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I      Surgeon  General's Office
 
 
 
SURGICAL OBSERVATIONS
ON
INJURIES OF THE HEAD;
AND ON
MISCELLANEOUS SUBJECTS.
         BY JOHN ABERNETHY, F. R. S.

Honorary Member of the Royal Medical Society of Edinburgh, and of the Medjcal Societie*
      of Paris, Philadelphia, &c. Assistant Surgeon to St. Bartholomew's
           Hospital, and Teacher of Anatomy and Surgery.
              PHILADELPHIA:            --

PRINTED FOR THOMAS DOBSON, AT THE STONE HOUSE,
          N<\ 41, SOUTH SECOND STREET
               Fry and Hammerer, Printers.
                    1811. 
 
SURGICAL  OBSERVATIONS,
On Injuries of the Head.
                  SECTION I.

 W^ HEN the Members of the Academy of Surge-
ry in France, and Mr.  Pott in England, severally
inculcated to the surgeons of their respective coun-
tries, the propriety and necessity of trephining the
cranium  under various circumstances consequent
upon injuries of the head,  they probably  recom-
mended a too free and frequent performance of that
operation. Such appears to be the opinion of many
respectable writers who have published  since their
time; particularly of M. Desault of Paris, Mr. Dease
of Dublin, and Mr. John Bell of Edinburgh. But
although these  writers  unite in censuring the fre-
quency of the practice, they are very far from being
agreed in other respects; and many material points
seem to me to require still further elucidation.
   Believing that the observations, which I have had
an opportunity of making at St. Bartholomew's Hos-
pital, enable me to throw some light on this impor-
tant and intricate subject, I am  induced to submit
to the public a short account of several cases that
occurred there, and  the  inferences which  I drew
from them. 
4            On Injuries of the Head.

  The difficulties connected with this part of sur-
gery are  sufficiently proved by this circumstance,
that, notwithstanding it has at all times excited the
attention of surgeons of the greatest talents, and pos-
sessing the most extensive field for observation,
much  difference of opinion still  subsists, and the
practice that ought to be followed in particular cases
yet remains a matter of dispute.  It is not, indeed,
probable, that any part of medical science can in a
short time receive all the improvement of which  it
is capable; for, in proportion as we advance in know-
ledge,  we are led to remark many circumstances in
the progress of a disorder, which had before passed
without notice, but which, if known and duly attend-
ed to, would clearly point out to  us the nature and
remedy of the complaint. Hence, the records of for-
mer cases are of much less value, as the  symptoms
about which we are now anxious  to inquire, have in
them been entirely overlooked.
  I was  led to this  remark by reading the Works
of Hildanus,  Wepfer, Du Quesnay, and  others,
wherein  are to be found a number of interesting
cases,  which I have been precluded from mention-
ing, as the nature of them  cannot be  exactly ascer-
tained in consequence  of this deficiency.
   Although I have been for many years attentive to
the treatment of persons who had suffered injuries
of the head, and also to the examination of the parts
after death, where the  case has terminated fatally;  I
still perceive so'many  circumstances which require
investigation, that I entertain no hope of  ever being
able to obtain, from my own experience,  all the in-
formation which is wanted. I  hope, however,  that
the hints offered in this essay may have the effect of
inducing surgeons to pay a closer attention to cases
 of this kind, and that thus, by their united observa-
 tions, the public may at length become possessed of 
            On Injuries of the Head.            5 *

that knowledge, which the labours of an individual
could never supply.
  In the accounts which we have of the former prac-
tice in France, it is related, that surgeons made nu-
merous perforations along the whole track of a frac-
ture of the  cranium;  and, as  far as I  am  able to
judge, without any very clear design. Mr. Pott also
advises such an operation, even with a view to pre-
vent the inflammation and  suppuration of the dura
mater, which he so much apprehended. But many
cases have occurred of late, where, even in fractures
with depression, the patients have done well without
an operation.  To confirm the accounts that have
been given of such cases, and by this means to coun-
teract,  in some degree, the bias which long accus-
tomed modes of thinking and  acting are  apt to im-
press on the minds of practitioners, I shall relate the
histories of  five cases, that occurred at St.  Bartho-
lomew's Hospital in the space of twelve months; and
afterwards offer a few  remarks  upon the  subject.
The principal circumstances only of each case are
related; for, as many examples of the same kind are
to be found in various surgical books, a minute de-
tail of particulars seems to be  unnecessar)^.


Cases of Fracture of the Cranium with Depression,
  which terminated favourably, although no Opera-
  tion was performed.

                    CASE I.
  A woman, ab'out forty years of age, was admit-
ted into the hospital for a wound on her head. About
a week before she applied for advice her husband 
 6            On Injuries of the Head.

 had knocked her down with a brass candlestick. She
 was  stunned  by the  blow, and  lay for some  time
 senseless;  but, on recovering, she felt no other in-
 convenience than the soreness  occasioned  by the
 wounded integuments. She had suffered some slight
 indisposition since the accident.
   On examining the head, the right parietal  bone
 was  found denuded  about two inches in extent; a
 fracture of the same length was also to be felt; and
 the bone on one side of the fracture was depressed
 about the  eighth of an inch.—She remained in the
 hospital a  fortnight, without any  bad symptom oc-
 curring, and was then, at her own desire, discharged,
 although the wound was not perfectly healed.


