs. These symptoms increasing, she was
unable in the course of a month to move about at all; but was
obliged to be lifted in and out of bed. At this time an indu-
ration of the muscles of the calf of each leg had taken place.
The indurated substance was about three inches in length, and
between two and three in breadth. It was severely painful at
times, and the integuments covering it were occasionally in-
flamed. There was also some pain and swelling in the ham.
Leeches, sedative lotions, and mercurial ointment had been
applied; cicuta and tonics had been given, but without allevi-
ating the symptoms. I first saw the patient about six weeks
after she had been obliged to keep her bed entirely; and the
peculiarities of the present case led me at once to refer its
origin to the state of the health in general. The appetite and
digestion were impaired, the tongue was much furred, and the
fæces blackish. I merely recommended fomentations to the
indurated parts, considering it the primary object to correct
the morbid state of the digestive organs. With this view the
compound infusion of gentian with the infusion of senna and
tincture of cardamoms was given, in such doses as to procure
an adequate evacuation daily, and five grains of the pil. hy-
drarg. were taken every second night. These simple medi-
cines were completely successful : after taking them a short
time, the discharges from the bowels were natural, and prop-
erly coloured with bile. The appetite returned ; the tongue
became clean, and the pains almost immediately ceased. No
cutaneous inflammation, indicating a disposition to suppuration,
appeared again over the indurated parts, which gradually re-
covered their natural state. In a fortnight the patient could go
about with a stick, and in two months could walk as well as
before her complaint. She has enjoyed better health, since
this time, than for many years before. *


* The state of the indurated muscles, in this case, was such as would
lead to the belief that suppuration would take place in different parts of
TREATMENT OF LOCAL DISEASES.
195
..
CASE XIII.
A gentleman, thirty-two years of age, who had been subject
for several years to occasional attacks of severe pain in the
bowels, was seized, about the end of August, with a violent
purging, which continued for a fortnight, and was attended
with fever. About a month afterwards, he felt pain in his leg
at night, which gradually became continued even during the
day, and obliged him to confine hinself to bed. In the begin-
ning of October a swelling was perceived near the inner ankle,
which suppurated, and was opened on the twentieth of the
same month. Two large tea cups full of dark brown matter
were evacuated. The discharge continued profuse for some
time, and afterwards diminished. Four other small gatherings
then took place in succession, and, bursting, continued to dis-
charge; each aperture fretting out into a full sore. About
the beginning of February I first saw this case, which was
considered as a disease of the bone. The five sores had aper-
tures in them leading to sinuses, which communicated with
each other. A probe introduced into one of these, near the
bottom of the tibia, could be moved upwards and downwards
along the surface of the bone, which was not, however, denu-
ded. From an upper ulcer the probe could be passed behind
the bone, and under the muscles of the calf; this indeed seem-
ed to be the original seat of the abscess, from which the sinu-
ses proceeded to their different outlets. The integuments
were edematous and firm to the touch, so that I could not
distinctly feel the outline of the tibia ; but I thought that the
bone was not altered either in form or size. The firmness
with which the patient stood upon the limb, and the want of
aching pain in the bone, contributed also to make me believe
that it was not diseased, and that the whole disorder consisted
in an unhealthy abscess, the discharge from which issued from
the various sinuses in the manner already described. I could
not but attribute such a disease to a general disorder of the
health, and indeed the patient's countenance and appearance
indicated a constitution much weakened and harassed by illness.
His tongue was furred, and the discharges from the bowels
were irregular, deficient in quantity, and of a blackish colour.

the hardness; indeed, I have seen many cases less formidable in appear-
ance terminate in that manner. Seeing how much the irritability of
muscles is disordered by that state of constitution which I have been de-
scribing, I think it is allowable to.conclude that most of the organic disea-
ses of muscles originate from this cause.
196
ON THE CONSTITUTIONAL ORIGIN AND
With a view to the correction of these symptoms, I directed
the patient to take five grains of the pil. hydrarg. every second
night, and the infusion of gentian with senna, so as to procure
one motion daily. But little benefit was obtained by these
measures; and in about a fortnight afterwards a thickening of
the integuments took place over the fibula ; a considerable
swelling gradually arose, and another abscess formed, which
burst in about three weeks, and discharged a considerable
quantity of brownish matter mixed with blood. During this
time the limb was merely poulticed, and the patient could not
leave his bed. His pain was extreme, and he had no rest at
night. The use of opium was necessary to alleviate his suf-
ferings, and opening medicines occasionally to procure stools.
He took but little nourishment, and his health greatly declined.
The disordered state of the stomach and bowels was much
aggravated by this local irritation. Indeed, the situation of my
patient was now particularly perplexing. The local disease
made the general health worse ; and the aggravation of this
general disorder, which appeared to have been the cause of
the local disease and of its continuance, proportionately increa-
sed the latter malady. The confinement to bed afforded an
additional obstacle to recovery; yet it was impossible to re-
move him in his present state, on account of the pain which
motion occasioned. The leg was insupportably painful in a
dependent posture. As change of air and exercise seemed
essential to his recovery, I was induced to try if Mr. Baynton's
excellent bandage, by supporting the weakened vessels, would
prevent their distention, and the consequent pain. The sores
were dressed, after as much matter had been expressed from
the sinuses as could be done without occasioning pain. Strips
of sticking-plaster were applied after the manner of a many-
tailed bandage; and the limb was afterwards rolled with a cal-
ico roller. The patient felt comfortable, and found his limb
strengthened. He was directed to wet the roller, if the parts
became heated. The effect of this treatment was surprising
both to the patient and myself. The pain, which had been
constant before pressure had been employed, ceased from the
time of dressing till five o'clock on the following morning; but
from that time it gradually increased till noon, when the dres-
sings were renewed. The cause of this occurrence now be-
came manifest ; for, upon opening the bandage, more than a
teacupful of matter was discharged from the different sinuses.


TREATMENT OF LOCAL DISEASES.
197
I dressed the limb as before, cutting holes for the escape of
the matter opposite to two of the chief sinuses. I desired the
patient to put his leg to the ground, in order to ascertain the
effect of the perpendicular position when the vessels were sup-
ported; and he experienced no inconvenience. The second
day passed as the former, without pain; and as the matter
poured into the sinuses readily escaped, he had no uneasiness
from its detention. I recommended him to sit up, and put
his leg to the ground several times in the day, in order to ac-
custom it to that position. After I had dressed it on the third
morning, the patient stood up, and took two or three steps
very feebly; but this was rather the effect of general weakness
than of particular infirmity in the diseased limb. 1 now ad-
vised him to go a little way out of town in a carriage. The
air and exercise, together with the freedom from pain, produced
a very beneficial effect. He began to recover his appetite, to
sleep at night, and acquired so much strength, that he was able
in a week to go about his house, and to resume his attention
to business. The discharge from the sinuses was very trifling,
and the sores looked much better. The patient now under-
took to dress his leg himself, and hired a lodging out of town,
so that I only saw him occasionally. His limb was so much
amended in the course of a fortnight, that it caused no more
trouble than that of daily dressing. But his health was not
good. His countenance had the same expression of illness as
when I first saw him ; his tongue was white and dry; his
bowels costive ; and the stools of an unhealthy colour. I
therefore recommended him to take again the same medicines
which I had formerly ordered him. His health now improv-
ed; his tongue became moister, and less furred; the bowels
more regular ; and the fæces coloured with a more healthy
bile. He continued recovering till the middle of April, when
he began to complain of the trouble of applying the sticking-plas-
ter, and used the calico roller alone. I did not see him for three
weeks, and then found him in a very desponding state. He com-
plained of the tediousness of his confinement, which had lasted
more than half a year, and said that he would willingly submit
to have the sinuses laid open, if that would make him well. I
found his leg well, excepting two orifices near the tibia ; three
ulcers which formed the apertures of as many sinuses, had
healed; the outline of the bone could be distinctly felt; and
there was no alteration of it in form or size. I was unable at

198
ON THE CONSTITUTIONAL ORIGIN AND

first to account for this despondency under such favourable
circumstances; but I soon discovered that it was the effect of
hypochondriacism. For his tongue was much furred and dry ;
and at the same time that he left off the bandage, he had also
discontinued his medicines. I urged him to return to them
immediately ; and called on him again in ten days, when he
perceived clearly the absurdity of his late despondency, as well
as its cause. He called on me on the 10th of July, with a
new swelling near the upper part of the tibia, which threatened
to form an abscess, similar to those which had formerly taken
place. I covered the limb with the bandage of sticking-plas-
ter, as at first. The new disease disappeared entirely ; and
the old ones were so much benefited by the exact and equal
pressure, that the patient felt no difference between the sound
and the affected limb. The ulcers gradually healed, and his
health is better than it has been for some years; yet still there
is an evident tendency to disorder of the digestive organs.

CASES.
SECTION JV.
ON MORE DEFINED DISEASES, AS CARBUNCLE AND SCROFU-
LA, ARISING FROM DISORDER OF THE CONSTITUTION.
IF, upon an extensive and accurate examination of the sub-
ject, it were to appear, that many very peculiar and very dis-
similar local diseases originate from a common cause, namely
fron weakness and irritability of the system in general, our in-
quiry would be further extended, and we should feel anxious
to know whether similar causes may not operate in the produc-
tion of more common and more frequent local disorders. As
far as my late observations have enabled me to determine, that
state of the digestive organs, which I consider as causing or
denoting constitutional disorder, exists prior to the formation of
a carbuncle; and is exacerbated during the progress of that
disease. This opinion indeed will appear probable, if we con-
TREATMENT OF LOCAL DISEASES.
199
sider the kind of persons who are attacked with carbuncles, and
the considerable derangement of health, which even a trivial
local disease of this nature occasions. I shall mention but one
case in support of this opinion, though I have made similar
remarks in several other instances.
CASE XIV.
I attended a gentleman, who was afflicted with carbuncles,
during three successive attacks, at the interval of about a year
between each. I made an incision through the indurated skin,
down to the subjacent sloughy cellular substance, and thus
brought the local disease to a crisis. This treatment was suffi-
cient in the two first attacks; the extension of the disease was
prevented ; the sloughs separated, and the wound healed. The
patient, whose mode of life was intemperate, had cough ; diffi-
cult respiration ; fullness and tenderness of the parts situated
in the epigastric region ; unhealthy secretion of bile; and in
short, all those symptoms which denote a very considerable de-
gree of disorder of the digestive organs : it is probable indeed
that some organic disease of the chylopoietic viscera existed.
After he had recovered from the carbuncle, I told him that the
most important disease still existed ; and urged him to be atten-
tive to his diet, and to the directions of his medical attendants.
He still however continued to live intemperately, and his disor-
der increased. He was indeed nearly dying from diseased
viscera, when he was attacked with carbuncle for the third time.
The division of the parts produced a temporary cessation of the
disease ; but it began again to spread in every direction from
its circumference, and he died.
It will not, I believe, be doubted, that biles are a slighter
degree, with some variation, of the same disease, which causes
anthrax and carbuncle ; and it is almost unnecessary to remark,
that some persons are subject to a successive formation of very
large and troublesome biles from the least irritation of the skin.
I have seen many persons thus affected; and there has been,
in every instance, disorder of the digestive organs, the correction
of which has prevented the return of these vexatious local dis-
eases. One gentleman, who had been tormented for many
years by the quick successive formation of biles as large as eggs,
has been free from them for some years; though he has had
other disorders, which denote such a condition of the constitu-
tion, as it has been my object to describe in this paper.

200
ON THE CONSTITUTIONAL ORIGIN AND
I have remarked in many instances that diseases of the ab-
sorbent glands, such as are usually and justly denominated
scrofula, occurring in adults, have apparently originated from
the disorder which I have described. In several cases the lo-
cal disease was of long duration, and had become worse rather
than better under various plans of medical treatment; yet it
amended regularly, and sometimes even quickly, in proportion
as the state of the digestive organs was corrected. I need not
detail any cases on this occasion, since every surgeon must
know them familiarly. The patients are commonly sent to the
sea-side, or into the country ; where enlarged glands subside,
and those which have suppurated and ulcerated heal; and the
local disease recovers, in proportion as the health in general is
amended.
There are cases of scrofulous diseases occurring suddenly,
and in various parts of the body at the same time, which seem
to originate in that state of the constitution which is occasioned
by disorder of the digestive organs. I have chiefly observed
these cases in children ; and they have followed some violent
febrile affection. In two cases which I shall particularly mention,
the smallpox was the antecedent disease. I have already sta-
ted, that when the health has been considerably disordered by
some violent disease, the digestive organs may become subse-
quently affected; and that this disorder proves a cause of many
secondary diseases.


CASE XV.
A child of two years old had the smallpox, from which he
did not seem to recover, but, on the contrary, fell into a very
bad state of health. The absorbent glands on the right side of
the neck became enlarged in succession, so as to form alto-
gether a very considerable tumor, which extended down to the
collar bone. The axillary-glands then became affected in the
same manner; the swelling was unusually great, and seemed
to extend under the pectoral muscle, elevating it, and forming
by this means a continuation of tumor with the glands of the
neck. These swellings had partially suppurated, and had
broken in two places, viz. in the neck, and about the margin of
the pectoral muscle : but no relief followed ; on the contrary,
the mass of disease seemed to be rapidly increasing. The
child was bowed forwards, so that the spine was much curved
in the loins; the left leg appeared paralytic, and a swelling was
The Property of
The Medical Society
City & County of Denver
TREATMENT OF LOCAL DISEASES.
201
perceived in the abdomen, which I could not but ascribe to an
enlargement of the external iliac glands. The child was ex-
tremely emaciated; his skin felt hot and dry; his tongue was
covered with a brown fur ; and the stools were black and high-
ly offensive. As there was no expectation that he could sur-
vive this desperate state, those medicines only were prescribed
that seemed likely to correct the state of the digestive organs ;
such as occasional doses of calomel, and rhubarb. A strict
attention to diet was also recommended. Under this treatment
the stools gradually became natural, and the tongue clean.
The disease seemed to stop immediately. As the health was.
restored, the swellings rapidly subsided; and the child became
one of the healthiest and stoutest of the family.

CASE XVI.
A female child, after having had the small pox, got into bad
health from disorder of the digestive organs. She was then
suddenly attacked with a scrofulous affection of the knee and
elbow of the opposite sides of the body. Two collections of
fluid had taken place beneath the fascia of the leg and thigh.
The joints were greatly enlarged, and the swelling was appar-
ently caused by an increase in the size of the bones. Had I
seen either joint, as a single case of disease, I should have said
that it would leave the chud a cripple. It was manifest, in the
present instance, that these local diseases were the consequence
of general ill health; and that the first object was to correct
the disorder of the system. The functions of the digestive or-
gans, which had been deranged, were restored 10 their natural
state by employing the same diet and medicines wbich had
been so signally successful in the preceding case. By these
means the health was re-established, and the local diseases
gradually disappeared.
I have heard it remarked by surgeons of great experience,
that patients often recover when many scrofulous diseases ap-
pear at the same time; although some of them may be so con-
siderable, that they would seem to warrant amputation, had they
appeared singly. The cases which I have related afforda
most clear and satisfactory account of the mode of recovery.
General irritation and weakness bring on diseases, to which
perhaps a predisposition may exist, in several parts of the body :
these cease when their exciting cause is removed.


INI
al
26

202
ON THE CONSTITUTIONAL ORIGIN AND
Of late indeed I have been equally surprised and rejoiced to
see swellings of the absorbent glands in children readily dis-
persed by that medical attention to correct errors in the functions
of the digestive organs, which I have described. Some of these
swellings came on rapidly, and some slowly, but these were so
large and so much inflamed, that if any person had formerly
told me they might be dispersed by such measures, I should
have thought the assertion an absolute absurdity from its direct
contradiction to my former experience. From amongst a con-
siderable number of cases, I shall relate the following.
CASE XVII.
The son of one of my friends, had gradually fallen into a
very bad state of health. The child was about six years of age,
and had been unwell for several months; when, in conclusion,
two glands in the neck became gradually enlarged, till each
had attained the size of a large walnut. The child's tongue was
much furred, his appetite very deficient and capricious; his
bowels had a costive tendency; his stools were never of a pro-
per colour. His flesh was wasted and flabby, his countenance
pale, his pulse feeble and frequent; and his general demeanor
languid and irritable. I told his father, that I could advise
nothing as a local application better than bread and water poul-
tice; and that the chief object of attention was the correction
of that disorder under which he had long laboured, so that his
constitution might regain its natural tranquillity and strength.
Upon this subject I promised to speak to the gentleman who
had hitherto attended the child. In about two days a deep red-
ness came over the most prominent part of each gland, de-
noting, as I concluded, a disposition in the internal parts to
suppurate. The child took half a grain of calomel with five of
rhubarb every second night, and ten drops of the acid. vitriol.
dilut. three times a day. In about a week, an evident amend-
ment was observed in the appetite, spirits, and colour of the
excretions from the bowels. In a fortnight, the spirits of the
child became, to use the words of the parents, ungovernable;
and an evident amendment of the health in general took place.
In a month, the child might be said to be well ; though he still
remained thin. After another fortnight, he discontinued all
medicine, except the occasional use of the powders, for at this
time all vestiges of enlargement in the glands had disappeared.
I do not relate this case as extraordinary for I have seen seve-

TREATMENT OF LOCAL DISEASES.
203
ral worse cases cured by the same means; and as I have said,
some of the swellings have come on tardily and others rapidly.
It is related merely, because in the same family another child
had suppuration of the glands, which left a sore that healed
slowly.
It cannot indeed be proved that these cases would have been
strumous; it can only be said, that to all appearance they were
the same as others which I have formerly seen suppurate, and
form sores slow in healing, and such as are generally denomina-
ted scrofulous.
CASE XVIII.
A slender child, about five years of age, had five swollen
glands on the right side of the neck, and three on the left.
Their magnitude was considerable, and the child's appearance
sickly ; and the disorder had so threatening an appearance,
that the gentleman who attended the family requested the pa-
rents to take some additional opinion on the case. The tongue
was furred, and the bowels so habitually costive, that sometimes
a week elapsed without any alvine evacuation. As the child
was feverish, he took at first some saline medicines in a state
of effervescence, which was afterwards changed for the diluted
vitriolic acid. He also took half a grain of calomel, every
second night, which gradually brought about a regular secre-
tion of healthy bile, and in about three weeks the child might
be said to be well, for his bowels acted regularly when no med-
icine was taken, and the discharges from them were properly
tinctured with bile. The use of calomel was now only recom-
mended, if the appearance of the stools varied from the rhubarb
colour. The swollen glands disappeared, nothing but a bread
and water poultice having been applied to them. The bodily
powers of the child were considerably augmented, and his as-
pect became healthy.


CASE XIX.
A boy between seven and eight years of age had a lameness
about the hip, which was so considerable as greatly to alarmn his
parents. There was no tenderness when the joint was com-
pressed either in front or from behind. The tongue was furred,
and he had been subject to slight paroxysms of fever, resem-
bling an intermittent. I recommended half a grain of calomel
with a few grains of rhubarb every other night. In a short

204
ON THE CONSTITUTIONAL ORIGIN AND
time the lameness so entirely disappeared, that I was no further
consulted on his case. About eight months afterwards, how-
ever, I was desired to see him with three considerably enlarged
absorbent glands on one side of his neck, and two on the other.
They had for many days continued to increase. He was at
that time feverish, and I now became more acquainted with the
state of his health in general. I learned that he ate rather
voraciously, and could not be restrained from taking very high-
ly seasoned food ; that though his bowels regularly enough
evacuated the residue of the food, the stools were of various,
and always of faulty colours, and very offensive ; that he per-
spired profusely upon the slightest exertion. His skin was
covered every where with scurf and eruptions; and his hands
were hard, harsh, and chapped. He took the medicines, as
in the preceding case, for about the same length of time, when
the glandular complaint was well. He continued the half grain
of calomel, however, for three months, for the secretion of bile
had not even in that time become healthy in quantity and quali-
ty. His skin was, however, perfectly smooth and free from
eruptions. His hands only retained in a slight degree their
former feeling.
I have also seen instances of sores apparently scrofulous left
after the suppuration and ulceration of diseased glands, which
had continued for more than a year, heal rapidly under the
same kind of treatment. I have however seen other instances,
in which the sores did not appear to be amended by such con-
stitutional treatment.
I have also observed several instances of strumous affections
of the fingers in children get well in proportion as the general
health has become established by correcting disorders of the
digestive organs. I need not, however, detail them. These
diseases were, in my opinion, strictly scrofulous. The nature
of the disease in the following case will not, I think, be doubted,
and on this account I relate it.




CASE XX.
A child about five years of age, after having had the measles,
got into a bad state of health, and had several scrofulous ab-
scesses form on the fore-arm. They became sores of various
sizes, but in general about that of a shilling; the surrounding
skin was thickened and of a purplish hue. The sores were foul
and without granulations. In this state they were when I first
TREATMENT OF LOCAL DISEASES.
saw the patient, and had continued with occasional amendment
and deterioration for two years. Being consulted on the case,
and perceiving the child appeared out of health, I examined his
tongue, which was furred; inquired respecting his appetite,
which was deficient, and the state of his bowels, which were
costive. The same medicines were prescribed as in the former
cases. In about six weeks the child got into remarkably good
health, which it had not enjoyed from the time of its first indis-
position, and the sores rapidly and soundly healed.
eases are preceded by general indisposition, of which the disor-
dered state of the digestive organs is an evidence, and may have
been a cause. The relief arising from the correction of this
disorder is indeed surprising, and the general knowledge of this
fact I have deemed my duty to promote to the utmost of my
power. When the appetite has been deficient, I have been
accustomed to recommend acids as medicines; when, on the
contrary, it has been good, and the digestion difficult and imper-
fect, I have recommended bitters and alkalies.
I mention this to account for my giving the vitriolic acid in
these cases. It is in addition to its medical properties, so plea-
sant, that even spoiled children will take it without agitating
themselves, and distressing their parents. It pleases me to be
able to give proofs of its utility ; because, I think, they will be
allowed to disprove that any specific good arises from the
administration of alkalies. Alkalies may be useful occasion-
ally in dyspeptic cases; but that they have no specific action in
the cure of scrofula, I have long thought from some experiments
which I made on this subject at the hospital. In cases of scrof-
ulous glands, I gave soda in doses which were gradually in-
creased till they affected the qualities of the urine, without per-
ceiving any benefit to accrue to the local disease from their use.
The pleasure which I feel in thus endeavoring to disprove the
specific virtues of alkalies arises from this circumstance: That
if I am light in my notion, that they are chiefly useful by their
operation in the stomach and bowels, it shows how much bet-
ter it is to be informed of what ought to be done for the cure
of diseases, than of the means by which it may occasionally be

the rational is to the empirical practice of medicine.
After having attempted to show that many non-descript disea-
ses arise apparently from the state of the constitution, and that

206
ON THE CONSTITUTIONAL ORIĠIN AND
carbuncle and scrofula are sometimes consequences of the same
cause ; it may be inquired, whether, if the same general distur-
bance of the health can produce so many varieties of local dis-
ease, it may produce many others, and even every variety.
Even in cancer, disorder of the digestive organs appears to be
antecedent to the local disease, and aggravated by its existence ;
but whether this disorder be the effect or cause of the constitu-
tional diathesis, cannot, I think, be at present determined.
CASES.
SECTION V.
ON DISEASES OF VARIOUS GLANDS, ARISING FROM DISOR-
DER OF THE CONSTITUTION.

I have also observed that diseases of particular organs seem
to originate, in many instances, from disorder of the system in
general. The testis of the male subject, and breast of the fe-
male have furnished me with examples of this observation. In
the cases to which I allude, the testes were alternately affected,
enlarging considerably, and then subsiding. * I have met with
numerous and interesting cases of such diseases of the breast ;
however, the relation of a few will be sufficient to inform the
reader of all that I know concerning this subject.
CASE XXI.
A lady came to London, to submit to the removal of a dis-
eased breast, if it should be judged necessary. The disease
had existed for more than two years. The breast of the affect-
ed side was one third larger than the other; indurated in seve-
ral parts; and so much enlarged and hardened in one place,

* The cause which excites and maintains alternate irritation and disease
of the testes, generally resides in the urethra; but there was no disease of
that part, in the cases which I now mention. The patients first became
unhealthy, and disorder of the testes followed. Similar affections are not
uncommon in pseudo-syphilis.

TREATMENT OF LOCAL DISEASES.
207
that this might have been taken for a distinct tumor, on a hasty
and inattentive examination.* This part was situated near the
margin of the pectoral muscle. The disease had resisted the
various means employed with a view to disperse it, such as
leeches, lotions, mercurial ointment, &c. It was occasionally
painful, and caused the patient so much mental anxiety, that the
surgeon, who attended her in the country, thought it should be
removed. The mammary gland of the opposite side was far
from being in a perfectly healthy state ; which circumstance
appeared to forbid an operation, since the same disease might
take place afterwards in the opposite breast. The patient's gen-
eral health was much impaired, her tongue was furred, her ap-
petite deficient, her digestion imperfect; the biliary secretion
was disordered, and the bowels costive. I ordered her to take
a compound calomel pill every other night, five grains of rhu-
barb half an hour before dinner, and the infusion of gentian with
senna, so as to procure a sufficient evacuation of the bowels
daily. Linen moistened in water was applied to the part in the
evening, or when it felt painful and heated. This plan of treat-
ment reduced the bulk of the diseased gland by at least one
third in the course of a fortnight. The patient went afterwards
into the country, still employing the same medicines; and was
entirely free from the disease in three months, though she felt
occasionally shooting pains, which probably indicated that her
health was not completely re-established



31 CASE XXIL.
A lady consulted me on account of a considerable swelling
of the breast, attended with much pain. It had come on sud-
denly, and had been painful about a week; but she thought
that a lump had existed previous to this time. The principal
tumor was on the side next the sternum, and was as large as an
hen's egg; it seemed to be distinct, yet there was a general
swelling, with partial induration of the substance of the gland.
The tongue was furred, the bowels costive, and the pulse fre-
quent; and she was, to use her own expression, very nervous.
* It may not be improper to observe here, for the instruction of the
younger part of the profession, that if a breast containing a portion which
is particularly indurated be examined with the points of the fingers placed
circularly, the disease will feel like a separate tumor; but if the flat sur-
face of the fingers be moved over it, its true nature will become manifest.

208
ON THE CONSTITUTIONAL ORIGIN AND
I directed her to use the same means as were mentioned in the
preceding case. Small doses of mercury act beneficially on
the bowels, by inducing regular and healthy secretions; and I
know no better method of administering it as a discutient. The
general induration of the breast and tumefaction of the integu-
ments subsided quickly under this treatment, and left the lump
in the same state which I supposed it to have been in before
the attack of general swelling and pain. In another week this
apparently distinct tumor was flattened on its surface, diminished
in size, and confused with the substance of the mammary gland
Its form varied each successive week; it first became oblong,
and afterwards seemed to separate into two parts; but in less
than six weeks no trace of it could be felt.

CASE XXIII.
A medical man, who resides in the country,brought his daugh-
ter to town for advice. She had apparently a tumor in her
left breast, between the nipple and the axilla ; in which part she
had felt a good deal of pain. The swelling was of very con-
siderable size, and the breast so tender, that I could not exactly
make out whether it arose from distinct tuinour, or from a par-
tial enlargement of the mammary gland. Want of time prevented
the patient's father from showing the case to another surgeon.
I could only give him this opinion; that in the present circum-
stances, no one would think of an operation. I recommended
the application of the lotio ammon. acetat. when the part felt
heated; and as the patient had disorder of the stomach and
bowels to a great degree, that the chief attention should be paid
to the state of these organs. A grain of calomel was directed
to be taken every second night ; rhubarb before dinner, and
inſus. gentian and senna, if necessary.
About two months afterwards, having occasion to be in that
part of the country where the patient resided, I called on her.
Her father then told me that the swelling had subsided con-
siderably, after his daughter's return into the country ; and that
of late he had not examined the complaint, as she told him she
felt no uneasiness from it.
When I now examined the breast, I could not perceive any
difference between it and the other. No vestige was left of a
disorder, which had been of such a magnitude, as to occasion
considerable alarm; a circumstance that excited the greatest

"TREATMENT OF LOCAL DISEASES. 209

surprise in the mind of her father, who was a practitioner of
much experience.*
Before I had paid attention to those complaints which arise
from, or are aggravated by, constitutional causes, I could not
have believed that such considerable local diseases, after resist-
ing various topical and general means, should give way so
readily and completely to small doses of medicine. It is only
by considering the manner in which this effect is produced,
that the subject can be placed in a proper point of view.
An attention to the state of the bowels is indispensably neces-
sary, even in the common practice of surgery. A simple cut
of the finger frets into a bad phagedænic sore, which resists
every local remedy so long, that amputation is at last proposed.
This is the consequence of bad health, which in its turn is
aggravated by the irritation of the sore. The patient has a
furred tongue, with other symptoms of disordered digestive or-
gans. An attention to this disorder corrects the painful state
of the sore, which now heals rapidly under simple dressings.
A patient has a disorder in the urethra, almost too trivial for
surgical attention ; yet producing much inconvenience. The
functions of the digestive organs are impaired, and he is hypo-
chondriacal. He consults a physician, under whose care his
general health is amended, and he no longer feels or thinks of
the local disease.
An erysipelatous inflammation of the leg is imputed to some
trivial cause ; as for instance a gnat-bite. It becomes worse
under the common remedies. The health has been long de-
clining, and the chylopoietic viscera are obviously deranged.
The erysipelas is quickly cured by medicines prescribed for
that disorder.
A patient has a trivial sore on his leg, which the surgeon
finds a difficulty in curing by the usual methods. The patient
feels indisposed, and has a manifest disorder of his digestive
organs. The sore begins to slough, and becomes very painful
The disorder of the stomach and bowels is augmented; so
great is the indigestion, that the small quantity of food which
the patient thinks it necessary to swallow for sustenance, feels
weighty and uncomfortable in the stomach ; and the vegetable
food becomes almost corrosively acid. Opium fails to procure


* I have also known cases of induration and suppuration of the salivary
glands, apparently caused by the same general disorder, and cured by the same
treatment.
27

210
ON THE CONSTITUTIONAL ORIGIN AND
sleep, or even to give ease. When the mortification has spread
so as to occupy almost one fourth of the integuments of the
leg, several very copious pultaceous stools of a greenish brown
colour are discharged from the bowels in the course of the night,
and the patient's feelings undergo an entire revolution. Before
this, the stools procured by medicine were watery and dark-
coloured. The patient now sleeps like one long harassed by
pain and watching ; his stomach is tranquil and willingly receives
aliment, which now produces no uneasy sensations. The skin
which had been hot and dry, becomes moistened with a gentle
perspiration, and the pulse beats with its natural frequency, and
in a tranquil manner. The effects of this favourable crisis
being maintained by medical treatment, the sloughs are thrown
off and the sore heals with a rapidity indicative of considerable
vigour of constitution, and further demonstrative of the slough-
ing not having been the effect of vascular weakness, but of ner-
vous irritation. I could relate numerous cases of erysipelatous
inflammation terminating in sloughing, in which the disease arose
from a similar constitutional cause.
In order further to elucidate this subject, I subjoin the
chief circumstances of a case which occurred since the pub-
lication of the second edition of this book.
A gentleman who once had à pimple on his leg spread by
sloughing, so as to produce a considerable chasm both in cir-
cumference and depth, was much alarmed when another
equally trivial complaint manifested the same disposition. He
was at this time in London on a visit, and desired me to at-
tend him. The patient was about 50 years of age, and a ro-
bust healthy looking man ; his pulse was remarkably vigorous,
and in all respects right; his tongue but slightly furred, and
his bowels regular. To me his apprehensions seemed unfound-
ed : he was, however, confined to a sofa, and a linseed poul-
tice applied for nearly three weeks, without any augmentation
of the disease, or any separation in the circumference of the
eschar. The slough had split into portions, and a fetid matter
oozed from it: at that time the poultice was changed to one
made with stale beer, with a view to excite a little action in the
indolent parts. It produced, however, irritation, and in one
night the sloughing of the integuments increased to one third
more than its former extent. The linseed poultice was again
employed, and after some weeks were elapsed, as no separa-
tion had occurred in the circumference of the slough, and it ap-


TREATMENT OF LOCAL DISEASES.
211
pearing penetrable by medical applications, weak acids, infu-
sions of bark, dilute spirits, and resinous tinctures were tried, to
learn the effect upon the slough and contiguous parts; some of
the slough had by this time separated, and new flesh of no un-
healthy appearance presented itself beneath the sloughing part
which extended no deeper than the skin. None of the appli-
cations seemed of any material benefit, and any thing of an
irritating nature appeared to produce irritation, with a slight in-
crease in the circumference of the slough. As the sloughing
of the skin seemed to be the effect of disease extending in it
while the cuticle was entire, and when consequently no appli-
cation could have any peculiar effect, but would act as a simple
stimulus; and as all stimulants appeared injurious, I contented
myself in future with the application of the linseed poultice and
simple dressings. Under their use the sloughing of the skin
continued to spread during a period of about six months, when
the patient died.
The disease began about the middle of the tibial side of the
leg, and extended towards the front and outside, till it occupied
about three-fourths of its circumference : it extended also to-
wards the ankle, and to within about two inches of the upper
end of the tibia. At one time it spread by a dusky-coloured
inflammation, suddenly occupying a considerable extent of skin;
yet in this district there were parts more discoloured, and pre-
senting an appearance similar to that arising from the transuda-
tion of blood from the veins in dead bodies. The parts so dis-
coloured first sloughed, leaving several insular portions of skin
still preserving its vitality. Some of these portions slowly per-
ished, others never completely mortified. At other times the
mortifications spread slowly, and merely from the circumference
without any previous disease in the skin being apparent : every
new extension was preceded by constitutional disturbance;
and when the patient felt well and was tranquil, the disease
continued stationary at times for a fortnight or three weeks. As
the sloughs successively separated in the order in which they
took place, a healthy granulated surface appeared beneath them,
which cicatrized ; and cicatrization also taking place from those
portions of skin which did not completely perish, the sore heal-
ed with more than usual celerity, so that a short time before
the patient's death there was much less slough and appearance
of disease than at former periods.
Having described the local treatment of this unfortunate case,