                   CASE II.
   A  boy,  about twelve years old, received  a  kick
 from a horse in Smithfield, which stunned him; and
 he was immediately brought to the  hospital.  The
 integuments of the forehead were divided by the in-
 jury, and the lower part of the os frontis, and super-
 ciliary ridge of  the frontal bone depressed at  least
 a quarter of an inch below its original level; the de-
 pressed portion measuring  about an inch and a half
%in length.
   It is obvious that the bone could not be thus de-
 pressed without a fracture  of some part of the basis
 of the skull occurring at the same time, on which
 account the case might be  considered as more dan-
 gerous.—In less than two  hours he had recovered
 from the immediate effect of the blow, being at that
 time  perfectly sensible.  Fourteen ounces of blood
 were taken from his arm; his bowels were emptied
 by a  purge; and saline medicines, with antimonials,
 were directed to be given. He went on tolerably
 well for two days, at the end of which time, evident 
On Injuries of the Head.           '1
symptoms of considerable irritation of the brain took
place. He now complained of pain in his head; slept
little; and, when dozing, often started, or was con-
vulsed in a slight degree. To remove these  symp-
toms, he was  bled twice, took  opening medicines
occasionally, was kept quiet, and without light, and
was  allowed only a spare diet.  By continuing this
plan for about three weeks, he perfectly recovered.


                   CASE III.
  A man between thirty and forty years of age, re-
ceived a blow  on the forehead from a brick thrown
at him, by  which the frontal bone  was fractured
about half an inch above  the  orbit: the  fracture
measured two inches in length,  and the upper por-
tion of the bone was depressed  about the eighth of
an inch. He was not even stunned by the blow, and
walked to the  hospital without assistance, complain-
ing only of  soreness in  the wounded integuments.
Sixteen ounces of blood were  immediately taken
from his arm;  he was  confined (much against  his
inclination)  to a scanty and  liquid  diet, and was
purged every second day.—This patient did not ex-
perience any illness; and the wound soon healed.

                   CASE IV.
  A boy, about thirteen years  old, had a fracture,
with depression, of part of the temporal and parietal
bones. By similar treatment, he also escaped with-
out any material ill  consequences; but in this case,
part of the injured bone exfoliated. 
 8           On Injuries of the Head.

                     CASE V.
   A girl, thirteen years old, had a considerable frac-
 ture, with depression of the left parietal bone.  She
 was not brought to the hospital until ten days after
 the accident. When admitted, she was feverish, had
 pain in her head, and the little sleep she  got was
 very much disturbed: but, by the use of bleeding,
 with antiphlogistic medicines and regimen, she soon
 got perfectly well.
   The cases above  related are not offered to notice
 on account of  any striking  peculiarity attending
 them, but merely to show that such are not unfre-
 quent, as  they all occurred within the course of a
 year.  From  amongst a great number of  similar
 cases, I shall select  the two following, as the symp-
 toms  attending  them were more violent than ordi-
 nary.

                    CASE VI.

   A lad, seventeen  years of age, had his head pres-
 sed between a cart-wheel and a post;  by which ac-
 cident the scalp  on  both  sides  was turned down-
 wards, so  as to expose the lower half of the parietal.
 bones, the squamous part  of the temporal, and also
 part of the frontal and occipital bones;  about a quar-
ter of the cranium being thus completely denuded.
 The periosteum  was in several places stript off from
the skull,  the scalp much bruised, and the posterior
and inferior angle of the left parietal bone was beat-
en in.  The visible  part of the depressed  portion
 was an inch in length, and more than an eighth of
an inch below the level of the cranium; but the frac-
ture extended along the squamous part of the tem-
poral bone towards  the basis  of the skull: it could
not, however, be traced, as the temporal muscle had 
             On Injuries of the Head.            9

 not been removed from that part by the injury.__
 The scalp being cleansed was  replaced, retained in
 its situation by slips of sticking-plaster, and a slight
 pressure  by bandage was  applied.  The  boy was
 perfectly sensible, his pulse regular, and not quick-
 ened. He had bled considerably  from the temporal
 artery, which had been divided by the accident:
 eight ounces of blood were, however, taken from
 his arm; and some purging medicine was adminis-
 tered next  morning, which procured three or four
 stools.—The next day (Friday,J  his pulse beat
 nearly 120  in a minute; his skin was hot and dry;
 and he complained of pain in his  forehead. Twelve
 ounces of blood were taken away, and four grains
 of pulvis antimonialis  ordered to  be given three
 times a day. On  Saturday, the  former symptoms
 still continued, and were rather increased.  The an-
 timonial powder made him sick, or at least increased
 his disposition to be  s'o. Fourteen ounces  more of
 blood were taken from him; the vibratory feel of his
 pulse not being altered until that quantity was taken
 away: the blood, on standing, appeared very buffy.
 His skin, notwithstanding all this, still remained ex-
 tremely dry; some antimonial wine was given, which
 produced vomiting.  On Sunday,  his pulse was evi-
 dently lowered by the evacuations he had undergone,
 but it was still quick, and sufficiently strong.  The
 pain of the head remained as before. Having a suf-
 ficient number of stools, and the  sickness still con-
 tinuing,  the  antimonial  powder  was omitted. He
 was bled, however, in the vena saphena, and his feet
 and legs were afterwards immersed  in warm water;
 during which, he, for the first time, perspired copi-
 ously. A blister was also applied to his neck.—The
 scalp united, with only a  trifling  suppuration over
the fractured part of  the bone; and to this ready
union, the lowering plan, by preventing inflamma-
                       B 
10           On Injuries of the Head.

tion, seems very materially to have  contributed.
The matter collected  over  the  fracture was  dis-
charged by a puncture, and the boy got well.