212
ON THE CONSTITUTIONAL ORIGIN AND
The
I have only to relate the circumstances observed relative to the
system at large, and the medical treatment which was instituted.
tient had been accustomed to eat a well-cooked dinner,
and to drink a liberal quantity of wine afterwards. About four
months preceding this attack, he had very much diminished
his quantity of wine; and from this time he thought that he be-
came nervous and uncomfortable. His nervous feelings were
manifested by anxious looks and inquiries, and by impatience
to have things done at the moment and in the manner he wish-
ed: he was also apprehensive and solicitous about others, in
cases which warranted no such feelings. He was thirsty, and
generally had a tumbler of water on the table, which he sipped
occasionally, though he did not indulge himself in drinking it.
He ate his breakfast and dinner with appetite, and in moderate
quantity. His bowels were regular; and the biliary dischar-
ges, although not right, were not materially otherwise. The first
attentions were paid to the digestive organs,in the manner descri-
bed in the introductory remarks; but when the mortification was
extending, nitric acid and bark were exhibited. When the bark
was increased to a moderately large dose, in order to ascertain
whether it was likely to be of service to the local disease, it
rendered the patient slightly feverish, increased his thirst, and
caused the tongue to become dry and brown. These medicines
were changed for cordials, as camphor julep, with aromatic
confection;--which seemed to answer better. Opium was tried,
and seemed to be beneficial in moderate doses, administered
at regular intervals; but in larger doses it seemed injurious.
The patient throughout suffered very little pain, and slept well,
except at those times when a temporary disturbance of his
health, that has been mentioned, occurred. At those times, al-
so, the white part of the eye assumed a yellowish tint, and
there was an expression of languor and disquiet in his counte-
nance. As cordials agreed with him, a liberal quantity of wine
was permitted; nevertheless, he gradually became feebler, and
his flesh wasted, whilst his belly enlarged. Of this enlargement
he took notice himself: it first appeared to be merely tympan-
itic, but subsequently water was evidently effused. The right
foot and ankle became considerably ædematous; of the left or
diseased limb they were but slightly so. He had but little pain,
and talked of returning into the country. He was good-humour- ,
ed and cheerful almost to the last. " A short time before his
death his memory failed, and he thought but little even on his


TREATMENT OF LOCAL DISEASES.
213
own case. At last he was seized with profuse diarrhæa, con-
sisting of watery discharges; and, being exhausted, he slept
during the last 24 hours of his life.
Now, that the sloughing was not in this case the effect of
vascular debility, I infer not only from the state of the pulse,
but from the rapid healing of the sore : that his nervous sys-
tem was merely disordered and not diseased, was to me suffi-
ciently evident. Although I was extremely desirous of exam-
ining the body, I was not permitted to do so.
A patient supposes that his knee is strained; for pain and
inflammation of the joint suddenly come on, with deposition of
fluid into the articular cavity; this attack is attended with fever,
furred tongue, and unnatural discharges from the bowels.
Leeches, cooling washes, and poultices; in short, all topical
applications are unavailing. It is a case of rheumatic inflamma-
tion, for which a physician is consulted. Five or Six weeks
elapse without any abatement of the disease, the patient being
almost unable to stir in bed. An alteration in the health sud-
denly takes place; the tongue becomes clean, the bowels reg-
ular, and biliary secretion healthy ; and there is no longer any
pain in the knee. All the fluid is absorbed from the joint in
two days, and the patient walks about his chamber. Or there
may actually have been some local injury; but the consequences
are very considerable and violent, and quite incommensurate to
the cause. Such occurrences can only be explained by impu-
ting the effects to the state of the health in general.* .
A case like that described in the preceding sketch would,
I believe, be acknowledged by every one to be dependent on
the state of the constitution in general ; but I could bring for-
ward a great number of instances of chronic affections of joints,
incurable by local measures, which were evidently cured by
correcting those errors in the state of the digestive organs,
which were the cause or effect of general disorder of constitu-
tion. In diseases of joints, we find three distinct kinds of
cases. First a scrofulous disease of the bones, which ultimate-
ly affects their articular surfaces; secondly, an inflammatory
affection of the joint, producing effusion of fluids into its cavity,
and ulceration of the cartilages and ligaments; and in this case,


* As operations are injurious, so we ought not to perform them, if it can
be avoided, when the constitution is much disordered. I could relate
several instances of the wounds made in operations, assuming diseased ac-
tions from such a state of the constitution.

214
ON THE CONSTITUTIONAL ORIGIN AND
the most perfect rest, and most strenuous efforts by local means
to put a stop to inflammation are requisite; and thirdly, an
inflammation dependent on constitutional causes. This in-
flammation is sometimes of an active and painful nature, and
sometimes of a more indolent and chronic character; but what-
ever form it may assume, it is less prone to injure the structure
of the joint, and little susceptible of cure by local measures,
whilst it yields to those means which tend to improve the health
in general. When a diseased joint is so situated as to become
an object of examination, these circumstances will be sufficient-
Jy evident. I am induced to mention them chiefly on account
of such variety of affections occurring equally in the hip, as
well as in the other joints, in which case the benefit accruing
from different modes of treatment is less demonstrable to the
sight and touch. *


* As I know of no treatise on diseases of the hip in which the distinction
of cases is rnade; and as, from what I have seen, I cannot but consider
the subject to be very important; so I think I should do wrong to forego
the present opportunity of relating as succinctly as possible two of a con-
siderable number that have come under my observation, in order to excite
attention to this subject.
CASE J.
A boy about twelve years old was sent from school to London, being sup-
posed to have a lumbar abscess. There was a considerable collection of
fluid beneath the fascia of the thigh; but it received no impulse when the
patient coughed. The boy limped in walking, as if he had a diseased hip,
scarcely bearing on the affected joint. When pressure was made on the
front of the orbicular ligament, it gave him acute and considerable pain.
He was kept perfectly quiet in bed, blood was taken by leeches repeatedly
from the integuments opposite to the inflamed joint, and linen wet with
diluted aq. ammon. acet. constantly applied, till pressure no longer occa-
sioned pain. A blister was then applied over the joint, and the cuticle
being removed, the sore surface was dressed with savine cerate. This
dressing produced considerable inflammation and ulceration beyond the
blistered part, and caused the surface of the skin which had been deprived
of its cuticle to mortify. Near a month elasped before the sore healed.
At this time no fluid was discoverable beneath the fascia; no uneasiness
was felt when the joint was compressed; and the boy could not be prevent-
ed from getting up, because he felt as competent to walk about, as before
the occurrence of his disease. He went to school again in the country, and
after two years was put into a merchant's employ ; in which situation, he
was obliged to be constantly walking about the town. He then again be-
came lame in the same manner, but not to the saine degree. There was,
however, no effusion of fluid beneath the fascia of the thigh. A month's
rest with similar treatinent seemed to have cured this relapse; and I then
told his father that he must change the employment of his son-observing,
that though the joint might recover sufficiently to endure common exercise,
without injury, it was not to be expected that it would ever be able to sus-
tain violent exertions with impunity. I urged him, also, to let me know

TREATMENT OF LOCAL DISEASES.
215
CASES.
SECTION VI.
DISORDERS OF PARTS WHICH HAVE A CONTINUITY OF SURFACE
WITH THE ALIMENTARY CANAL.
I HAD formerly observed spasmodic strictures of the æsopha-
gus to disappear under various modes of treatment, in a man-
ner which I did not understand. Mercury seemed to effect
the cure in three instances. Many cases have occurred to me
lately, in which the irritation in the esophagus seemed to be
first excited and afterwards maintained by disorder of the di-
gestive organs. It will be readily allowed, that spasmodic

immediately if there was any return of lameness. About three months
afterwards, I met the father and his son in the street, and observed that
the youth limped in walking very much. I asked why I had not been
informed immediately, as I had requested, of return of lameness; and fur-
ther inquired, whether the boy still continued in the same situation. Being
told that he did so, I felt so much hurt at the cruel and absurd conduct of
his father, that I declared I would no longer interfere in their concerns,
nor was I asked to do so.
All that I can further relate of this case is, that a large abscess formed
and broke behind the trochanter, and that I once afterwards saw the poor
lad lying in St. Bartholomew's hospital with his thigh bone dislocated, in
consequence of the destruction of the ligaments of the joint.
CASE II.
A young lady of a delicate and susceptible constitution, who had suffer-
ed much uneasiness of mind on account of some of her friends, became so
excessively lame in the left hip that she could not move a few steps with-
out support. Pressure on the front of the joint occasioned considerable
pain. Her tongue was much furred, and her bowels greatly disordered,
and she had fits of agitated and difficult respiration. I recommended noth-
ing but tepid fomentations to the hip, and explained to her physician what
I thought would be right to be done with regard to the state of the diges-
tive organs
As she became better in health, her power of moving about increased,
and she went to the sea-side. After two years, there still remained some
tenderness, when the hip-joint was compressed and some thickening of the
parts which covered it. She, however, eventually got well, though no local
applications of any moment were made to the diseased parts. I need scarce-
ly add, that the means employed in the first case, with such striking success
would have been prejudicial in the latter, whilst those which were ser-
viceable in the last case, would have been futile and nugatory in the
former.

216
ON THE CONSTITUTIONAL ORIGIN AND
strictures of the esophagus, when long continued, may cause
a thickening in the affected part of the tube, and thus the stric-
ture may become permanent. One instance will be sufficient
to illustrate and verify this view of the subject.
CASE XXIV.
A lady, who had been in bad health for many years, and
was supposed by her medical attendants to have a stricture of
the esophagus, became at last incapable of swallowing any food,
except in very small quantities; she was even then obliged to
drink some fluid after each morsel, to facilitate its descent into
the stomach. Some mucus and blood rose into the mouth
after vomiting, which very generally followed the taking of food.
Under these circumstances, I was requested to pass a bougie,
in order to ascertain the state of the esophagus; but I declined
this examination, on account of the disorder which existed in
the stomach. The tongue was greatly furred; the parts in
the epigastric region very tender : the bowels much disorder-
ed; the secretion of bile either very unhealthy, or entirely want-
ing; every symptom, in short, which indicates an aggravated
form of disorder of the digestive organs, existed in a striking
degree. The stomach and bowels were brought into a better
state by such medical attentions as I have already so often
described; and the esophagus partook of this amendment: for
moderately sized morsels of food could now be swallowed
without the necessity of washing them down by liquids. The
general health also improved, and she became fat. But the
disorder of the digestive organs, which had been of long con-
tinuance, was not completely subdued ; she was still subject
to relapses, and in some of these the difficulty of deglutition
again occurred. *
The throat and mouth are the parts next in order; but it is
unnecessary to relate additional cases under this head : some
of the instances already recorded will be sufficient to confirm
my sentiments on this subject, and the propriety of the practice
which I have recommended.
That diseases of the nose may be caused or aggravated by
irritation arising from the stomach is a proposition, which will,
I think, be readily granted. Indeed it seems surprising that



* This patient has now for more than four years been free from this
disorder.
(TREATMENT OF LOCAL DISEASES.
217

the operation of this cause has been so little adverted to in books
of surgery ; since the phenomena which prove the fact are so
well known. Are the monstrous noses, caused by excessive
drinking of vinous and spirituous liquors, to be otherwise ac-
counted for, than by irritation arising from the stomach? And
do not worms in children cause a teazing sensation in the ex-
tremity of the nose? I had seen in private practice, several
cases of irritation and swelling of the end of the nose, in some
instances accompanied with small ulcerations of the pituitary
membrane. In these cases, the skin over the nose, which was
tumid, became rough and discoloured: the middle of the discol-
oured part became sound; whilst the circumference retained its
morbid actions, the disease there spread in a small degree.
In these cases the tongue was furred; and there were evident in-
dications of disorder in the stomach and bowels. The disease
was checked, and cured, by attention to this disorder. I was
strongly impressed with the opinion, that if these cases had
been neglected, they would have terminated in that herpetic
ulceration, which so often affects the end of the nose. I have
also seen several instances of that herpetic ulceration in its con-
firmed state more materially benefited by medical attention to
correct the disorder of the digestive organs than by any local
application : and I feel confident that it may be frequently
cured by such endeavours.
I have observed, in all the cases of that noisome and intract-
able disease, ozæna, which have come under my care lately,
that the stomach and bowels have been disordered ; and more
benefit has been obtained by endeavouring to bring these organs
into a healthy state, than by all the local applications which had
been previously tried. I stated to a medical friend my opin-
ions respecting one patient, who came from the country, and
begged to know the effect of the treatment which I had pro-
posed. He informed mne, after some months, that he had not
been able to succeed in correcting the visceral disorder ; and
after relating the means which had been used, he adds, “ The
patient was now attacked with a bilious disorder, to which she
had formerly been subject, and for which I gave her six grains
of calomel in a bolus, which soon relieved her. During this
attack the nose seemed well; there was no fetor in the dis-
charge, and she recovered her sense of smelling.” However,
the disease returned afterwards as before. -
28
218
ON THE CONSTITUTIONAL ORIGIN AND
I have known several instances of persons who have for a
long time been subject to polypi of the nose, in which the poly-
pi ceased to grow after some attention had been paid to correct
a disorder of the digestive organs.
In farther confirmation of the opinion, that diseases of the
nose depend much upon the state of the stomach, I shall men-
tion the case of a woman, who had a disease of the nose, which
I expected would, at least, prove very tedious and very trouble-
some, but which got well speedily under simple dressings, in
consequence, as appeared, from the effect of internal medicines.

CASE XXV.
This patient was between thirty and forty years of age;
had a furred tongue, bowels alternately costive and lax, and
the discharges discoloured. An enlargement of the left ala
nasi, caused by a great thickening of the parts covering and
lining the cartilage, had gradually taken place. The skin was
discoloured, and an ulcer, about the size of a sixpence, had
formed on the under surface of the ala. The sore was deep,
with a sloughing surface, and uneven and spreading edges.
Spermaceti cerate was employed as a dressing; and the ex-
ternal skin was frequently bathed with Goulard's wash. She
was ordered to take internally five grains of rhubarb an hour be-
fore dinner, five grains of the pil. hydrarg. every second night,
and the infusion of gentian with senna occasionally. The sore
ceased to spread, the swelling gradually subsided, and all dis-
eased appearances were removed in the course of a month.
The patient also found her health considerably amended.
In most cases of deafness, there is probably a state of irrita-
tion, and a tendency to inflammation, throughout the passages
of the ear. The external meatus may be unusually sensible,
the secretions being either suppressed, or discharged in an un-
natural quantity. The lining of the Eustachian trumpet is
thickened; and hence it becomes partially obstructed. It
must be admitted that such a state of the organ is likely to be
aggravated by a cause, which maintains or produces irritation
in the nose. When dullness of hearing also depends on a tor-
pid state of the nerves, it may be caused by the same circum-
stance, which is known to affect the sensibility of other nerves.
Indeed, I have remarked that the hearing of many persons
has considerably varied with the state of their health in general;
TREATMENT OF LOCAL DISEASES.
219

so that I felt no surprise from the occurrence related in
the following case.
A gentleman applied to me on account of some pseudo-
syphilitic symptoms, which I told him would gradually become
well. I advised him, at the same time, to be particularly attentive
to the state of the digestive organs, which were generally disor-
dered by the effects of the poison. He took five grains of the
pil. hydrarg. every second or third night. The disorders for
which he had consulted me were all removed in the course of
two months ; when I received a letter from him, saying, that
he thought it a duty he owed to me and to the public to inform
me, that the lenient course of mercury, which I had recom-
mended, had cured him of a considerable degree of habitual
deafness.
It is well known that ophthalmy frequently arises from con-
stitutional causes; and in such cases the digestive organs are
generally deranged. The health will be most speedily restor-
ed, and the local disease most effectually diminished, by correct-
ing the disordered state of the abdominal viscera. There is
no necessity for enlarging upon this subject; yet it may be
useful to state what I have observed respecting those ophthal-
mies, which take place subsequently to gonorrhea, and
which have generally been ascribed to a retropulsion of that
disorder, or to the accidental application of the discharge to
the surface of the eye. In the worst of the cases, which I
have seen lately, there was considerable redness and irritability
of the eye, lasting nearly a fortnight. The digestive organs
were deranged in all the instances, to which I allude ; and I
attribute the comparative well-doing of these patients to the
attention which was paid to their correction. In other
cases, which I had formerly been witness to, where evacua-
tions by bleeding and purging, &c. were employed, the disor-
der was extremnely obstinate ; nay, several patients lost their
sight.
The cases of ophthalmy connected with gonorrhæa appear
to be of two kinds. In the worst case, and that which I have
happened to meet with most rarely, there is, I think, reason to
suppose that some of the discharge from the urethra has been
accidentally applied to the surface of the eye. This circum-
stance may be inferred from the copious and puriform discharge
which takes place from the conjunctiva which is continued for
about three weeks, and from the disease not yielding to any

01
220
ON THE CONSTITUTIONAL ORIGIN AND
remedies which usually relieve other ophthalmies. The milder,
and, to me, more commonly occurring case, seems to be the
result merely of irritability of constitution. With relation to
this subject, I may mention that I know a patient who has seve-
ral times had discharge from the urethra and inflamed eyes,
alternately with each other; and both apparently arising from
constitutional causes. I shall also add the following striking in-
stance of ophthalmy connected with gonorrhæa, in which the
inflammation of the eyes can neither be supposed to be the
effect of local contamination nor of metastasis.


copious.
His
; his bowels had
the stools were bland
CASE XXVI.
A gentleman, having a gonorrhea and being in a remote
part of Scotland, felt himself obliged to go to the west of Eng-
land with the greatest expedition. He came to London by the
mail coach, and during the journey his eyes became greatly
inflamed, and he was much tormented with dysury; he was
indeed so ill, upon his arrival in town, as to be unable to pro-
ceed on his journey. His eyes were exceedingly red and
painful, and the lids tumid. He had frequent and urgent de-
sire to void his urine.
The discharge from the urethra was very copious. His
tongue was much furred; his bowels had a costive tendency ;
the stools were blackish and offensive ; his pulse frequent, and
neither full nor strong ; his skin hot and rather dry. He said
that formerly having a gonorrhea, he had been affected with
ophthalmy in the same manner. He was directed frequently
to bathe his eyes with a lukewarm decoction of poppies; but
the chief attention was paid to the state of his stomach and
bowels. He took five grains of the pilul. hydrarg. every night,
and other medicines to procure a sufficient alvine evacuation
daily. On the third day he had severe rheumatic pains in his
shoulder. On the fourth, his knee became affected with rheu-
matism, and so much swollen that he was incapable of mov-
ing about, though his eyes were much better, so that he was
able to sit up and bear the window-shutters of his chamber to
be left open, which he could not before have permitted. On
the fifth day, though better, his eyes were still much inflamed, his
dysury troublesome, and he was unable to walk from the rheu-
matic affection of his knee. The discharges from the bowels
had been regularly observed, and they still continued of a very
wrong colour, till the evening of this day, when he had a stool
TREATMENT OF LOCAL DISEASES.
221

properly tinctured with healthy bile. He now felt a sudden
and surprising amendment, which appeared equally so to others
on the following day; for I found him walking about with very
little lameness, his eyes requiring no further attention than
wearing a green shade, and he had no dysury. In two days
he pursued his journey, nor did he experience any relapse.
There is a chronic ophthalmy, which is, I believe, generally
considered to be venereal, probably from the difficulty of curing
it, and probably from mercury being frequently beneficial to it.
As cases of this description evince how much ophthalmies are
likely to depend upon constitutional causes, I shall briefly relate
the following, to identify the kind of disease to which I allude.
CASE XXVII.
A gentleman had for more than two years been more or less
subject to a chronic ophthalmy. When he was very bad, he
had twice used mercury for its cure, and with temporary suc-
cess. The last mercurial course was a considerable one, as
the relapse of his disorder was attributed to the insufficiency of
the former one. The ophthalmy, however, returned with as
much, if not with more severity than formerly. The eye was
extremely red, very irritable, and his vision very imperfect.
I found the patient shut up in a close and dark chamber, from
which he rarely ventured to stir, lest he should catch cold.
His tongue was furred, and his biliary secretion faulty. I di-
rected small doses of mercury every second night, merely as
probilious medicines, and requested him to pay attention that
his bowels were kept clear without being what is called purged.
I also urged him to go out into the air, and use active exercise.
By pursuing these measures, the ophthalmy was nearly well
in about three weeks. He now either caught cold or fancied
that he had done so ; his general health became disturbed, and
his ophthalmy returned. It got well, however, as the distur-
bance of his constitution wore off; and though he had two or
three times, during a year, some trivial returns of ophthalmy,
yet they were always induced by general disorder, and readily
got well by measures directed to correct disorders of the ali-
mentary canal.
That cutaneous diseases * are much connected with the state
of the stomach, is generally known. Hence various medicines
* It may perhaps be right to advert to the direct and sudden sympathy
which exists between the skin and the stomach. In affections of the lat-
222
ON THE CONSTITUTIONAL ORIGIN AND
have been recommended to correct disorders of that viscus,
with the view of removing the more evident, but consequent
disease of the skin. The account, which I have given of dis-
orders of the digestive organs, may lead to a more rational and
less empirical treatment, and to the more just appreciation of
the value and mode of action of remedies, which are sanc-
tioned by experience. It is almost superfluous to relate any
case to authenticate so well known a fact; the following, how-
ever, may be found interesting and instructive.
A patient in St. Bartholomew's hospital had an herpetic dis-
ease of the skin. This had healed in the middle, and spread
in the circumference to such a degree, that it occupied nearly
the whole length of the leg, and included two thirds of its cir-
cumference. The skin had recovered a moderately sound state
in the centre. The disease was propagated in the circum-
ference by an ulceration, which threw out a projecting and
firm fungus of a tawny colour, of about half an inch in breadth.
A small groove or channel separated this fungus from the sur-
rounding inflamed skin, which had not yet ulcerated. A simi-
lar disease occupied the back part of the arm; this was of an
oval figure, and resembled, in every circumstance, that which
I have already described upon the leg. These diseases had
existed for nearly two years, and continued to spread in op-
position to every mode of treatment. Mercury had been em-
ployed, even to salivation, without any inarked alleviation of
the local complaint. I immediately perceived that the diges-
tive organs were greatly deranged: upon correcting this dis-
order, the skin surrounding the disease became pale ; and all
disposition to spread ceased. The fungus, however, still pro-
jected, and did not heal; it was therefore dressed with a weak
solution of kali arsenicatum. This remedy seemed to subvert
the diseased actions, which had produced the fungus; so that,
in less than two months, the patient was discharged from the
hospital, perfectly well.

ter organ, the skin is dry and cold, moist and cold, hot and dry, or moist
and dry; and it suddenly changes from the one to the other condition,
as the state of the stomach varies. When the digestive organs are disor-
dered, the irritable state of the skin is manifested by the effects of blisters
and other irritating applications. A blister produces a tormenting local
disease, and even a Burgundy pitch plaster causes extensive erythema.
Indeed, when the constitution is irritable, all the modes of counter-irrita-
tion, which surgeons employ under other circumstances with success for
the cure of local diseases, are likely to do harm; and thus these curative
methods obtain discredit in consequence of their ill-timed employment.
TREATMENT OF LOCAL DISEASES.
223

I have seen similar herpetic diseases, of much less extent,
succeed to the absorption of matter from sores upon the geni-
tals. These have got well when the patient has gone into the
country, and appeared again when he has returned to town.
They have healed under a course of mercury, and broken out
again when it was discontinued.
In this review of disorders, occurring in parts having a con-
tinuity of surface with the digestive organs, I have traced them
from the stomach. Another set of diseases may originate
from the same source. The large intestines suffer more in ad-
vanced stages of these disorders than the smaller ones; hence
disorders of the rectum, and particularly many irritable disea-
ses about the orifice of that bowel, are deducible from this
cause. I shall not, however, prolong the account by the relation
of cases; but content myself with assuring the reader, that the
opinion has been derived from facts, and not from precon-
ceived notions of the operation of such disorders.
I subjoin to this section a case, to show how irritation in the
vagina and contiguous parts may be connected with disorders
of the digestive organs. Cases of considerable discharges from
that canal frequently occur in children, and which I believe to
depend chiefly on constitutional causes : disorder of the diges-
tive organs induces dysury, and from the urinary organs the ir-
ritation may be communicated to the vagina.
Previous to the history of the case, I shall add a few obser-
vations as to the different meaning of the words disorder and
disease, which I believe have been generally used in differently,
being considered as synonymous. When I first published
these observations, I then wished to have defined these terms,
and to employ them strictly according to the meaning I should
attach to them; but I forbore doing it, thinking it might be
construed into mere affectation. Disorder, I should define to
be an unhealthy state of the feelings or functions of parts, with-
out any apparent alteration of structure :—and disease, a visi-
ble alteration in the appearance or structure of the affected
part.-Disorder is nervous; disease is the effect of vascular
actions, excited by nervous disorder. An organ may become
diseased to a certain degree, and yet, disorder ceasing, its
feelings and functions may be natural and healthy ; yet disease
must have a tendency to establish disorder. That disorder
alone will destroy life, is proved by numerous facts : our chief
attention should therefore be directed to the tranquillizing of
STI
Co
224
ON THE CONSTITUTIONAL ORIGIN AND

the nervous system, with a view to prevent the occurrence of
disorder, which continuing, may lead to the production of dis-
ease. If, however, disease be already established, the same
attention must be continued, to prevent its increase, and to relieve
that nervous disorder which has produced it, and is attendant
upon it. Though the facts, proving that disorder alone may be
fatal to the individual are not uncommon, yet I think it may be
right to relate one case, to show distinctly what kind of cases I
am alluding to.
A female child, five years of age, having disorder of the di-
gestive organs, had also discharge from the vagina and dysury :
afterwards several sores formed about the labia pudendi, which
were foul and fretful, and did not heal under any of the appli-
cations that were tried. The tediousness of the case induced
the parents and medical attendant to wish for an additional
opinion. Being consulted on the case, I suggested some un-
important alteration in the local treatment, and urged particular
attention to diet, and to the regulation of the functions of the
bowels and biliary secretion, which was extremely wrong.
The sores after a little time became materially better, but the
disorder of the digestive organs rather increased, when, after the
child had for several days discharged nothing from the bowels
but a substance resembling clay in consistence, and of a slate
colour, it died suddenly of nervous disorder.
The body was very attentively examined; and though the
alimentary canal was slit open throughout the greater part of
its extent, no morbid appearance could be discovered : the
other abdominal and pelvic viscera were alike sound in structure ;
the gall-bladder was greatly contracted, appearing as if it had
contained no bile for a considerable time : not the slightest
morbid appearance could be observed in the examination
brain, which was made with the greatest attention.
rthe
att
SECTION VII.
In this section I shall mention what information I have ob-
tained by dissection, relative to the causation of other diseases
by those of the digestive organs. The reciprocal sympathy,
which exists between the brain and the digestive organs, is
TREATMENT OF LOCAL DISEASES...
225

generally admitted; but the kind and the degree of the effects
arising from this sympathy, are not, perhaps, in general, suffi-
ciently understood. These organs mutually increase each
other's disorder; till the affection of the sensorium leads to the
greatest disturbance of the nervous functions, and even those of
the mind.
All this may happen without any visible disease of the brain.
Dr. Kirkland particularly directed the attention of medical
men to nervous apoplexy; and the observations which have
been made since his time have proved, that not only a gene-
al derangement of the functions of the nervous system, produ-
cing apoplexy, but also partial effects of a similar nature, causing
hemiplegia and paralysis, may take place without any visible
change of structure in the brain. I have met with numerous
instances of this kind ; but could not determine whether the
affections were merely nervous, or whether they were produ-
ced or aggravated by disorder of the digestive organs. I only
know, that the patients died affected by apoplexy, hemiplegia,
or more local paralysis, without any derangement in the evi-
dent structure of the brain. I may also mention, that I for-
merly examined the brains of three persons who died in a co-
matose state, in consequence of the metastasis of rheumatism.
In these cases no morbid appearance was observed in the brain,
except some slight marks of inflammation of the pia mater. It
therefore appears clearly to me, that disorder and a consider-
able diminution of the nervous functions may take place, with-
out any organic affection of the brain. The perfect recovery
of patients, which sometimes happens, after such disorders,
anay also be considered as additional evidence of there having
been, in such instances, no organic disease of the brain.
There can be no doubt but that epilepsy may in like manner
take place without any morbid alteration of the structure of the
brain, or its membranes. Some of the persons whose heads
were examined, without the discovery of any disease of those
parts, had been subject to attacks like those of epilepsy. Dr.
Henry Fraser has, of late, published a decisive instance in
proof of this fact. A patient died of epilepsy, and his brain
was examined with particular attention by Mr. Cooper, with-
out any morbid alteration of structure being discovered.* In
general, however, morbid appearances are evident in the brains
* See Fraser on Epilepsy, page 39.
29
226
ON THE CONSTITUTIONAL ORIGIN AND

of those persons who die of epilepsy. Tubercles are most
frequently met with. There is, however, a disorder of struc-
ture which I wish briefly to mention, as I do not find that it
has been noticed. In two persons, who died of epilepsy, I
found the medullary substance of each hemisphere altered
from its natural structure; it had lost its natural firmness, and
smoothness of surface, and appeared like thick curdled cream.
Now, if disorder of the digestive organs is capable of caus-
ing or aggravating nervous disorder, even to the production of
those effects which have been mentioned, when there is no al-
teration of structure ; it must be granted that such a state of
irritation of the sensorium may lay the foundation of an ex-
citement of the vascular structure of the brain, and thus very
frequently produce organic disease. When this has occurred,
it will aggravate and establish the nervous affection, and thus
perhaps render it insusceptible of cure.
Such are the general observations which I have made, by
means of anatomical inquiry, relative to these subjects. With
respect more especially to the investigation of my present ob-
ject, I have examined the bodies of six patients, in whom dis-
ease most certainly began in the abdominal viscera, and was
continued in them to the conclusion of their lives. Neverthe-
less, the patients seemed to die rather of nervous disorder, than
of disease of the parts first affected. One of the patients died
affected with apoplectic symptoms, and five with hemiplegia.
In all these cases the liver was greatly diseased, and the
bowels also exhibited diseased appearances. In three of the
cases there was considerable inflammation of the membranes of
the brain, and a good deal of water in the ventricles. In two
of them no morbid appearance of the brain was discovered. I
have also examined a child, who was supposed to die of hy-
drocephalus, accompanied by great disorder of the stomach
and bowels. In this case the bowels were inflamed, the liver
sound, and the brain perfectly healthy in appearance; yet
there had been so great a diminution of sensation and motion,
as to leave no doubt of the existence of hydrocephalus. I am
aware, that great opportunities of observation, accurate atten-
tion to the history of diseases, and anatomical examination of
fatal cases, are requisite to enable us to form just notions rela-
tive to the present subject. I thought, however, that it might
not be improper to state what had been the result of my own
inquiries by dissection, in order to promote a more general at-
tention to the subject.
TREATMENT OF LOCAL DISEASES.
227
T
1
When my attention was first directed to the subject of sym-
pathetic affections of other organs, caused by disorder of those
concerned in digestion, my primary object was, to endeavour
to ascertain, by dissection, how far pulmonary diseases origi-
nated from such a source. I have, in the course of my in-
quiries, had several opportunities of examining the bodies of
patients who apparently died of phthisis, combined with diseases
of the digestive organs. In these cases, both the history and
dissection tended to prove, that the chylopoietic viscera were
the seat of the greatest and most established disease, and that
the pulmonary affection was a secondary disorder. The liver
was greatly diseased, and the lungs were also beset with tuber-
cles; yet a.considerable portion of those organs was sound.
But dissections can never conclusively ascertain the truth of
the opinions which I have stated; for the same disposition to
disease existing in the constitution may equally affect both the
pulmonary and digestive organs. Nay, observations made in
dissection in general, would tend to disprove the opinions allu-
ded to; for diseases of the lungs are very commonly met with
in dead bodies, while those of the liver and bowels are much
less frequent. Yet considerable disorder of the digestive or-
gans does exist, and may continue for many years, without any
organic disease being apparent: it is possible, therefore, that such
disorder may excite disease of the lungs, and thus produce a
worse disease in the latter organs, than what existed in the for-
mer. In short, the opinions, which I have delivered cannot be
either ascertained or refuted by anatomical researches alone.
Accurate attention to the state of the digestive organs may
determine this important subject, and lead to the prevention
and cure of the sympathetic diseases which I have mentioned.
The attention alluded to is not of that general kind, which ad-
verts only to the quantity of the ingesta, and the periodical ex-
pulsion of the egesta; but one that more strictly observes wheth-
er the viscera are free from irritation, and whether their secre-
tions are healthy or otherwise. My opportunities of acquiring
practical information on this subject must necessarily have
been very limited ; yet I have seen many cases which, to me,
appeared to prove, that pulmonary irritation sometimes pro-
ceeds from disorder of the digestive organs. In cases of sur-
gical diseases, accompanied by disorder of the digestive organs,
I have also occasionally observed a cough attended with ex-
pectoration, to cease upon the correction of the disorder of
those organs.

228
ON THE CONSTITUTIONAL ORIGIN AND

A case, which happened about five years ago, strongly imi-
pressed these opinions on my mind. A servant of mine told
me, that his wife was dying of a consumption, which had been
rapidly increasing for six months, and had baffled all attempts
to relieve it. Thinking that I could procure her some medi-
cal assistance from the hospital, I went to see her. The case,
however, seemed past hope. She was extremely emaciated ;
her pulse beat 140 in a minute; her face was flushed; she had
a most distressing cough; and spit up more than a pint of mu-
cus, mixed with pus and streaked with blood, in twenty-four
hours. The circumstance, however, which most disturbed her
was a continual purging of black and offensive matter. She
told me that her bowels were first disordered that an unheal-
thy state of those organs had preceded the pulmonary affec-
tion, and was indeed habitual. I thought it unnecessary to
trouble my medical friends in so hopeless a case; and order-
ed some pills, containing one grain of opium, to be taken in
such a quantity as was necessary to stop the purging. As she
informed me that the disorder began in the bowels, I added to
each pill half a grain of calomel. By these means the pur-
ging was so much checked, that she did not find it necessary
to take more than two pills in twenty-four hours; and when
she had taken twelve, the mercury, very unexpectedly, affect-
ed the mouth. From that period, the stools became of a nat-
ural colour and consistence; the cough and expectoration cea-
sed ; and she was soon sufficiently recovered to go into the
country; from whence she returned apparently in good health.
Now if it were to be ascertained, that pulmonary irritation,
which might of course produce pulmonary disease, sometimes
arises from disorder of the digestive organs;* it would be
right to inquire further, whether it produces such effects, by
the nervous disorder it occasions, and by its operation on the
health in general, or by means of a more immediate sympa-
thy existing between the pulmonary and digestive organs. I
do not mean to insinuate, by what has been said, that pulmo-
* In the second part of my surgical and physiological essays, in which
I related experiments, made with a view to ascertain the functions of the
skin, I mentioned that as it was manifest the skin and lungs were both en-
gaged in the function of throwing forth carbonic acid gas, it followed, that
when from vicissitudes of the atmosphere or weakness of the sanguifer-
ous organs, the circulation and secretion of the skin were much diminish-
ed, the lungs would be liable to plethora, and have to perform more than
their ordinary duty, which circumstances were likely to induce irritation,
and perhaps consequent disease of those organs. Those experiments, as
they are not of practical importance, I shall not reprint.
TREATMENT OF LOCAL DISEASES.
229
nary diseases do not arise originally and idiopathically ; but
only to suggest that they may arise sympathetically, or in con-
sequence of disorder of the digestive organs. The propor-
tionate number of cases, in which they originate in this man-
ner, can only be determined by very extensive experience.
That the stomach and bowels are disordered, during the pro-
gress of phthisis, will, I conclude, be readily admitted ; and
that an attention to correct such disorder is requisite, must be
acknowledged, from what has been said relative to the influ-
ence of such treatment upon various local diseases.
The actions of the heart seem to me also to become disor-
dered from sympathy with the stomach. That palpitations,
and feeble or intermitting actions of that organ arise from this
cause, is proved by their ceasing, when the state of the stom-
ach becomes changed. The palpitations which take place
after eating, in cases where the heart is irritable, further evince
the sympathy which exists between these organs. Surgeons
are occasionally consulted on cases of palpitations of the heart,
which the patients mistake for aneurisms; and I have seen ma-
ny instances, where the great degree of palpitation led to a
belief, that some organic affection existed. This has ceased
on an amendment of the general health, apparently arising
from an amelioration of the state of the digestive organs, and
the patients have continued in perfect health. I have not col-
lected any accurate narratives of the cases that I have seen ;
none at least which I could properly present to the public as a
proof of the fact. There is nothing, however, of which I am
more perfectly convinced ; for I have felt it to be true in my own
person. After considerable and unusual fatigue, I was seized
with pain, and a sensation of coldness in the region of the
stomach. I had no appetite, and the biliary secretion was
suppressed. Whilst this disorder continued, which was for
many weeks, my pulse intermitted very frequently, and I was
distressed with hypochondriacal sensations. Upon an altera-
tion in the state of the digestive organs, and a renewal of the
biliary secretions, which happened very suddenly after taking
five grains of the pil. hydrarg. my pulse became perfectly reg-
ular, and my mind tra
The observations, which I have made in surgical cases, lead
me also to attribute many hemorrhages, and particularly those
from the nose, to a sympathetic affection of the heart and ar-
teries, excited by disorder of the digestive organs.
If such a state of the system in general, as I have described,