                   CASE VII.
  A lad, eighteen years of age, had the squamous
part of the temporal bone  beaten in; the fracture ran
horizontally, about  a quarter of an inch above the
zygoma, and could be distinctly traced with the fin-
ger, introduced through the torn scalp and temporal
muscle, for two inches. The upper part of the bone
was depressed about one-eighth of an inch; and it
was impossible to trephine  below the fracture in
order to elevate the depressed portion.  The lad had
recovered from the immediate stunning occasioned
by the injury;  nor was there any symptom  that in-
dicated material derangement of the functions of the
brain from the pressure which it sustained.  He was
bled largely, and took a purging medicine, and was
moderately well on the following day. On the second
morning he was again purged;  and when I saw him
at noon nothing materially wrong appeared; but when
I came  to the  hospital at  eight  in the evening I
found he had  gradually become delirious, and that
he then could scarcely be kept in bed.  His skin was
hot, and his pulse frequent and strong. These symp-
toms could be attributed to nothing but inflamma-
tion of the brain;  he was  therefore immediately and
largely bled. He now became quiet and manageable;
but the next morning his  replies to  all questions
were incoherent,  his pulse frequent, his skin hot,
and his tongue dry.  The bleeding and purging were
repeated, and at night a  blister was applied to his
neck. On the following  morning he was  sleeping
and feeble, but his answers were rational; as the fre-
quency  and fulness of his  pulse  increased in the 
            On Injuries of the Head.            11

evening, he was again bled. The inflammation of the
brain was now subdued, and the patient gradually
recovered. The wound healed without any exfolia-
tion of bone,  and when he was discharged from the
hospital there was not the most trivial circumstance
which could induce us to suspect that the brain had
sustained any injury from  the accident. His sleep
was sound and undisturbed, and the sudden motion
of his head in  any direction occasioned no giddiness
or inconvenience.
  It appears very clearly, I think, from these cases,
as well as from a great number of others to be found
in books, that a slight degree of pressure does not
derange the functions of the brain, for a limited time
after its  application.  That it does not do so at first
is very obvious; as persons are often perfectly sen-
sible, and free from head-ach and giddiness imme-
diately after the injury.  Whether it may not pro-
duce such an  effect at  some remote period, is not
so easily determined, since  this cannot be  ascer-
tained but  by a continued acquaintance with the
persons  who had received the injuries. All, how-
ever, whom I  have had an opportunity of knowing
for any length of time after the accident, continued
as well as if nothing of the kind had ever happened
to them.  In Mr. Hill's Cases  in Surgery, two in-
stances of this sort are  related; and  Mr.  Hill knew
both the  patients for many years afterwards, yet did
not perceive any inconvenience to arise. It deserves
to be mentioned too, that one of the patients was a
sailor, and therefore, probably, led a life of irregu-
larity as  well as of exertion.  The result of cases of 
12          On Injuries of the Head.*