230
ON THE CONSTITUTIONAL ORIGIN AND
and which is manifested by circumstances denoting the digest-
ive organs to be in an unhealthy state, and the nervous system
to be likewise disordered, may, in some instances, cause vari-
ous local diseases of parts not essential to life, the care of
which custom has consigned to the surgeon; and may, in oth-
er instances, produce disorders of organs essential to our ex-
istence, the care of which is allotted to the physician,—the sub-
ject must be allowed to be of the highest importance. Of late,
indeed, I have been inclined to consider these circumstances as
the cause of the complicated diseases which are met with in man,
so much more frequently than in animals. In man the brain is
more sensitive, and liable to be disordered by mental affections. In
man the digestive organs are liable to be disordered by stimu-
lating and unnatural diet. Sedentary habits and impure air
co-operate to aggravate these disorders. The affections of the
brain and digestive organs mutually increase each other; and
thus a state of constitution arises, which is productive of the
most general and complex diseases. But even these do not
seem to me to be the most calamitous terminations of sucli
causes. The disorder of the sensorium, excited and aggravat-
ed by the means which have been described, frequently affects
the mind. The operations of the intellect become enfeebled,
perplexed and perverted; the temper and disposition irritable,
unbenevolent and desponding; the moral character and con-
duct appears even liable to be affected by these circumstances.
The individual in this case is not the only sufferer, but the evil
extends to his connexions and to society. The subject, there-
fore, appears to me of such importance, that no apology need
be offered for this imperfect attempt to place it under general
contemplation.*
I have endeavoured to slow, in the introductory observa-
tions, that a state of nervous disorder and a disorder of the
digestive organs, may reciprocally produce each other'; and
that when both occur, they become mutually increased, and
thus derange the constitution in general, so as to prove the ex-

* The ancients, who formed their judgment of the nature of disorders.
by observing the excretions, denominated an irritable and desponding state
of mind, Hypochondriasis; and when a more fixed and irrational dejec-
tion took place, they deemed it an atrabiliary disorder, and called it Melan-
cholia. There can be no doubt of the correctness of their observations ;
for if the disorder began in the nervous system, it would generally pro-
duce and become aggravated by that disceder of the digestive organs,
from which they denominated it.
TREATMENT OF LOCAL DISEASES.
231
citing or predisponent causes of numerous dissimilar and im-
portant local affections. I shall, in conclusion, for the reasons
mentioned in the preface, offer the opinions which the consider-
ation of the foregoing and similar cases have impressed on
my mind. When I find in diseases that the functions of the
digestive organs are impaired and disturbed, I consider this
disorder as the cause or effect of a more general derangement
of the system at large. When it seems to be the cause, and
when it can be speedily corrected and removed, then the re-
lief and cure of those local diseases which may have taken
place, is in many instances so sudden and surprising, that I
think it impossible to consider the disorder of the general
health and the local disease, in any other relation but that of
cause and effect.
The cure of local diseases by means that cannot be suppos-
ed to act otherwise than by correcting errors in the functions
of the digestive organs, incline me to differ in opinion from
those who consider the local diseases alluded to as the effect
of impurity of the fluids, and to coincide with others, who con-
sider them as the result of general irritation, frequently induced
by that of the abdominal viscera.
When I see the same local diseases removed by the same
means, though more slowly, I do not wonder at the tardiness of
the cure; and perceiving that the amendment of the local dis-
ease is proportionate to that of the health in general, I feel war-
ranted in forming the same opinion as to the mode in which
the cure is effected. When I see local diseases disappearing
and re-appearing as the constitution in general is tranquil or
disturbed, I feel confirmed in my opinion concerning their
origin.
If the actions of any part of the body be excited, and in-
creased by accidental causes, it may reasonably be inferred,
that in a state of health they will be simple and common, unless
the stimulant be of a peculiar nature; but if the actions be spe-
cific and diseased, we may naturally conclude that the cause
of their becoming so is constitutional. The occurrence of simi-
lar local diseases in different parts of the body, furnishes an
additional proof that the cause of such diseases is constitutional.
It must indeed be very difficult to ascertain the causes of
the peculiarities of local diseases; but when I see such a varie-
ty of them cured, sometimes suddenly, by means which tend



232
ON THE CONSTITUTIONAL ORIGIN AND
only to tranquillize and invigorate the constitution, I become con-
firmed in the opinion that a similar state of health may lead to
the production of dissimilar local diseases.
I have further observed with respect to this subject, that per-
sons who have been out of health, but with no other distinguish-
able errors in their constitutions than such as I have described,
I mean nervous weakness and irritation, with a marked disorder
in the functions of the digestive organs, have been liable to a
succession of dissimilar local diseases. In such instances, I
have seen in succession enlargements of absorbent glands, biles,
rheumatic affections of joints, and dysury : yet all local diseases
have ceased as the health became re-established, by attention
to correct the disordered functions of the digestive organs. I
have seen also in the same patient enlargements of absorbent
glands, rheumatic disease of a joint, and an eruptive disease of
the skin, which have all equally got well as the general health
improved, by similar medical attention. Nay, the continuance
of local diseases in some instances, after the disorder of the
constitution has been relieved or cured, does not in my opinion
invalidate the foregoing conjectures respecting their origin. Lo-
cal diseases, however induced, may have become established
by habit, or continued from that state of disorder into which
they have reduced the part that they have attacked. A local
disease, however excited, may, as we know from experience,
be of such a nature as that its actions never cease, and as we
have not succeeded in curing. I allude to cancer, which oc-
curs, in conclusion, in such constitutions as I have endeavoure
to describe.
It has been said that I have been hasty in drawing these
conclusions. Yet, as may be seen in my first publication, I
mentioned, in speaking of disorder of the digestive organs as
exciting or aggravating nervous irritation, and thereby causing
local diseases, it followed that the nervous irritation might ex-
ist, and produce disease, without this usually exciting cause. I
then, too, brought forward instances of local diseases produced
by local causes, in order to establish our opinions of the inde-
pendent nature of local diseases. I further remarked, that
constitutions disposed to local diseased actions, might naturally
be supposed to be liable at the same time to a manifest disor-
der of the nervous system and of the digestive organs; and
from thence, as I observed, might have arisen that connexion
between local disease and general disorder, which I have so


TREATMENT OF LOCAL DISEASES.
233

continually remarked. I likewise added, that though the cases
related naturally suggested an opinion, that there is some con-
stitutional cause for the production of local diseases, they ap-
pear to me insufficient to prove it. After having, however,
drawn the opinions which I offered from a very considerable
number of cases, and having been solicitous to state both sides
of the question as fairly as I was able, that the reader might
judge of it for himself, I trust no imputation of haste can pro-
perly be attached to my conduct. În my own opinions I place
very little confidence; yet it is impossible to avoid forming
them, and I think it proper to relate them, for the reasons which
have been stated in the Preface.
That such opinions as have been delivered in the four para-
graphs preceding the last, are deduced from a partial, though
most commonly presenting view of the subject, I now readily
repeat; because I have seen instances of local diseases, in
which I could not trace any disturbance of the nervous system,
or of the digestive organs, apparently adequate to their pro-
duction. With respect to some of the striking cases which I
have related, wherein the suddenness of the cure made it, I
think, evident that the local disease was the effect of nervous
disorder, induced by that of the digestive organs; it may be
further inquired, how is it possible, that a similar cause should
produce such various effects ? Is it because a state of weak-
ness and irritation having occurred, those local diseases ensue,
to which there is a predisposition in the constitution ? And
are we to consider the general disorder of the system, as the
exciting or predisponent cause of the local disease?
Granting it were ascertained, that local diseases generally
arise from disturbance of the constitution at large, and conse-
quently, (as it has been my chief object to state,) may be
most readily and effectually cured by measures which tran-
quillize or invigorate the constitution, still it would be very im-
probable, and contrary to common observations, to suppose that
local diseases might not arise without any material constitution-
al disturbance.
Though I am strongly impressed with the opinion, that the
primary causes of local diseases, are, in general, such as I have
represented, yet I think it probable, that there may be adjunct
circumstances at present but little understood, which by their
co-operation lead to the peculiarity of such diseases. In our
present state of knowledge, therefore, I think it better to con-


se
30
234
TREATMENT OF LOCAL DISEASES.
sider the disturbance of the system in general, as merely the
exciting cause of local diseases. With this view of the subject,
the cases recorded show how suddenly local diseases are fre-
quently cured, when the exciting cause is removed; how gen-
erally they decline in proportion as the exciting cause is dimin-
ished : and thus they indicate how they may be prevented by
a timely attention to mitigate and remove that cause.
It may not be improper further to state the opinions which I
have formed respecting the origin of diseases of particular or-
gans, and which may be considered as local diseases, though
they are not generally alluded to when that term is employed.
If we may be able to trace the origins of diseases of the absor-
bent and salivary glands, of the breast and testes, to constitu-
tional causes, why may we not reasonably expect that similar
circumstances may produce diseases of the lungs, liver, and
kidney? It seems to me improbable that so complex a struc-
ture as the human body, should be so correctly formed, as that
every part should possess its due proportion of vessels and
nerves, endowed with an exact degree of natural and relative
strength ; or, in other words, that there should be no such thing
as comparative weakness or irritability of the different organs
of the body, such as should predispose them to disease.
, We may therefore account rationally, and in conformity to
acknowledged facts, for the production of diseases in vital
organs, by supposing, that a state of general weakness and
irritability being induced, the naturally weak parts suffer in the
greatest degree, and in consequence they most readily become
the subjects of disease. But when diseases of vital or other
organs occur, it is probable that another cause contributes to
their production; that is, the sympathy which each organ has
with the disorders of another. If, then, the organ thus sym-
pathetically affected be naturally disposed to disease, its struc-
ture may be irremediably spoiled in consequence of vascular
actions, excited through the medium of nervous irritation. If
this opinion be correct, it is highly important, as the medical
indication in this case is to remove the exciting cause, and our
attention becomes directed to an organ in which perhaps there
is but little manifestation of disorder; or if there be, which is
likely to be overlooked when the attention is so forcibly at-
tracted to an apparently far greater evil.*

* See the case beginning at page 228.
ON ANEURISMS.
The exposure of a portion of an artery, and tying it in order
to stop the current of blood into an aneurismal sac, as proposed
by Mr. Hunter, may be said to have been a new operation, at
least in modern surgery. It is not therefore surprising that er-
rors were at first committed in the mode of performing it. The
hemorrhages, which took place after the operation in the first
cases in which it was performed, arose from the ulceration of
the artery that had been tied. The vessel in these cases
was laid bare and detached in some degree from its surround-
ing connexions, and the middle of the detached portion
was tied by a single ligature. An artery thus circum-
stanced must necessarily inflame; which it would do in
different modes and degrees, accordingly as the state of the
constitution, or of the part was more or less healthy; and this
inflammation produced the ulceration of the vessel.
The occurrence of hemorrhage led some surgeons to adopt
a practice which cannot but be considered as injurious. They
applied a second ligature above the other, leaving it loose, but
ready to be drawn tight if the first should not answer. The
second ligature, however, must not only keep a certain portion
of the artery detached from the surrounding parts, but must
also give additional irritation to the inflamed vessel; and on
both these accounts it is more likely to make the inflammation
end in suppuration or ulceration.
The mode of performing the operation for the aneurism,
which Mr. Hunter's judgment and experience taught him to
adopt, was to expose and disturb the artery as little as possible,
and after having tied it to bring the surrounding parts into con-
tact with it again. Though an experienced and skilful operator
may accomplish this object with very little disturbance of the
artery from its natural situation and connexions; yet I cannot
but suspect that surgeons in general may not be so successful,

236
ON ANEURISMS.

especially in cases where, from the deep situation of the vessel,
the surrounding it with a ligature depends more on feeling than
on sight.* Also, though when the artery is sound and the
constitution healthy, ulceration may not ensue, even though the
artery is in some degree separated from its surrounding connex-
ions, and tied by a single ligature; yet it is surely proper to
guard against those circumstances which tend to produce its
ulceration. As large arteries do not ulcerate when they are
tied upon the surface of a stump after amputation, it occurred
to me that it would be right to tie them, in cases of aneurism,
as nearly as possible in the same manner and under the same
circumstances. The large vessels on the surface of the stump
continue to possess all their natural surrounding connexions,
whilst they are left in a lax state, in consequence of their di-
vision.
To accomplish this object in cases of aneurism, I propose
that the operation should be performed in the following man-
ner :-The operator should divide the immediate coverings of
the artery, till he has fairly exposed its surface. When he
can touch the bare vessel, he will not, I believe, find any dif-
ficulty in separating from it, by means of his finger and thumb,
or the blunt edge of an aneurismal needle, the cellular sub-
stance that connects it to the contiguous parts. This part of
the operation is not painful and should be performed slowly.
The firm sides of the vessel enable the surgeon clearly to dis-
tinguish its surface, and by keeping the finger in exact contact
with it, a passage may be made completely round the artery.
Care should be taken not to elevate the artery more than can
be possibly avoided, because the artery would be stretched in
its longitudinal direction by so doing; and care should also be
taken not to injure the contiguous veins or nerves. When the
operator has thus gently insinuated his finger between the ves-
sel and its surrounding connexions, so that an inch of its surface
is every where exposed, two ligatures may be put under it, one
of which is to be carried upwards, and the other downwards,
as far as the artery is detached, and then tied as firmly as pos-

COL

* It can neither be considered as a compliment to Mr. Home, nor an af-
. front to any other surgeon, to suppose that no one can perform the opera-
tion for an aneurism after Mr. Hunter's method better than he does. Yet
in a series of cases published in the second volume of the Transactions of
a Society for the promotion of Medical and Chirurgical Knowledge, he-
morrhage from ulceration of the artery appears to have been a frequent oc-
currence.
ON ANEURISMS.
237

sible. The artery should then be divided by a probe-pointed
bistoury in the inter-space between the two ligatures, but nearer
to the lower ligature than to the upper one.
In my opinion, large arteries should always be tied with
moderately thick ligatures, because we may then draw the
noose as tightly as possible, without apprehension of cutting
or tearing the coats of the vessel, or of breaking the ligature.
The latter occurrence would in many cases prove a very em-
barrassing circumstance, and it might be very injurious on ac-
count of the jerk communicated to the artery to a considerable
distance. Also, when an artery is tied with a thick ligature, the
compression made by it is not so great as to produce a speedy
mortification and separation of the end of the vessel, so that
the ligature remains, in general, a fortnight before it is detach-
ed, and therefore, time is allowed for the consolidation of the sides
of the vessel prior to its separation.* When an artery is thus tied
incases of aneurism, it possesses its natural surrounding connex-
ions and support, and is left loose, in consequence of its division.
It appears, indeed, in most respects, similarly circumstanced
to an artery tied upon the surface of a stump ; and as I never

* Doctor Jones, whose numerous and accurate experiments have thrown
much light upon the natural means by which hemorrhages are suppressed,
thinks that the ligatures should be round and firm; because such cords are
most likely to cut the internal coats of the artery. I am solicitous that
they should be strong and moderately large ; because as far as I have re-
marked, large ligatures remain longest on the arteries before they are de-
tached; and in examining the stumps of patients who have died after am-
putation, I have frequently seen the sides of the artery unclosed, even
ihough the ligatures have păllen off froin them.
Though ligatures when applied to the principal arteries of amputated
limbs are scarcely ever known to slip or become projected from their situa-
tion, yet it has been apprehended that such an occurrence might take place
in cases of aneurism, from the greater determination of blood into the ar-
teries of the limb in such cases. To obviate such an effect, Mr. Henry
Cline suggested the following method of securing the ligature in its situa-
tion. His suggestion was adopted by Mr. Cooper, who thus describes the
operation in which it was instituted.
• An incision being made on the middle of the inner part of the thigh,
and the femoral artery exposed, the artery was separated from the vein and
nerve and all the surrounding parts, to the extent of an inch, and an eyed
probe, armed with a double ligature, (each cord of which was armed with
a needle,) was conveyed under the artery and the probe cut' away. The
ligature nearest the groin was first tied; the other was separated an inch
from the first and tied also; then the needles were passed through the
coats of the artery, close to each ligature, and between them; the thread
they carried was tied into the knot of the ligatures which had been already
secured around the vessel; and thus a barrier was formed in the artery, be-
yond which the ligature could not pass.” See the first number of the
eighth volume of the Medical and Physical Journal.
238
ON ANEURISMS.
knew hemorrhage from ulceration of the vessel take place af-
ter the operation for aneurism, when it was accomplished in
this manner, I cannot but continue to practise and recommend
this method of securing the artery. That the operation for
the aneurisim will succeed when only a single ligature is em-
ployed, has been proved by experience ; but as hemorrhages,
independent of ulceration of the artery, so frequently arise
from an inflammatory action of the vessels, every thing tend-
ing to produce a tranquil state of the wounded parts cannot
but deserve to be put in practice, and the relaxation of the ar-
tery by its division, must, I think, contribute to this effect.
The cases of aneurisms which I am about to recite, are not,
however, intended to illustrate any mode of condu
eration, but merely to show the powers which nature possesses
of carrying on the circulation, and maintaining the limb in its
pristine state of vigour and strength, even though so large an
artery as the external iliac may have been tied, and thereby
rendered impervious.


e op-
CASE 1.
Feb. 1796.-James Lindsey, aged thirty-four, about a year
ago perceived a swelling beneath the calf of his right leg; and
soon afterwards, whilst walking, he suddenly felt, he said, “ as
if he had been struck on the part by a cannon-ball,” the pain
being so great that he could not move for several minutes.
The pain, however, gradually abated; but the swelling of the
leg had continued to increase since that time. The whole call
was now lifted up by a quantity of blood effused beneath it.
The muscles appeared thin, and were so extremely tense
as to occasion great pain, accompanied with considerable
erysipelas of the whole leg; so that a speedy ulceration and
sloughing, or sudden rupture of the distended part, was hourly
to be dreaded. Under these circumstances, tying the artery
above the aneurism, was the only means of relieving the patient
from his present suffering, and of preserving him from sudden
death. But what was particularly discouraging, both to the
patient and surgeon, was the discovery of another aneurism,
situated in the femoral artery of the opposite limb. No pre-
ternatural pulsation, however, could be felt in any other part
of his body. The operation was performed by Sir Charles
Blicke in the following manner :--An incision about three inches
in length was made through the integuments of the middle of

ON ANEURISMS.
239

the thigh, so as to expose the inner edge of the sartorius mus-
cle and the fascia covering the artery, which was divided to
the extent of somewhat more than an inch. The artery was
separated from its connexions for one inch of its length. Two
ligatures were put under it, and firmly tied, and the artery was
divided in the interval between them. The lips of the wound
were then brought together by slips of sticking-plaster. This
patient's limb was for some time much colder than the other,
and nearly three days elapsed before it had regained its natu-
inflammation quickly subsided. The divided integuments
united above and below the ligatures, but not between them ;
and there was also a large discharge from the wound; which cir-
cumstance was probably owing to the state of the patient's con-
stitution, which was much reduced in point of strength. This
man, however, did not complain of the least throbbing, tension,
or pain in the wounded part; and this entire exemption from
the sufferings of other patients, I could not but attribute to the
division of the artery. The upper ligature came away on the
tenth, and the lower on the fifteenth day; after which the wound
healed gradually, though very slowly.
opposite thigh was almost ready to burst; the tumor having ac-
quired a pyramidal form, and the skin covering the apex hav-
ing yielded so much as to form a kind of process from the tu,
mor. Indeed the integuments at this part were so thin, that
we every hour expected them to give way. The aneurism
was situated so high, as to make it probable that the disease
extended above the place where the arteria profunda is sent off.
The patient had hitherto refused to submit to the operation;
but on reflecting that if the tumor should burst in the night, he
must perish unless the bleeding vessel could be immediately
secured, he consented to let me tie the artery in the groin,
whilst we had day-light and proper assistance. The tumor ap-
proached so near to the groin, as to prevent us from compres-
sing the artery against the bone ; for, in attempting this, the
compress occupied the place where the incision ought to be
made, and our endeavours to make a compression still higher
were ineffectual; they weakened, but did not interrupt the pul-
sation of the tumor. As the artery was so imperfectly com-
pressed, hemorrhage took place during the operation, which,
though not dangerous to the patient, proved extremely embar-
240
ON ANEURISMS.

rassing to the surgeon; for, in attempting to lay bare the fascia
of the thigh, I divided, by the very first incision, so many small
arteries supplying the inguinal glands, and also so many veins,
that the blood which was poured forth, completely filled the
space made by the incision, and overflowed the sides of the
wound. The application of the sponge, the usual resource on
these occasions, was of no avail; for the wound was instantly
filled again, so that the whole operation was to be done
upon parts covered with blood, where the only guide in its
performance was the feeling. I did indeed see some exposed
inguinal glands, and found that I had divided two of them
in trying to get at the fascia of the thigh. As soon as I could
distinctly feel this part, I made a small opening through it, and,
introducing my finger, I divided it upwards as far as Poupart's
ligament, and downwards as low as the aneurismal sac would
allow me. The pulsation of the artery now served as my guide.
Laying aside, therefore, all surgical instruments, I made way
with my finger, in a perpendicular direction, till I could touch
its coats, and then, with my finger and thumb, separated it from
its connexions, so as to be able to grasp it alone between them.
I then passed two ligatures under it by means of an eyed probe,
and drawing one of them upwards, and the other downwards,
as far as the space would permit, I tied them firmly. The up-
per ligature was about half an inch from the os pubis, and the
lower one the same distance from the arteria profunda, which
vessel I had distinctly felt before I tied the ligatures.
There are, perhaps, few situations of aneurism where the ar-
tery can be tied so separately and distinctly as here; the pul-
sation directs the surgeon to the precise situation of the vessel ;
and if he only keeps sufficiently close to its sides when he
passes the ligature round, neither the vein nor the nerve can
be included. I did not divide the artery between the two
ligatures : it was suggested that it were better not to do so ;
and I knew that I could obtain all the advantages of a relaxed
state of the vessel, by merely bending the thigh upon the pel-
vis. The patient did not, after the operation, suffer any kind
of pain from the wounded parts; which, I think, shows, that
the artery did not inflame much in consequence of the ligature.
The suppuration was moderate, and every thing relative to the
wound went on as well as could be expected. The limb, and
particularly the foot, was colder than that of the opposite side ;
but in about three days, it gradually acquired its natural tem-

ON ANEURISMS.
241

perature; and it all along retained a perfect state of sensibility,
which I considered as a proof that it was sufficiently nourished.
To prevent the heat from being carried off faster than it was
generated, the limb was wrapped in flannel ; but I avoided the
application of any artificial warmth, lest its stimulus should prove
injurious, by exciting action when the powers of life in the part
might have been considerably diminished.
The blood in the aneurismal sac did not appear to have
coagulated before the operation; for the bulk of the tumor
could be greatly lessened by pressure, whenever the patient
would allow the attempt to be made, so that I conclude the
limb had received a considerable quantity of blood through th
femoral artery, until that vessel was tied. The tumor dimin-
ished greatly after the operation, and the blood contained in it
became coagulated. This reduction of the swelling, I think,
was owing to a considerable part of the blood passing onwards
through the femoral artery : and I regretted afterwards, that, at
the time of the operation, I had not endeavoured to press all
the blood from the aneurismnal sac; which experiment would
have shown how far it was fluid or coagulated.
Every thing, with respect both to the state of the limb, and
the patient's general health, went on well till the fifteenth day,
when the upper ligature separated, and the blood gushed in a
full stream from the open extremity of the vessel. This for-
tunately happened during the attendance of the surgeons at the
hospital, and the bleeding was stopped by pressure until their
arrival. The stream of blood which flowed upon any remis-
sion or wrong application of the pressure was so large that
we did not dare to remove the patient even from the bed on
which he lay. Mr. Ramsden undertook, in this situation, to
prevent the further escape of blood from the vessel, whilst I
proceeded to tie the artery above Poupart's ligament. Accord-
ingly, I first made an incision, about three inches in length,
through the integuments of the abdomen, in the direction of
the artery, and thus laid bare the aponeurosis of the external
oblique muscle, which I next divided from its connexion with
Poupart's ligament, in the direction of the external wound, for
the extent of about two inches. The margins of the internal
oblique and transversalis muscles being thus exposed, I intro-
duced my finger beneath them for the protection of the peri-
toneum, and then divided them. Next, with my hand, I pushed
the peritoneum and its contents upwards and inwards, and took

31
242
ON ANEURISMS.
hold of the external iliac artery with my finger and thumb, so
that I was thus enabled to command the flow of blood from the
wound. It now only remained that I should pass a ligature
round the artery, and tie it; but this required caution, on ac-
count of the contiguity of the vein to the artery. I could not
.see the vessels; but I made a separation between them with
my fingers. Having, however, only a common needle with
which to pass the ligature, I several times withdrew the point,
from the apprehension of wounding the vein. * After having
tied the artery about an inch and a half above Poupart's liga-
ment, I divided that part, and thus laid the new and the former
wound into one. I traced as well as I could with my finger,
the continuation of the artery, from the place where the liga-
ture wàs now made, to that where it was formerly applied. I
wished to have divided the artery, and to have suffered it to
retract behind the peritoneum ; but I found it so attached to
the surrounding parts, as to render such division difficult, and
perhaps not advisable.
The lips of the wound were brought together with sticking-
plaster, and one suture only was made opposite to the natural
situation of Poupart's ligament. The peritoneum was pressed
back into its place, and the protrusion of it restrained by bring-
ing together the integuments with straps of sticking-plaster.
No perceptible alteration occurred in the state of the limb
after this second operation ; but the patient's health was con-
siderably reduced, by his having suffered from the complaint
nearly twelve months, by having undergone three operations,
and by the loss of a considerable quantity of blood. No adhe-
sion took place between the divided parts; the edges of the
wound were open and sloughly; the wound was painful, dis-
charged a great deal of pus, and was so extremely tender, that
he could not bear it to be touched. Still no greater mischief
appeared till the fifth day after the operation, when a hemor-


* It would be, I think, an useful addition to our surgical instruments for
such purposes, to have needles made with handles of pure, and conse-
quently flexible, silver, and with steel points that have edges just sharp
enough to pass through the cellular substance; but neither so pointed nor
so sharp, as to endanger the wounding any parts of consequence that may
be contiguous to those round which they are passed. When the points of
these instruments were once passed underneath the vessel, the surgeon
could bend their handles so as to accommodate them to the space they
have to turn in, and thus avoid an inconvenience which, I believe, most
surgeons inust have experienced : I mean, the great difficulty of turning
a common needle in a deep and narrow wound.
ON ANEURISMS.
243

rhage of arterial blood took place in such quantity, that there was
no doubt but that it arose from the principal artery; though the
ligature with which it was tied still remained firm. The pa-
tient's health was now so impaired, and his weakness so great,
that an attempt at tying the artery still higher up would have
appeared like torturing him without any hopes of ultimate suc-
cess. The wound was therefore cleansed and dressed; some
compresses were applied upon it, and bound down by the spica
bandage. By this treatment the hemorrhage was stopped ;
and the attendants were ordered to make a pressure on the
bandage if any fresh bleeding should occur. The compresses
were renewed for three succeeding days; and though occa-
sionally the wound bled, yet it was not profusely, or in such
quantity as to destroy the patient: his strength however grad-
ually declined; a troublesome cough occasioned extreme pain
in the wound, and in the course of the eighth day after the last
operation, he died.
DISSECTION.
No marks of disease were discoverable in the aorta, or in
the internal iliac artery. The external iliac was covered by a
great number of lymphatic glands, which prevented it from
being readily distinguished; yet, when separated from these,
it did not appear diseased. For nearly two inches above the
part which was tied, the lymphatic glands covering the artery
were considerably enlarged, having no doubt become addition-
ally swollen from the irritation excited by the ligature. The
external surface of one of them next the wound, had ulcerated ;
and the ulceration penetrated through the gland, and commu-
nicated with the artery, as was afterwards made evident by
slitting open that vessel. It was through this aperture that the
blood had escaped; for the ligature still remained firm upon
that part of the artery which it had inclosed. From this liga-
ture to the place where the vessel had formerly been tied, the
artery was so closely connected with the surrounding substance,
that dissection was required to separate them. The parts of
the artery from which the former ligatures had separated, were
about half an inch asunder, and the canal of the vessel ap-
peared perfectly open. The whole of the vessels from the
bifurcation of the aorta, to the aperture in the tendon of the
triceps muscle, were now removed, and carefully dissected;
and after being stuffed and hardened by spirits, they were cut
244
ON ANEURISMS.
open to show the state of them internally. A coagulunı of
blood, about two inches long, was found above the part where
the last ligature was made. At what time this coagulum had
been formed, is perhaps difficult to ascertain ; it did not seem
to have taken place after death, for above it the artery contained
no blood; and if it had occurred immediately after the opera-
tion, it is probable that it would have prevented the hemorrhage.
I have already remarked, that the man did not bleed for some
time previous to his death; in which interval, perhaps, this
coagulum had been formed. The ulcerated opening from
the artery through the diseased gland, admitted the pas-
sage of a moderate-sized bougie. The ligature, which
still firmly inclosed the artery, had brought its sides in contact,
so as to render it probable that they would have united. All
the other parts of the femoral artery were quite open, so that
a large bougie could be passed from the lower end of it, through
the aneurismal sac, to the place where the ligature now re-
mained. About half an inch of the artery was wanting, which
had been, as it were, cut out by the ligatures in the first ope-
ration. The sides of the arteries below the part which was
tied were thicker than natural, and their internal surface was
rough, and of a yellowish white colour. The arteria profunda
was filled with coagulated blood, and had become reduced to
less than the natural size. The sides of the artery of the op-
posite limb had firmly united at the part where it had been tied.
No coagulum was found in it, and it had not diminished in size
in any remarkable degree above the part which was closed.
It may be inquired in this case, why the artery did not heal,
but upon the separation of the ligature remained widely open.
That the ligature was tightly applied is, I think, evident from
its suppressing all hemorrhage till its separation on the 15th day.
I am inclined to attribute the want of union in the artery to its
unhealthy state, which opinion is confirmed by the dissection,
which showed that even the lower orifice of the artery had not
healed, whilst the artery in the other limb which was tied much
further from the aneurism, and where the vessel was more
likely to be sound and healthy, had become firmly united.
The event of this case would induce me to tie the artery as
remotely from the seat of aneurism as could with propriety be
done.
In this first operation of tying the external iliac artery, I was
urged to perform it by the impulse of the moment, for the



ON ANEURISMS.
245

death of the patient would otherwise have been inevitable. In
this case I thought, I disturbed the peritoneum too much, and
tied the artery higher than was necessary. As the limb,
however, did not appear to suffer materially, I felt it a duty to
perform a similar operation in the following case. The vessel
was tied lower down, so that it was brought into view at the
time of the operation. It was tied with two ligatures and divided
in the interval; it afterwards firmly united at each extremity,
and the ligatures came away at the usual time: neither did
there appear any deficiency, in the nutrition of the limb. These
circumstances afford reasonable expectations of success in
future operations of this kind; yet in the present instance the
operation appeared to have been too long delayed, and the
patient to have died from an event which was not foreseen, but
which might perhaps have been prevented.
CASE II.
– Wrungel, a German, by trade a sugar-baker, of a
sickly aspect and slender make, about 5 feet 7 inches high,
and near 40 years of age, was admitted into St. Bartholomew's
hospital, on account of an aneurism in the femoral artery, close
to Poupart's ligament. This he imputed to a strain about three
weeks before. The tumour at the time of admission was of
the size of a small orange, and the blood contained in it was
fluid; for it could be entirely expressed from the aneurismal
sac. At a consultation on the treatment of this case, I said
that I did not think a surgeon warranted in tying the external
iliac artery, till he was in some measure compelled to it by the
progress of the disease, for the following reasons. 1st. An
aneurism, in proportion to its increase and duration, obstructs
the passage of the blood through the natural and principal
channels, and obliges it to circulate by other courses, which are
enlarged according to the exigency of the case. It seems
highly probable, that in proportion to the size of the artery
which is tied, and the magnitude of the part to be nourished
after that operation, so will be the degree of previous enlarge-
ment in these collateral channels, which is necessary to ensure
its success. On this account the operation should be delayed
longer in an inguinal aneurism than in any other.
2dly. The operation of tying the external iliac artery must,
in the present state of our knowledge, be considered as very
serious in its nature, and uncertain in its event. I had then
246
ON ANEURISMS.

only once tied this vessel, when a man would otherwise have
bled to death from the femoral artery; and though the limb
was nourished, the artery ulcerated. The operation was done
a second time in London, and the limb mortified; but no fair
practical inference can, I am told, be drawn from the latter
case, as the operation was postponed till mortification was as it
were impending.
3dly. There is some chance in aneurisms of a cure sponta-
neously occurring from the closure of the artery above by the
coagulation of the blood. To cite those instances only which
have come within my own knowledge, and which it seems right
to mention, as it increases the stock of facts before the public,
I have known such a spontaneous cure take place twice in the
popliteal artery, once in the arteria profunda femoris, and once
in the axiliary artery. For these reasons it was agreed to
postpone the operation in the case of the present patient till
circumstances should appear to demand its performance.*
* There was, about twelve months ago, a soldier in the York hospital,
who had an aneurism of the femoral artery, but the external tumor had
so much overlapped Poupart's ligament, and interposed itself between the
integuments and the fascia of the external oblique muscle, as to render an
operation very difficult, if not impossible. In this case, the integuments
mortifying, occasioned a simultaneous coagulation of the blood in the artery,
for though the coagula came out, yet there wils no fresh hemorrhage, and
the patient recovered.
Since the preceding edition of this book, I have seen two other cases of
the spontaneous cure of aneurisms: one was in the external iliac artery,
and the aneurismal sāc formed a large tumour within the abdomen, extend.
ing as high as the umbilicus, and across the belly as far as the linea alba.
In the other case, I conjecture, that the aneurism was in the common
trunk, which gives rise to the right cephalic and subclavian portion of the
brachial artery. The pressure of the aneurismal sac had caused the ab-
sorption of the ribs beneath the clavicle, so that the tumour presented
itself so exactly in the situation of the axillary artery, that I believe most
surgeons would at first sight have supposed that the tumour, which was
as large as a large fist, and beat vehemently, to have been an aneurism of
that artery ; yet, when the subclavian artery was pressed above the clavi.
cle, the pulse at the wrist was stopped, without lessening the pulsations of
the aneurism. The patient had come to London, supposing that some
operation might be undertaken for his relief. His digestive organs were
disordered, and his heart throbbed violently against his side. I recom-
mended him to live on as spare a diet as he possibly could, observing to
him that, by keeping his vessels in a state free from plenitude, he was
most likely to lessen that forcible action of the heart which caused the in-
crease of his disease, whilst at the same time the same measures would
tend to insure the complete digestion of every portion of aliment he re-
ceived into his stomach, and thereby improve the state of his digestive
organs. I urged him also to regulate the functions of the other viscera
concerned in digestion. I heard that about six months afterwards he was
very well; and lately, upon inquiry, was informed that he was as well as
at any period of his life.
ON ANEURISMS.
247