this kind, which I have met with in authors, does
not lead to the apprehension of any future mischief:
nor is it easy to conceive that the pressure, which
caused no ill effects at a time when the  contents of
the cranium filled its  cavity completely,  should
afterwards prove injurious when they have adapted
themselves to its altered size and shape. Severe ill-
ness, indeed, does often intervene between the re-
ceipt of the injury and the time of its recovery; and
many surgeons might be  inclined to attribute this
to pressure;  but it equally  occurs where the depres-
sed portion is elevated;  several instances of which I
shall have occasion to relate, and many others are to
be  met with in authors.  This is  a  circumstance
which nothing  but  very extensive  experience  can
show in a true light. If,  for instance, a surgeon who
was prepossessed with the opinion that elevation of
the bone is necessary in every instance of depressed
cranium, should have acted upon this opinion in the
first, third, fourth, and  fifth  cases, and afterwards
have  employed proper evacuations,  his  patients
might, perhaps, have had no bad symptoms, and he
would naturally have attributed their well-doing to
the mode of treatment  which he had pursued: yet
these cases did equally  well  without  an operation.
If the same surgeon had been witness to the dis-
turbance  which arose  in the second,  sixth,  and
seventh cases, he would, without doubt, have attri-
buted them to the continuance of pressure  made by
the bone; yet  these cases also did  well by medical
treatment only: and when the symptoms  which come
on thus, are of  the inflammatory  kind, they may
generally be removed  by the same means. Many
cases also are to be  met with in books, and some
are related  in  the  subsequent part of this Essay,
where not only great but even fatal mischief ensued,
notwithstanding the brain had been  relieved from 
On Injuries of the Head.           13
pressure at an early period.  Another surgeon, pre-
judiced against the use of the trephine, might, with
equal injustice, consider the mischief, which ensues
in certain cases, as entirely owing to the operation.
   The degree of pressure, which the brain can sus-
tain without  great injury to the system,  may pro-
bably vary according to the disposition of that or-
gan to be  affected  by it,  the suddenness of its
application, and the direction in which it  is made:
and although it must be very difficult to obtain any
precise knowledge on this subject, yet there is great
reason to believe that the brain can bear«more pres-
sure without injury to it, than was  formerly suppo-
sed. The first of these circumstances seems evident;
for in some persons a slight  pressure  produces se-
vere symptoms;  whilst, in others,  a much greater
degree  is  borne without  inconvenience.  We  can
rarely judge  of the effects of pressure when any part
of the cranium  is beaten  in by a blow;  for in that
case the shock generally occasions stupefaction. In-
ternal hemorrhages, perhaps, afford us the best cri-
terion whereby to determine the effects of pressure
on the brain. The eighth case will serve as an illus-
tration of this remark,  where it appears that a con-
siderable hemorrhage must have taken place before
it deprived the patient of his faculties; for he walk-
ed home, undressed himself, and went to bed, after
the trunk of the middle artery of the dura mater had
been ruptured. In cases of apoplexy also, the hemor-
rhage is  generally very  large  before it  produces
those consequences which destroy life.
   The authorities quoted  by Morgagni, as well as
his own observations, show that people may recover
from apoplexy even after a considerable effusion of
blood has taken place.  But as  the records of such
cases are not common, and as it appears to me that
further confirmation of them would be highly use- 
14          On Injuries of the Head.
ful, I have obtained permission of Mr. Wilson to
mention a remarkable case of this kind, which oc-
curred to his notice.—A gentleman fell down  sud-
denly, and remained for some time in that lethargic
state which is usual in  apoplectic cases; but after-
wards gradually recovered his faculties both of mind
and body, and continued to exercise them very per-
fectly for two years, when a second attack of the
same kind took place,  and destroyed  him. Upon
opening the head,  the  cause  of his death  became
evident; for a large quantity of blood was found in
the ventricles, and at the basis of the cranium. But
what  seemed particularly worthy of attention, was
a cavity in the right  hemisphere of the brain,  ex-
tending from the front to the  back part of the cere-
brum, being  more than four  inches in length,  and
more than an inch in breadth.  Within this cavity
were contained  flakes of coagulated lymph, and a
bloody-coloured fluid,  which Mr. Wilson, whose
abilities and accuracy of observation entitle his opi-
nion to  the fullest  credit,  was convinced were the
remains of the blood extravasated at the first attack.
  I also examined the brain  of a gentleman,  with
whom, for the last five years  of his life, I was  inti-
mately acquainted. When I first knew him, he was
slowly recovering from a  severe  fit  of apoplexy,
which had paralyzed  the  left  side  of his body.
Though he could not raise his left arm to his head,
nor move his  left thigh and leg with freedom, yet he
walked  about moderately well, and could  work in
his garden. Every winter he was subject to fits of
the gout, and every summer to such a plethoric and
inflammatory state of the vessels of the head as to
threaten another apoplexy. He was once immediate-
ly and most completely relieved from very distress-
ing feelings from the latter cause, by the abstraction
often ounces of blood from the temporal artery.  The 
On Injuries of the Head.           15
last fit of apoplexy, which I have mentioned, was
the third, with which he had been afflicted. The
first affected his speech, the second  his right arm,
and the third produced the effects which I have re-
lated. His bodily  and mental powers remained how-
ever very vigorous, even during the five last years
of his life. On dissection three apoplectic cells were
found.  One was situated superficially  in the left
lobe of the cerebellum, one in the  left hemisphere
of the cerebrum,  and one, which had probably been
the cause of the last and greatest degree of paralysis,
in the middle of  the right hemisphere of the brain.
Nothing but the membranes, which immediately
invest the  brain, covered the effused  substance,
which had become of a gelatinous nature. I do not
exaggerate, when I say,  that  this cavity was  large
enough to have held six ounces of blood.
   Though a slight degree of pressure does not im-
mediately affect  the functions of the brain, yet  it
may act in another way;—it may excite inflammation
of that organ, as it does of other parts of the body. Its
power in this respect, however, will probably lessen
by the part becoming accustomed to it; and the cases
on record, where fractures with depression have done
well, as  well as  those of recovery from apoplexy,
are proofs, that the cause which in the first instance
was injurious by  its pressure,  may continue to exist
without inconvenience.  Such cases ought surely to
deter surgeons from elevating the bone in every in-
stance of slight depression,  since, by the operation,
they must inflict a further injury upon their patients,
the consequence of which it is impossible to estimate.
From all, therefore, that I have learned from books,
as well as  from  the observations I have made in
practice, and from reasoning upon the subject, I am
disposed to join in opinion with those surgeons, who
'are against  trephining in  slight depressions of the 
16           On Injuries of the Head.

skull, or small extravasations on  the  dura matter.
In the latter, it is probable the compressing cause
will soon be removed by absorption;  and in the former,
according to the observations of Mr. Hill* and Mr.
Latta,f the bone will regain its natural level if the
subject be young. In adults, however, and especially
in persons of advanced life, this circumstance cannot
be expected; so that in them the accommodation of
the parts to each other, necessary for preventing fu-
ture'mischief, must be effected by a corresponding
alteration in the form of the brain.
  A circumstance, however,  frequently occurs, that
may render the surgeon doubtful as to what course
he ought to  pursue; this happens when, at the same
time that the skull is slightly depressed,  the patient
labours  under the effects of concussion.  The cir-
cumstances, which generally serve to distinguish
those two injuries, will be noticed hereafter. At pre-
sent it is only necessary to observe, that, as the effects
of the latter gradually abate, a little delay will enable
the surgeon to  decide upon the nature of  the mis-
chief, and take his measures accordingly.  Where
the patient retains his faculties, nothing farther is
necessary than  a  continuance of the antiphlogistic
plan; and should any inflammation afterwards  take
place, the same means, employed  in a degree  pro-
portioned to the urgency of the symptoms, will in
most instances  be successful without elevating the
bone. This  happened in four of the  six foregoing
eases, which are related without any view to this par-
ticular point.—But if, from a peculiar disposition of
the brain to be affected by pressure, the torpor of
that organ should continue; or if, after inflammation
of the brain has taken place, the  pressure should