Our poor patient therefore lay in the hospital during two
months, in which time his disease gradually increased, and his
health declined. Towards the latter part of the time he suf-
fered a great deal of pain in the front of his thigh, which de-
prived himn of rest, and the whole limb was largely ædematous.
These symptoms would naturally arise from the pressure which
the aneurism must make on the anterior nerves and absorbents
of the thigh. The tumor had advanced towards the surface,
and the skin had become slightly inflamed, yet the protruding
part of the tumor was not of greater extent than when he was
first admitted into the hospital, and no judgment could be formed
of that part which was more deeply situated, on account of the
general swelling of the thigh. The blood could even now be
expressed from the prominent part of the tumor, and I felt
anxious, less the obstruction to the circulation in the main ar-
tery should not have been sufficient to have obliged the blood
to circulate by other channels. It deserves to be remarked,
that the aneurism may extend considerably beneath the fascia
of the thigh, causing pain and ædema by its pressure, and yet
that part which advances towards the surface may be of no
great magnitude.
The patient's sufferings increased considerably during the
week preceding the operation, so that he declared his present
state was almost insupportable, and solicited that something
might be done to change it either for the better or the worse.
He never, however, was able to explain the cause of this un-
common degree of anxiety and inquietude.
The operation was ‘undertaken on Saturday, the 24th of
October. An incision of three inches in length was made
through the integuments of the abdomen, beginning a little
above Poupart's ligament, and being continued upwards; it
was more than half an inch on the outside of the upper part of
the abdominal ring, to avoid the epigastric artery. The apon-
eurosis of the external oblique muscle being thus exposed, was
next divided in the direction of the external wound. The
lower part of the internal oblique muscle was thus uncovered,
and the finger being introduced below the inferior margin of
it and of the transversalis muscle, they were divided by the
crooked bistoury for about one inch and a half. I now intro-
duced my finger beneath the bag of the peritoneum, and car-
ried it upwards by the side of the psoas muscle, so as to touch
the artery about an inch above Poupart's ligament. I took


248
ON ANEURISMS.

care to disturb the peritoneum as little as possible, detaching it
to no greater extent than would serve to admit my two fingers
to touch the vessel. The pulsations of the artery made it clear-
ly distinguishable from the contiguous parts, but I could not get
my finger round it with the facility which I expected. This
was the only circumstance which caused any delay in the per-
formance of the operation. After ineffectual trials to pass my
finger beneath the artery, I was obliged to make a slight inci-
sion on either side of it, in the same manner as is necessary
when it is taken up in the thigh, where the fascia which binds
it down in its situation is strong. After this I found no diffi-
culty in passing my forefinger beneath the artery, which I drew
gently down, so as to see it behind the bag of the peritoneum.
By means of an eyed probe two ligatures were conveyed round
the vessel ; one of these was carried upwards as far as the ar-
tery had been detached, and the other downwards: they were
firmly tied, and the vessel was divided in the space between
them. Nothing further remained than to close the external
wound, which was done by one suture, and some strips of stick-
ing-plaster. The threads of the upper ligature were left out of
the wound above the suture which closed its edges, and those of
the lower beneath.
.: A few remarks on this operation may be permitted. To di-
vide the parietes of the abdomen, push aside the peritoneum,
and tie the external iliac artery by the side of the psoas muscle,
is an operation more formidable in sound, and on its first pro-
position, than it is in reality. It is performed almost without
shedding blood, so that the principal circumstances of it are
very evident. When I formerly performed this operation, I
was urged to it by immediate necessity : I tied the artery much
higher than in the present case, disturbed the peritoneum in a
greater degree, and, contrary to my own principles, I did not
divide the artery. In the present case, having time to delibe-
rate upon the steps of the operation, I detached merely so much
of the peritoneum as enabled me to reach the artery, as far as
I conveniently could above Poupart's ligament; but not so far
as to make it difficult to ascertain that I surrounded the artery
only with my finger, without injuring any of the adjacent parts,
nor so far but that I could draw down and distinguish the arte-
ry which I included in the ligature. The remembrance of the
swelling in the external iliac glands, and of the ulceration of the
artery in the former case, led to this difference of conduct.
ON ANEURISMS.
249

The poor man was greatly exhausted by the operation, and
his leg which had been chilled by exposure during the opera-
tion, continued very cold for a long time afterwards. It was
wrapped up in flannels, to prevent the dissipation of its own
heat; but I would not apply any artificial warmth to restore its
temperature, lest it should act as a stimulant.
He could not compose himself after the operation, nor did
he sleep during the night, so that on the following day his state
was very unpromising. His pulse beat 160 in a minute; his
tongue was covered by a dark brown fur; he looked agitated,
and a purging took place, which was not restrained till the fol-
lowing night by a cordial and opiate mixture. Respecting his
pulse, it is proper to mention that it beat 120 most days in the
week preceding the operation.
His thigh was as warm as that of the sound side, his leg
cooler than the opposite one, and his foot many degrees colder.
He had, however, perfect sensation in his toes, and power of
moving them. The leg and foot were rubbed with oil three
or four times a day, in order to prevent any stagnation in the
veins, and to diminish perspiration. It was well covered as
before by flannels.
On Monday, the 2d day (Oct. 26) the pulse was less fre-
quent: he had slept a good deal during the night, and seemed
stupified by the opium; but was on the whole so little better,
that I concluded he would gradually sink in consequence of
the shock of the operation. The temperature of the limb was
a little increased. The man however took bread and milk and
other food in moderate quantities, whenever it was offered to
him : the purging having ceased, the quantity of the opiate was
diminished. He rather improved in the evening, and rested
well during the night; so that on (Oct. 27) the third day after
that of the operation, every circumstance wore a favourable as-
pect. His pulse did not exceed 100, and was moderately firm
and full ; appetite had increased : the temperature of the
limb was a good deal augmented, so that his foot was scarcely
colder than that of the sound side; and the ædema of the limb
was considerably diminished. I now dressed his wound, in
which he had not complained of pain, nor of any tenderness,
when the surrounding parts were compressed. The incision
appeared but as a line, except at the neighbourhood of the liga-
tures, where it was a little open, and from whence there issued
a moderate quantity of as healthy pus as I had ever seen. The
d
.
APPLE
32
250
ON ANEURISMS.
ao
surrounding parts were perfectly natural, both in appearance
and sensation. On the fourth day (Oct. 28) he was still
better : his pulse 90 ; his appetite good; his sleep sound; and
his limb lessening in size, and increasing in warmth. The stu-
dents at the hospital had dressed the wound before my arrival,
and reported that the discharge was tinged with blood.
On the fifth day (Oct. 29) he was still better, his pulse be-
ing but 80 when I counted' it. The wound and contiguous
parts looked remarkably well, but a bloody sanies was dis-
charged, which I felt unable to account for.
On the sixth day (Oct. 30) the state of his health and limb
continued as well, if not improving. The bloody discharge
however had increased in quantity, insomuch that it ran through
the coverings of the wound, and soiled the bed; it had also be-
come fetid. From the first occurrence of this bloody discharge
I felt considerable uneasiness respecting it. I could not be-
lieve that a healthy wound would secrete such a sanies, and I
felt apprehensive lest the wound should spread from disease.
Nothing however took place to confirm this idea. It seemed
probable also that if the aneurismal sac were not entire, some
of the blood being exposed to the air might tinge the discharge
from the wound, and grow putrid. I frequently pressed on the
tumor, but could press no blood from the wound. In this state
of uncertainty it was, however, pleasing to observe, that the
patient's health continued in every respect better than could
reasonably have been expected.
The circumstances of the case remained very much the same
during the seventh and eighth days after the operation. On the
morning of the ninth, (Nov. 2) when I came to the hospital, I
met Sir Charles Blicke, who told me that the poor German was
dying ; intelligence which equally surprised and shocked me.
He was indeed in a dreadful state, appearing like a man far
advanced in typhus fever. His pulse was 150; his tongue
covered with a brown fur; his intellect wavering, and the ac-
tion of his muscles tremulous. On examining the wound with
a view to discover the cause of this great and sudden alteration,
and pressing on the tumor beneath Poupart's ligament, I forced
out a great quantity of blood, rendered fluid and highly fetid
by putrefaction, insomuch that it instantly blackened the probe
with which it accidentally came in contact.
The cause and circumstances of the bloody discharge were
now made clear; the surface of the exposed coagulated blood

ON ANEURISMS.
251
of the aneurism had at first tinted the discharge from the wound,
and then had, by gradual dissolution, been more plentifully
commixed with it, and given it a degree of putridity. Till,
however, the whole mass had become putrid, and had been
converted in consequence into a fluid, it could not be forced
out from beneath Poupart's ligament when pressure was made
on the tumor; nor did it till that period excite inflammation in
the surrounding parts by its acrimony, or derange the constitu-
witcobsorption.
tion by its absorption.
After entirely expressing the putrid blood, I washed out the
cyst with warm water, till it returned untinged. The relief
which was by these means afforded to the poor man was very
striking and considerable. His pulse became moderate, his in-
tellects clear; he had some refreshing sleep, and again took food
in moderate quantities. On the following day, when the integu-
ments beneath Poupart's ligament were compressed, a consider-
able quantity of fetid discharge and air were forced out. It was
not however at all tinged with blood, and appeared to me to be
merely the secretion from the cyst which had contained the blood.
I directed that this discharge should be pressed out, the cavity
syringed, and a poultice applied three times a day; but finding
a considerable quantity of fetid fluid still lodged in the cyst, I
thought it right to make an opening into it beneath Poupart's
ligament, to afford it a more ready exit. No abatement in
the quantity, or alteration in the quality of the discharge, was
however remarked; it seemed to be such as a sloughing sore
commonly furnishes.
This fever came on in the evening of the eighth day (Nov. 1)
after that of the operation ; and I am convinced it would have
speedily destroyed the patient, had not the cause been detect-
ed and removed. The powers of his constitution rallied
again ; his pulse was firm, and often not more than 100; he
took sufficient food, and slept moderately well. But the part,
as has been said, did not go on well, and seemed to prevent
any increase of strength. For a week I was not without
hopes that some favourable change might happen, but after-
wards I lost all such expectations, as his already much reduced
powers were still further declining ; nevertheless, he held out
more than another week, when he died on November 16, the
twenty-third day after the operation. A few days before his
death both ligatures came away with the dressings.




252
ON ANEURISMS.
DISSECTION.
A very slight adhesion had taken place between the sigmoid
flexure of the colon and that part of the peritoneum which was
opposite to the wound; but there was no other appearance of
that membrane, or of the bowels, having suffered any inflam-
mation in consequence of the operation. The peritoneum was
separated from the loins, and from the posterior half of the left
side of the diaphragm, by a considerable collection of blood,
which extended downwards to Poupart's ligament, and com-
municated under that ligament by a small aperture with the
aneurismal sac. This opening was situated in the direction of
that crevice which is found between the internal iliac and psoas
muscles. The only rational explanation that can be given of
the formation of this collection is, that the blood had burst its
way from the aneurismal sac in the vacancy between the mus-
cles just mentioned; after which it would readily and exten-
sively separate the peritonium in the manner described. I am
inclined to attribute to this circurnstance the undefinable dis-
turbance of health which the poor patient suffered during the
week preceding the operation. It may, perhaps, excite sur-
prise that this collection did not become putrid.
No particular account can be given of the aneurismal sac be-
neath Poupart's ligament, since it and the contiguous parts had
sloughed in consequence of the irritation of the putrid blood. A
small aperture had been made by this sloughing in the front of
the orbicular ligament of the hip joint, and a small extent of the
thigh bone was, by the same cause, deprived of its periosteum.
A bougie was passed from the lower end of the femoral ar-
tery into the sac.
The extremities of the external iliac artery, which had been
divided in the operation, were united together by a firm new-
formed substance; the sides of each extremity were perfectly
closed, and a small plug of coagulated blood was found in each.
Having thus given as brief an account as I am able of the
circumstances of this case, as they appeared to me, I cannot
conclude without mentioning the observations of others, partic-
ularly as they may assist in suggesting rules of conduct for fu-
ture operations on similar cases. It has been said that the irri-
tation of the aneurismal bag was probably a spontaneous oc-
currence, and not the effect of the acrimony of the putrid
blood. But the suddenness of this attack, the manifest exist-
ence of a cause sufficient to produce it, and the total absence


ON ANEURISMS.
253

of such an occurrence in all other cases of aneurism, render
this supposition highly improbable.
It has also been imagined that part of the discharged blood
might have returned from the lower end of the artery. This
latter opinion is very improbable, since, after the complete re-
moval of the blood, none returned by that channel : and in the
first case which I have related, none returned by the inferior
part of the artery, though the area of it was still of its natural
dimensions, and unobstructed. This latter observation had
tended to diminish my confidence in the powers of the com-
municating channels, and made me wish to defer the perform-
ance of the operation as long as possible. It seems evident
that in the present instance it was too long delayed.
It would be desirable in future to perform the operation be-
fore an extensive diffusion of blood had taken place; indeed,
could the adequateness of the collateral arteries for the supply
of the limb be established, it would be proper to operate at an
early period of the disease.
It deserves to be considered whether, in cases where it is
probable the blood has become diffused, it might not be right
at the time of the operation to open the aneurismal bag, and
remove the blood. I should, however, be inclined to postpone
this attempt; for, perhaps, no necessity might exist, as putre-
faction might not take place. A few days will determine the
degree of life of the limb, and would make a wound less likely
to ulcerate or slough. Should signs of the putrefaction of the
blood ensue, or the probability of such an occurrence become
evident, I should think it necessary to make a small opening
into the aneurismal bag for the removal of the contained blood.
This being done, if no blood came from the lower orifice of
the artery, there would be no necessity for tying it.

CASE IIT.
to excess, was admitted into St. Bartholomew's hospital, with
a very large femoral aneurism, reaching as high as Poupart's
ligament. The whole limb was ædematous, but in no very
considerable degree. She was quite incapable of using the
least exercise, or of sitting upright; and, even in bed, she
suffered continual pain, which was much aggravated during the
pulsation of the aneurism. The pain was so violent as to pre-
clude sleep. She had no appetite : her pulse was feeble and


254
ON ANEURISMS.
frequent, generally exceeding 100; but her tongue was not
furred; and her bowels were regular.
On Saturday, 11th October, 1806, the operation was per-
forrned in the same manner as in the last case. An incision,
about three inches in length, was made thr ugh the integuments
of the abdomen, in the direction of the artery, beginning just
above Poupart's ligament. Having divided the skin and apo-
neurosis of the external oblique muscle, I introduced my fin-
ger between the margin of the internal oblique and transverse
muscles and the peritoneum. I then divided their lower edges
upwards, in the direction of the external wound, to the extent
of an inch and a half, with a probe-pointed bistoury. Having
thus made room for the admission of my finger, I put it down
upon the artery, felt its pulsations, and gently insinuated it be-
neath the vessel ; and then, with the aneurismal needle, passed
under it two moderately thick ligatures, carrying them upwards
and downwards, as far as the detachment of the artery permit-
ted, and tying them as firmly as I could. I next divided the
artery in the interval, but níuch nearer to the lower ligature
than to the upper one. The wound was afterwards closed, in
the middle by a ligature, and in other parts by sticking-plaster.
Upon removing the patient to bed, she complained of great pain
in the wound, and in her head; and was very restless and ungov-
ernable. She wished for something to procure sleep, and I gave
her twenty-five drops of laudanum. This, instead of having the
desired effect, made her much more restless ; she was continu-
ally changing her position in bed, and complaining of violent
headach. At night she became inore tranquil. The one foot
was much colder than the other ; but the limbs at the knees
were nearly of an equal temperature.
Sunday, 12th. I visited her early in the morning, and found
that she had been moderately quiet during the night; that she
had suffered much pain in her foot, but none in the wound.
The pain in the limb she described as having first attacked the
thigh, next the leg, and afterwards the foot, which last pain had
now ceased. The foot was warmer than it was the preceding
evening, and in a state of perspiration : it was four degrees of
heat lower, by Fahrenheit's scale, than that of the healthy limb.
The superficial veins of the leg were filled with blood. Her
pulse was 96. She had no appetite. I left her with a promise
to visit her again at night, recommending her to lie quiet, and
take some simple nourishment. About noon, one of the dres-