    * Cases in Surgery, p. 113.
    if Pract. Syst. of Surgery, vol. ii. p. 172. 
On Injuries of the Head.           17
 then appear to be particularly injurious, the elevation
 of the bone ought not, I think, to be deferred. And
 from some of the cases related by Mr.  O'Halloran,
 in the fourth volume of the Transactions of the Royal
 Irish Academy, it appears that this operation, if not
 too  long delayed,  will  give effectual  relief under
 such circumstances.
   The older surgeons certainly trephined unneces-
 sarily, in consequence of their belief, that the brain
 was an organ of so delicate a structure, that the least
 degree of pressure would be highly injurious; whilst
 others, from having witnessed the frequent ill success
 attending the operation, and from having observed
 that  many  patients  had recovered unexpectedly
 when it was omitted, seem inclined, too generally,
 to reprobate the practice. Under these circumstances,
 it appeared proper,  by the  recital of instances, to
 show what  kind  of cases would probably do well
 without  having recourse to it.  With  this' view I
 have laid before the public the preceding cases; and
 I wish, in conclusion, to offer in this edition, a few
 additional  remarks  on  the circumstances which
 would influence my conduct with regard to the im-
 mediate performance, postponement, or omission of
 the operation.
   The preceding cases  show, that in general there
 is no necessity for trephining in such fractures of the
 skull as occurred in them. It may further be stated
as an argument against the hasty performance of this
 operation, that it  is likely to aggravate  the  inflam-
mation of the brain,  which in the majority of cases
comes on in consequence of the injury.
  If it can be shown, that injury done  to the scalp
and bone, where there is no fracture or concussion,
may sometimes be productive of inflammation of the
brain, it would then follow,  that the injury inflicted
on these parts m the operation of trephining would 
 18           On Injuries of the Head.

 probably aggravate the  inflammatory  symptoms,
 which are to be expected to succeed to all violent
 blows on the head.  To show  that disorder  of the
 brain is likely to take place from its sympathy with
 the parts which contain that organ, I relate the fol-
 lowing cases.

                   CASE VIII.

  A coachman  standing on a small ladder to clean
 the top of a  carriage, slipt  and fell, with his head
 against  the  window, which was  drawn up  at the
 time. The  window being thus broken, the sharp
 edge of the glass divided and turned down the scalp
 to a considerable  extent from  off  the parietal and
 frontal bones.  In this state he came to my house,
 with the arteries bleeding profusely.  I tied two of
 them, replaced the scalp, and sent him to the  hospi-
 tal:  the next day he did not appear much indisposed;
 but after another day or two had elapsed, he suffered
 much from inflammation of the scalp, part of which
 was even in a sloughy state.  The patient had, at
the  same time, violent fever, and great  disorder of
his  stomach  and bowels. Small doses of calomel and
gentle aperients were given for the  latter affections;
and he also took saline,  and other  febrifuge  medi-
 cines. After about a week had elapsed, the scalp as-
sumed a much better appearance, the inflammation
having subsided, and the sloughs  being detached.
Nevertheless, his febrile state  became aggravated,
 and a kind  of delirium and symptoms indicating
 inflammation of the brain, came on, which venesec-
 tion did not subdue. The patient died, and his head
 being examined, it  was found, that the brain  and
 its membranes had undergone  considerable inflam-
 mation, which, from the degree of effusion between
 the tunica arachnoidea and dura mater, and between 
              On Injuries of the Head.           19

 it and the pia mater, appeared to have lasted for a
 considerable time.

                    CASE IX.

   A man had the scalp bruised and torn down from
 off the frontal bone by the wheel of a cart. He was
 not stunned at all by  the  accident. The bruised
 scalp mortified and the bone was left bare.  He re-
 mained  in the hospital waiting for exfoliation, and
 as he had no illness, but little attention was paid  to
 him. After about two months, however, he became
 weak, and ultimately delirious, and died; on exa-
 mination,  an  abscess containing  about  one  ounce
 and a half of pus was found in the front  lobe of the
 cerebrum, beneath the  dead  bone, and full half an
 inch from the surface.
   If then  irritation and inflammation of the scalp
 and bone may sometimes produce similar affections
 of the brain and  its membranes,  this very circum-
 stance affords an  argument for performing the ope-
 ration in a certain description of cases, in which,
 indeed, its necessity may not be immediately appa-
 rent. I allude to those cases in which, though the
 bone be  but slightly depressed, and may not occa-
 sion decisive symptoms of pressure, yet it may be
 broken into many pieces, and the scalp be so bruised,
 or otherwise injured, as not to be likely to unite by
 adhesion. Inflammation and suppuration  must now
 ensue in the scalp, and  some  of  the pieces of the
 bone will probably perish, and must be detached by
 tedious processes, which may induce disease in the
 subjacent membranes of the brain, as well as in that
portion of the organ which they invest. I have there-
fore  deemed it necessary to trephine in some cases
of this description; and  I think it will be useful to
relate briefly one case of this kind. It will also serve 
 20          On Injuries of the Head.

 as a contrast to that which  immediately succeeds
 to it.

                    CASE X.

   A drunken woman was knocked down on Black-
 friars Bridge, by a blow with a  cane, which had a
 round leaden head,  about an inch in diameter.  A
 circular piece of bone was beaten in to the depth of
 a quarter of an inch, and starred or broken into ma-
 ny fragments. By  dividing the scalp, I had the pow-
 er of reflecting a portion of the integuments, so that
 I could trephine the bone, and remove the shattered
 and depressed pieces. I also took out a clot of coa-
 gulated blood as large as a walnut. The wound was
 closed by sticking plaster, a compress laid over the
 part, and bound on by sticking-plaster. The patient
 was largely bled, and a  dose of purgative medicine
 was given.
   It was difficult to determine whether the  sleepy
 and stupid state of the patient was chiefly the effect
 of the injury or inebriety.  She  complained  loudly
 during the operation. The next day, when the stu-
 dents of the hospital  wished to examine whether the
 dressings were displaced or not,  she refused to per-
 mit them; but on my entering  the ward, she said, ay,
 now he is come, you may examine if you please.  I
 need only add further, that a treatment calculated to
 prevent and control inflammation was strictly per-
 severed in, and that the patient shortly became per-
 fectly well.

                    CASE XI.

   June 3, 1802. A coachman, twenty-three years of
age, was thrown from his box. The middle  of the
anterior edge of the right parietal bone was fractured. 
On Injuries of the Head,          21
and a piece about the size of a sixpence was slightly
depressed. He soon recovered from the stunning oc-
casioned by the fall, and did not come to the hos-
pital till the succeeding day.  As  he  was perfectly
well, he was but slightly bled, and no bad conse-
quences of this injury appeared for two months. At
this time he came again to the hospital, complaining
of spasms in his left arm. The wound,  which was
not yet healed, being examined, the depressed bone
was found to be loose, and was removed, which al-
leviated the spasms. Soon afterwards a portion of
the external table of the skull also came away.  In
the middle of September his health  seemed much
deranged, and he continued to get weaker  till the
middle of October.  The dura  mater  had gradually
become protuberant, and covered  with a fungus;  it
at last gave way, and coagulated blood was  dis-
charged, mixed with detached pieces of the sub-
stance of the brain.  The left arm  had now  lost  its
sensation, though the patient could feebly direct its
motions. On the 17th of October the patient became
very ill, and  much  bloody serum was discharged
from the wound. He was delirious during the night,
but on the next day understood all  questions pro-
posed to  him;  blood  and  brain  were  discharged
through the wound. On the evening of the i9th he
died.  There was found a vacancy in the membranes
of the brain, opposite to the deficiency in the bone,
through which the effused blood and injured brain
had been discharged. In other respects these mem-
branes were perfectly sound. The whole right hemi-
sphere of the brain seemed to be reduced into a pul-
py and fetid mass, composed of a mixture of blood
and brain; except that the cortical substance, to the
depth of about half an inch, remained sound. This
large cavity communicated with the left ventricle
under the fornix. 
2-2          On Injuries of the Head.

   It may be further stated as an argument against
the immediate performance of the operation of tre-
phining, in cases where its necessity is dubious, that
it deprives the brain  and its membranes of that na-
tural support which they receive from the bone. Un-
der these circumstances, when inflammation comes
on, the volume of the parts contained in the cranium,
will be so considerably augmented by the preter-
natural distention of  their vessels,  and subsequent
effusion of fluids, as to be protruded up into one
aperture. The dura mater is likely  to give way, and
the pia mater becoming exposed, will  be more sub-
ject to inflammation. It now  sustains the pressure
which was formerly supported by the dura mater, and
in its turn ulcerates, and the brain will protrude and
produce fungous excrescences. These circumstances
are more particularly likely to happen in children;
in them, indeed, the dura mater is so firmly connect-
ed with the bone, that it is rarely separated by ac-
cidental violence, and it is even  difficult to tear off
the bone, when it has been perforated by the trephine.
The argument against  immediately trephining the
cranium, unless urged to it by  great necessity, ap-
plies, therefore, more strongly to cases of children
than to similar accidents occurring in adults. These
remarks show the  necessity  for the most copious
evacuation after the operations of the trephine, in
order to prevent as much as possible the augmenta-
tion of the bulk of the contents  of  the  cranium by
subsequent inflammation and effusion, and which is
productive of the prejudicial effects above stated.
   With a view to obviate these, the  plan of treat-
ment instituted by  Mr.  Mynors  of  Birmingham,
highly deserves imitation. Having, by a simple di-
vision of the scalp, gained room for the application
of the trephine, and removal  of the depressed bone, 
             On Injuries of the Head.          23

he closed the wound attentively, and the scalp uni-
ted by adhesion to the dura mater on which it lay.
A gentle pressure, such as would give to the mem-
branes of the brain that support which they  were
wont to receive from the bone, seems also likely  to be
useful.
   There are, doubtless, some  depressions of the
skull that it would be absurd not to elevate by an
immediate operation, for in them  the pressure on
the brain would of itself be productive of fatal con-
sequences.  The arguments  which  I  have stated
against the immediate performance of the operation,
apply therefore, in my opinion, only to dubious cases;
to those in which, perchance, upon the subsidence of
the  inflammatory  symptoms,  the pressure may be
found not to be so great, but that it may be borne
without  detriment, though there is a  risk that  it
may be detrimental.                    ,
   Under these circumstances, by postponing the
 operation, we avoid the aggravation of the inflam-
 matory symptoms which immediately succeed to the
 injury, and  those  consequences which arise from
 leaving  an aperture  in the cranium into which the
 contained parts are likely to be protruded. I say, by
 postponing the operation, because, if upon the sub-
 sidence of the inflammatory symptoms, the pressure
 by  itself is found to produce prejudicial effects,
 we are still at liberty to perform it, nor is it  likely
 to be attended with that violent inflammation which
 arises from the injury   and operation  conjointly.
 There must be dubious cases; for a degree of pres-
 sure which might be borne in one person without
 inconvenience, may, in another, occasion a torpid
 state  of the brain, or other symptoms requiring its
 removal. Mr. O'Halloran's cases appear, therefore,
 to me very valuable, because they show that the 
24          On Injuries of the Head.

operation  of trephining will succeed under these
circumstances;  and, I know, that  it has been twice
performed of late in London with perfect relief  of
those symptoms for which it was required, and with-
out being followed by any inflammation which was
not readily controlled.
» 
On Injuries of the Head.          25
                  SECTION II.

Injuries of the Head attended with Extravasation of
           Blood upon the Dura Mater.

   In the three following cases the skull was broken,
and depressed at the part which  covers the middle
artery of the dura mater, by which means that ves-
sel was lacerated. The attention of surgeons has not
been sufficiently directed to this event, although it is
of the  utmost importance; for the life of the patient
might often  be saved, if the nature of the accident
were known, and the bone speedily perforated.—
These cases likewise  display, in a  very  striking
manner,  some  of the effects caused by great pres-
sure on the brain.