ON ANEURISMS.
255

sers, observing that her skin was hot, and the tongue dry, gave
her some saline medicine, with a small quantity of antimonial
wine, which occasioned vomiting, and such continual nausea,
that she refused all kinds of food. The limb, at night, contin-
ued in the same state as in the morning. She was free from
pain : her pulse 120. As she was without an evacuation, I
gave her a pill, containing two and a half grains of pil. aloet. e
myrrh. with the same quantity of extract of colocynth, order-
ing it to be repeated in the morning, if necessary.
Monday, 13th. The foot was nearly of the same tempera-
ture with the other. She had had two stools, and felt much
more comfortable. Still, however, she had an aversion to all
kinds of nourishment. Her pulse was 150 and 160, at differ-
ent times of the day. I may here mention, that every subse-
quent day, she had one or more stools, without having recourse
to opening medicine; and whenever she was more irritable or
disturbed than usual, she had a tendency to purging. In the
evening of this day, I inquired if she had a wish for any par-
ticular kind of nourishment ; and, at her suggestion, gave her
half a pint of porter with some ginger and toasted bread. This
seemed to agree with her stomach, as she slept the whole night,
and awoke much refreshed the next morning. Her tongue
was then clean ; she took some tea and muffin for breakfast,
and broth and bread, in moderate quantities, in the course of
the day. Half a pint of porter was allowed her at dinner and
supper. Her pulse this day (Tuesday) was 95. The foot
warmer than the other. The wound was dressed for the first
time; it appeared well closed, and discharged but little.
Wednesday, pulse about the same number; had slept during
the night, but not so soundly as on the preceding one. The
wound and contiguous parts were tender; there was a consid-
erable discharge, which was fetid ; the lower ligature came off
the artery. The artery, as I have mentioned, was divided
very near to the lower ligature; and it is probable, that, in the
restlessness of the patient subsequent to the operation, the mo-
tions of the limb had drawn the artery from out of the liga-

T
ture. *
* I have never made use of the expedient suggested by Mr. Henry Cline,
for securing ligatures upon arteries, since I never felt its necessity; and
because I have always thought it right to tie a large artery with so thick a
ligature, that it would have been unsuitable to the practice which he has
recommended. One advantage arising from tying a large artery with a
256
ON ANEURISMS.
Thursday. The wound very tender, and the skin had in-
flamed very much : pulse 84.
Friday. The discharge from the wound less in quantity,
and more puriform ; pulse the same in number, but very feeble.
Saturday. The patient had been seized in the middle of
the night with severe headach and shivering, and in the morn-
ing she could eat no breakfast. Her tongue was rather dry,
and slightly covered with a brown fur : pulse 95, and feeble.
Half a pint of wine was allowed her in sago, in addition to the
porter; and she took the infus. menth. vitriol. of the hospital,
with some tincture of gentian.
Sunday. She was much better : tongue moist and clean, and
her appetite much improved. She disliked the bitterness of
the medicine, peppermint water was therefore substituted for
the common mint water, and the tincture of gentian was omit-
ted: pulse 82 ; skin cool.
Monday. In the same state as yesterday : granulations ap-
peared in the wound below the ligature, which closed it in the
middle. This part of the wound is now about an inch in
breadth, and a third more in length. The wound above the
ligature about one fourth of an inch across; and the new flesh
by which it is united, of a tawny colour, and flabby texture.
The surface of the skin, to a considerable extent from the
wound, red and excoriated.
Tuesday. She had a return of headach, with loss of appetite :
her pulse 96. There flowed from the wound a considerable
discharge, of an offensive smell, and seemingly irritating to the
skin over which it passed. She complained of having had a
restless night; and observed that, in general, she found her-
self well or ill, as the preceding night had passed comfortably
or otherwise. Thinking it probable that the irritable state of
the wound might contribute, in a great measure, to prevent her
from sleeping, I dressed it with an aqueous solution of opium,

TE

thick ligature is, that it may be drawn as tight as possible, without appre-
hension of cutting the vessel, or of its speedily coming off from it. Should
1, in any future instance, think it right to oppose any mechanical obstacle
to the ligatures coming off the vessel which it encircles, I should do it in
the following manner. Having tied a large knot at one end of a small
thread, I would pass it, by means of a common sewing-needle, through
the middle of the artery, in front of the ligature which encircleg it. I
would then form a second thick knot on the thread, close upon the surface
of the vessel. These two knots would, I think, present a considerable
obstacle to the slipping of the circular ligature from off the end of the
artery.
ON ANEURISMS.
257

and smeared the excoriated skin with lard, to prevent the
acrimonious discharge from affecting it. All appearance of
granulations in the wound had vanished. I ordered her fifteen
drops of laudanum in her night draught; and, instead of the
infus. menth. vitriol. I gave her decoct. cinchon. 3ij, with 3j of
tinct, card. comp. every four hours.
Wednesday. She had a comfortable night, with much sleep :
her pulse 80. The wound greatly amended. The discharge
puriform, less fetid, and smaller in quantity. The new flesh
above the ligature florid; and granulations appeared again on
the sides of the wound, below the ligature. The same treat-
ment was continued.
Thursday. She had not rested so well, and complained of
headach. The wound, however, was rather better than on
the preceding day. I cut out the ligature which closed the
wound in the middle, thinking it might tend to keep up irrita-
tion. She attributed the pain in her head to the opium she
had taken : to ascertain this point, I ordered the dose to be
increased to twenty-five drops. .
Friday. She had slept well, and was free from headach :
her pulse under 80. This day, the ligature, from the upper
part of the artery, came away with the dressings. The ex-
coriated skin had healed; the redness was inconsiderable.
The wound, in every part, had a healing appearance. It seems
unnecessary to detail particularly the subsequent part of the
case. She was kept in bed to the end of the third week,
when she was allowed to sit up, that her bed might be made.
I thought this caution requisite, from knowing that ligatures are
detached from arteries before the sides of the vessel are united.
I also confined her to bed during the whole of the fourth week ;
but advised her to move the limb about frequently. The
wound healed like a healthy wound; and was nearly closed in
a month after the operation. During the third week, when
the wound no longer proved a source of irritation, her pulse
did not exceed 75 strokes in a minute; it was generally lower,
and once I found it to be only 68. At the expiration of the
month, she got up daily, and walked about the ward ; although,
on her admission into the hospital, she was incapable of walk-
ing at all. There was not the least ædema of the limb. Its
circumference, at the calf, was but one third of an inch less
than the opposite side. Having walked inany times the length

258
ON ANEURISMS.
of the ward, she became tired, and thought that the limb which
had been operated on, felt more fa
than the other. The
aneurismal tumor remains at this time of a considerable size.
It is certainly more than one third less than at the time of the
operation.
I have related the case thus particularly, in order that the
reader may judge of it for himself. To me it appears, from
this and the former cases, that, in an advanced state of fenioral
aneurism, the artery may be tied above Poupart's ligament,
with as little detriment to the circulation of the limb, as in other
cases of aneurism, where the operation is attended with very
constant success. The symptoms immediately subsequent to
the operation, appear to me to have arisen entirely from the
irritable and weak state of the patient. She had pain in the
head from the operation ; and so she had afterwards, when-
ever her health was disordered by irritation. Her pulse, prior
to her taking the medicine which acted as an emetic, was 96 ;
but the subsequent day it was 150 or 160. This appears to
be the result of the state of the stomach, for that becoming
tranquil, the pulse was again reduced to 95 or 96. In a con-
stitution so weak and irritable, a wound was not likely to heal
kindly; and all the subsequent circumstances of the case are
satisfactorily explained, as the effects of an irritable wound,
acting upon an irritable constitution. Upon the wound becom-
ing healthy, at the expiration of a fortnight, all variations of the
constitution ceased. I cannot, therefore, but consider the per-
plexing circumstances that succeeded the operation, as the
effect of the patient's peculiarity of constitution, and not as
arising from the operation itself, or from the state of the limb
consequent to such an operation. A similar operation has
lately been performed by Mr. Frere, of Birmingham, with
success. The patient being healthy, the wound healed with-
out difficulty.
Mr. Tomlinson, of Birmingham also, performed a similar
operation with equal success, so that it seems proved that the
external iliac artery may be tied, in the case of a femoral aneu-
rism, with as little detriment to the limb, as occurs from tying
the femoral artery in a case of popliteal aneurism. I lately
saw the woman who was the subject of the last case which I
have related, and there is no distinguishable difference in the
size or strength of the two extremities.



ON ANEURISMS.
259

CASE IV.
J. Peterson, a Swedish sailor, about forty years of age, was
admitted into St. Bartholomew's hospital, on account of an
aneurism of the femoral artery, just below the groin. He was
a thin man, but had strong muscles. He had a languid appear-
ance; his pulse was small and feeble; his appetite, accord-
ing to his report, moderate, and bowels regular; his tongue,
however, was much furred. As the upper and most prominent
part of the aneurismal tumor was ascending above Poupart's
ligament, so as to make it probable, that if it increased it might
overlap the ligament, and render the operation difficult, delay
was inadmissible, and the operation was performed on Satur-
day, 25th February, 1809. It was accomplished as in the
preceding case. I put my finger behind the peritoneum, and
clearly distinguished the cylindrical form, and firmness of the
artery ; but I could not perceive its pulsation. I pressed on
the vessel, and the beating of the aneurism ceased : I remitted
the pressure, and it was renewed. Having thus ascertained
that I had my finger upon the artery, I tried to separate it, so
as to get my finger round it; but I could not succeed. I then
tried with the point of the aneurism needle, carrying it close to
the artery from without, towards the cavity of the pelvis; but
the vessel yielded so considerably, that I did not accomplish it.
I tried in a contrary direction, and though the artery receded
from its situation, as I think, fully half an inch, yet by
perseverance I accomplished my purpose. I then passed an-
other aneurismal needle, threaded with a double ligature,
through the track that I had made, and tied each ligature firm-
ly. I have related these circumstances, that the reader may
know why the artery was not tied as it was in the preceding
case. I could not bring the artery into view. I might have
done so lower down nearer to Poupart's ligament; but the ap-
prehension of producing any communication between the air
and the blood of the aneurismal bag, which might occasion its
putrefaction, made me tie the artery at some distance above
the ligament. The recession of the artery in this case, before
the pressure made by the aneurismal needle, was so considera-
ble as to excite my surprise.
The patient lay upon his side with his thigh bent upon the
pelvis, and for the first three days after the operation without
pain, or any apparent disturbance of his constitution. He was
fed with bread and tea, and bread and broth, and his bowels

260
ON ANEURISMS.
were regular. The wound seemed closed by adhesion, except
at its lower part, where the ligatures came out. On the fourth
night, he was seized with violent and distressing pain in the
epigastric region, and on the left side of his chest : he had not
the least sleep, and felt very anxious and disturbed. His pulse
beat the next day 130 in a minute : his skin was hot and dry,
his face flushed, and his tongue covered with a dry brown
crust. Two grains of calomel were given to him, and efferves-
cing saline draughts were taken every four hours. The calo-
mel produced a purging stool during the night, which had not a
drop of bile in it. The following day his pulse exceeded 100
only by a few strokes, his skin felt temperate, his tongue was
moist, and not so brown or incrusted. His pain, also, was
much diminished, though the epigastric region was still tender.
His saline draughts were continued, and he was directed to
take five grains of the pilul. hydrarg. each night. The next
day he was still better; his pulse 90, his skin moist, and his
tongue cleaner: he took food without disgust, though not with
much appetite. As he had no evacuation from his bowels, a
little opening electuary was given him, and the saline draughts
were changed for the infus. menth. vitriol. with a little tinct.
cardam. He had a stool in the night, which was of a light
ochre colour; that is, a light brown, which dilution would not
convert into a yellow. He continued the same medicines till
the tenth day after the operation, with an evident amendment
in his health ; though the alvine discharges which we contrived
to procure daily, were still of the colour above described, but
somewhat deeper.
On the tenth day, after observing his tongue and pulse, &c.
those who saw him, joined with me in opinion, that he was in
better health than when he was admitted into the hospital.
During this constitutional disturbance, the upper part of the
wound became open, and the discharge was offensive and irri-
tating, and excoriated the skin over which it flowed. I there-
fore greased it with fresh lard at each dressing, to prevent as
much as possible the discharge from acting upon it. Some
swelling of the parts on that side of the wound next the ilium
also took place. Still there was nothing very materially wrong,
and the state of the wound gradually amended as the patient's
health became tranquil.
On the tenth day, the ligatures came away, and then the
patient first complained of a pain on the inside of his thigh, just
above his knee.


ON ANEURISMS.
261

On the 11th day he repeated his complaints, and said that
the pain disturbed him, and prevented his sleeping during the
night. I knew not to what to attribute it; I thought it might indi-
cate some irritation of the anterior crural nerve; however, as the
patient remained pretty well, I gave no directions respecting it.
On the 12th day, when I visited the patient, I was shocked
at his appearance. His countenance expressed great anxiety
and despondency; and his pulse was more than 120. His
tongue was covered with a brown fur. He had missed his
regular evacuation from the bowels. Being clear that the cal-
omel had been of essential service before, I gave himn two grains
of that medicine, and ordered again the effervescing draughts.
On the 13th day he was no better, but more languid. The
calomel had produced two copious loose stools, scarcely tinted
wwith an ochre colour. I requested Dr. Roberts to see him,
who directed him to take a grain of opium at night; ordered
him sago and wine for food, and the inſusion of cascarilla with
tinct. of columnbo.
Fourteenth day. He neither seemed better nor worse ; he
had slept four hours in the night. A slight blush of the skin
appeared on the inside of the thigh, such as indicates in-
flammation of the absorbing vessels. Fomentations and poul-
tice were directed to this part. Dr. R. also ordered half a
grain of calomel, with five of cicuta, to be taken night and
morning.
Fifteenth day. He was considerably better, though his leg
continued painful ; the pain however was diminished. He was
directed to continue the same medicines; and to insure a good
night, if one grain of opium failed to give him rest, he was
allowed to take another after four hours.
Sixteenth day. Not quite so well. He had had no evacua-
tion for the last twenty-four hours. He took a little opening
electuary.
Seventeenth day. He had a stool during the night, and was
better. His thigh was ædematous, but not painful. The pain
was descending towards his ankle. Dr. Roberts wished him
to take the blue pill in preference to the calomel. Five grains
were therefore given each night.
Eighteenth day. He was better, and continued gradually
to improve till the twenty-fourth day, when he declared he felt
quite well, and had had six hours' comfortable sleep. The
colour of the stools had been gradually improving, and on that

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ON ANEURISMS.

day, when such a marked amendment took place, the stool
might be said to be nearly properly tinctured with bile, and of
a proper consistence.
During this time an abscess had formed on the inside of the
thigh, a little above the knee, where the absorbents of the
limb began to inflame, and the matter had been discharged by
a puncture made with a lancet. Swelling in the ham likewise
took place, and was apparently caused by the irritation of the
absorbents in that part, but no matter formed in it, and the leg
also became ædematous. The wound made by the operation
had healed firmly, and all tumefaction about it had subsided.
As the patient's bowels acted regularly, no medicines were now
given him.
After about a week had elapsed, he was seized as before
with pain in the epigastric region, rheumatism in the right
shoulder, and inability to move the right arm. His counte-
nance again expressed despondency and disturbance ; his pulse
was frequent and his skin hot; the abscess also was painful and
discharged copiously, and became distended with matter, so
that it seemed necessary to enlarge the aperture, which had
nearly healed. His tongue was much furred, and his stools
had no bile in them.
He again took calomel at first, and afterwards the pilul.
hydrarg. and the secretion of bile was gradually renewed and
increased, as in the preceding instances, which produced a
proportionate amendment in his general health. His limb also
was so much improved as to enable him to walk about the
ward, and to go out occasionally into the air.
Believing that living in a better air would greatly contribute
to the restoration of his health, he was soon afterwards dis-
charged from the hospital; looking as well as he did on his
admission, and capable of walking with but little infirmity. He
was advised to take the pilul. hydrarg. every second night, till
the secretion of bile was right, and to take them afterwards
whenever he perceived it to be deficient or faulty. He was
also enjoined to keep his bowels regular in other respects.
The cases which I have related and referred to, show that
the current of blood through the external iliac artery may be
stopped, without occasioning any material or even evident dim-
inution of the powers of the limb. It also appears to me that
this operation does not disturb the constitution in a greater
degree than a similar one performed upon arteries of less
10
ON ANEURISMS.

magnitude. It is true, that considerable disorder of the consti-
tution took place in the cases which I have related, but it
health of the patients, and not as a necessary consequence of
the operation. In the last case, every thing went on favoura-
bly till a disorder of the digestive organs occurred. To such
disorder it cannot be doubted that there was a strong pre-
disposition; and of which, the operation by its effects on the
mind as well as the body, confinement in an hospital, and great
alteration of diet may be considered as the exciting causes. I
think it probable that the state of the constitution might have
greatly contributed to produce the general irritation of the ab-
sorbents of the limb, which was first observed on the day
when the ligatures came away. I cannot doubt but that the
inflammation of these vessels did, as indeed it generally does,
greatly disturb the constitution and aggravate its disordered
state. These conjectures appear to me to be verified by the
last occurrence which I have related. When the wound was
healed, and the limb so well as that it probably could impart
no irritation to the general system, from leaving off the mercu-
rial medicine, disorder of the digestive organs recurred, and
produced the effects which I have described. .
That the femoral aneurism, when it occurs near to the groin,
may, like other aneurisms, sometimes be cured by the pro-
cesses of nature, is proved by experience ; yet this is not like-
ly to be the common event of such cases. I knew two in-
stances of patients dying of hemorrhage from such aneurisms.
The sufferings both of body and mind, in these cases, were
shocking. The patients were unable to move, and the disten-
tion of the integuments and pressure on the nerves occasioned
and uncertain of the hour when their sufferings might be termi-
nated by a fearful and fatal hemorrhage. I think myself there-
fore fortunate that I was first, as it were, compelled to perform
an operation, which, I trust, may be found to diminish the suf-
ferings, and preserve the lives of those afflicted with this dis-
ease.
THE END.
C
: Med. Lib. ASSO

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