                   CASE XII.
   A man was knocked down by the iron hooks of a
crane,  which fell upon his head from a considerable
height. He was stunned at first, but soon recovered
his powers of mind and body so far as to walk home,
undress himself, and go to bed. A surgeon was sent
for, who, on his arrival, found the man senseless,
and in a deeply apoplectic  state. The patient was
immediately  brought to St. Bartholomew's Hospi-
tal, when the functions of life seemed nearly sus-
pended, as he  was almost  without sensation, his
breathing being slow, irregular, and stertorous, with
an  unequal,  intermitting pulse, and cold  extremi-
ties.—The scalp covering the right parietal bone
was wounded; and on dividing it more extensively,
a fracture with depression was discovered, running
                       D 
26            On Injuries of the Head.

obliquely across the anterior and inferior angle of the
parietal bone, over the temporal bone„ and extend-
ing to the basis of the cranium,  before the mastoid
process.  Several perforations with the trephine were
made along the course of the fracture, and the de-
pressed portion taken away. A surprising quantity
of congealed blood was found upon the dura mater;
the coagulum being not less than  an inch and half in
thickness, and six or seven inches in circumference.
On the removal of this coagulum,  the brain, which
had  been indented by its pressure, remained in the
same state as before, nor did it  ever regain its ori-
ginal level; so that the patient experienced but little
benefit from the operation, and he died about twelve
hours after receiving the blow.
  The dura mater, in this case, was  not torn through'
in any part; so that the blood could not have come
from any vessel within that membrane. The source
of such a profuse hemorrhage, however, could  not
be doubtful, when it was  known that  the  fracture
crossed, and had  probably wounded, the  principal
artery of the dura mater; yet that vessel did  not
bleed after it was exposed.

                   CASE XIII.
  A boy, about fourteen years of  age, fell from a
scaffold near two stories high, and pitched on his
head. When brought from Islington to the hospital,
he appeared to be almost in a dying state. The an-
terior inferior angle of the parietal, and part of the
frontal bones, were found depressed. A piece of the
cranium being taken out with the trephine, I disco-
vered beneath it a large  quantity  of coagulated
blobd; I therefore made the  next perforation nearer
to the trunk of the principal artery of the dura ma-
ter, from which I concluded that this  hemorrhage 
            On Injuries of the Head.           27

had taken place.  Having  gently removed some of
the coagulum, and introduced my finger  into the
aperture which had been made, I passed it as far as
the second joint, before I could touch the dura ma-
ter. Fluid arterial blood now gushed out in  such
quantities as to keep the bone covered on which I
was next to trephine. I  ran  no risk, however, in
performing the operation; for the dura mater was
depressed so much  that it could not  be injured.
But to guard against even the possibility of such an
accident, I introduced my finger  between the dura
mater and skull, and then  perforated the bone with
the trephine. Having thus removed a third piece,
which was directly over the principal artery, I took
out about four ounces of coagulated blood;  upon
which  the dura mater quickly rose to its original
level, and the hemorrhage from the wounded artery
ceased.  I now entirely removed the depressed por-
tion of bone,  and thus uncovered all the dura mater
which had been  detached; so  that I could distinctly
feel its connexion with the cranium all round. This
satisfied  me  that no more extravasated blood was
left behind.—The lad,  who  at  the beginning lay
quite insensible, with a feeble, intermitting pulse,
and laborious interrupted respiration, became rest-
less, and expressed sensations of pain  towards the
latter part of the operation. Being now asked', how
he found himself? he replied, very well; Whether
his head ached? he answered, no;  If he  was sure
that he felt no pain? he said he was sure, and wished
we would leave him alone.—I  now took twelve
ounces of blood from his  arm, and he was put to
bed, where he passed the  night  quietly.  The next
morning his  bowels were completely emptied  by a
purge; and  saline medicines, with  antimony, were
given,  so as to keep the skin in a gentle state of
perspiration.  During the day he was sleepy, and 
28           Qn Injuries of the Head.

lay quiet;  answered questions very  rationally, and
complained  of pain and  giddiness in his head.—
The third day he was disturbed, and less rational.
Eight ounces of blood were taken from him, and a
blister was applied to his neck. These means relieved
him greatly, and he became quite tranquil and col-
lected.—On  the sixth  day, symptoms of irritation
again took place, and were again relieved  by similar
treatment. The dura mater had granulated, and the
whole wound looked healthy.  Every thing went on
remarkably  well until  the fifteenth day, when  the
patient was  seized with rigor and pain in his head,
and the  healthv  aspect  of the  wound  was  also
changed.  The following  day, there was perceived,
in the  middle of the exposed dura mater, an aper-
ture through which a protrusion of the brain arose,
covered by the pia mater, which retained its natural
appearance.  In less than  twenty-four hours this tu-
mor increased to the size of an orange;  its surface
was dark-coloured, and irregular, and the pia mater
no longer distinguishable. The following morning
the boy died; and his friends had removed the body
from the hospital before I knew of his decease.
   I regretted very much that I could not examine
the nature of this fungus  or hernia cerebri, as it was
a phenomenon which I had more than once contem-
plated with  surprise, and the nature of which I was
afterwards fortunately enabled to ascertain.

                   CASE XIV.
   A man was knocked  down in Smithfield  by a
brick-bat, thrown at  him  by some villains against
whom he had appeared as evidence upon a trial. He
was immediately brought to the hospital; but  in a
state of profound apoplexy.—The right side of the
frontaLbone, and the lower part of the parietal, were 
On Injuries of the Head.           29
beaten in; the area of the depressed piece being two
inches in diameter. After making three perforations
in the circumference, I was enabled to remove the
depressed portion. I then took out a large handful
of coagulated blood, which lay upon the orbitary
process of the frontal bone, and had so pressed back
the anterior lobe of the brain, that I could, with my
finger, touch the  transverse  spinous process of the
sphenoid bone. The brain now rose slowly, in  con-
sequence, I suppose, of the blood gradually finding
its way  through  the compressed vessels; and the
man  began to show signs of returning sense.—He
was bled, and his bowels were emptied by a purge.
The next day he  was so far recovered as  to give an
imperfect account of the accident;  but on the third
day, he died  convulsed.
   On dissection,  some blood was found between the
dura and pia mater, and traces of inflammation ap-
peared on the latter membrane.
   Mr. Hill, of Dumfries,  relates  a case (the fifth,)
where the artery of  the dura mater was ruptured
without  either fracture or depression of the skull;
and when  he trephined a  second time,  four  days
after the accident, he found  so large a coagulum of
blood lying upon that membrane, as to make  him
afraid of removing it all at  once: but on taking out
a few ounces of  it, the patient, who had  hitherto
lain in a  state of apoplexy, looked up, on  being spo-
ken to, like one awakened from sleep,—knew, and
named every body, and raised the arm belonging to
the opposite  side, which had been paralytic   from
the time of the accident.
   In Mr. Latta's Surgery  also,  a similar  case (as
shown on dissection) is related, in which an uncom-
mon  slowness of the pulse, and coma without ster-
tor, were the symptoms produced. 
30            On Injuries of the Head.
   These aases show that a fracture of the  skull is
not likely to be followed by an equal degree of ex-
travasation in every part, as the vessels connecting
the dura  mater to the cranium  are, in  most  parts
of that membrane, of a small size.  If these are acci-
dentally ruptured, a slight hemorrhage ensues, which
soon stops, and only a thin  stratum of coagulated
blood is found when the bone is removed. But if
the fracture  happens  in the track of the principal
artery of the dura mater; if the trunk, or even a con-
siderable branch of that vessel be  torn, the  hemor-
rhage will be profuse, and the operation of the tre-
phine become  immediately necessary to preserve
the life of the patient. In the three cases that I have
related, the  operation  was done very shortly after
the accident: in the first case, the brain was so com-
pressed that it did not regain its level; in the third,
it  rose slowly as the blood found its way through
the vessels;  and in the second, it rose quickly, and
the functions of the brain were as quickly restored.
It can scarcely be doubted, then, that if the opera-
tion had been performed in these cases as soon as it
became necessary, when, perhaps, only  one instead
of many ounces of blood were poured forth from the
torn vessel, the lives of the patients might have been
preserved.
   It is of great importance to distinguish accurately
the nature of such cases; and the distinction is not
difficult when there is an interval of sense between
the blow and the stupor occasioned by the effused
blood.  In  the first related case, for instance,  the na-
ture of the accident was made sufficiently evident by
this circumstance. But though we are assured that
the patient labours under the effects of compression,
we cannot, in many instances,  know the situation oi 
On Injuries of the Head.           31
the compressing cause.  In other cases, again, where
there is no interval of sense  after the accident,  we
are at a loss to determine whether the senseless state
be the effect of compression or of concussion. Every
surgeon must acknowledge that it  would be a very
desirable thing to ascertain  when  blood is effused
between the dura mater and the skull; for if the ex-
travasation has happened in the more interior parts,
a surgical operation is  not likely to afford relief.*
Now, if the  extravasation which compresses  the
brain, be situated immediately beneath the bone, I
think there are signs by which it will be disclosed;
and as sufficient notice  has not been taken of these,
I wish particularly to call the attention of surgeons
to them.
   I have already  said, that, unless one of the large
arteries of the dura mater be wounded, the quantity
of blood poured out will probably be inconsiderable;
and the slight compression of the  brain which this
occasions, may not be  attended with any peculiar
symptoms;  or perhaps it may occasion some stupor,
or excite an irritation disposing the subjacent parts
to become inflamed: but both these effects will gra-
dually abate, nor will  any inflammation  ensue, if
proper means are taken to prevent it.  It is indeed
highly  probable, that,  in  many  cases  which  have

  * In those cases, which I  have seen, where blood was extra-
vasated between the dura and pia mater, and a division of the
former membrane was made for  its discharge, in some in-
stances the serous part of it  only could be evacuated; for the
coagulum was spread over the  hemisphere  of the  brain, and
had descended as low as possible towards its inferior part; in
others, though  a portion of  the effused blood was discharged
in a fluid or grumous state, a considerable quantity which  was
coagulated remained behind, so that very little relief was ob-
tained by the operation. It seems  then, that extravasation be-
tween the dura mater and the cranium is almost the only case
which admits of being remedied by the use of the trephine. 
32           On Injuries of the Head.
done well without an operation, such an extravasa-
tion has existed.  But if there be so much blood on
the dura mater as materially to derange the func-
tions of the brain, the bone, to a certain extent, will
no  longer  receive blood from  within; and by the
operation performed for its exposure, the pericrani-
um must have been separated  from its outside.  I
believe that a bone  so circumstanced will not be
found to bleed; and I am, at least, certain, it cannot,
with the  same freedom and celerity as it does when
the dura  mater remains connected  with it internally.
I need hardly say, that, in the  cases which I have
related, there was not the  least  hemorrhage. But it
is right to mention, that I  have also twice been able,
by attending to the want  of hemorrhage from the
outside of the cranium, to  ascertain  the extent to
which the dura mater was detached within; and very
frequently,  when  symptoms appeared to demand a
perforation of the skull, I  have  seen  it contra-indi-
cated by the hemorrhage from the bone;  and, as
the event has proved, rightly.
  When the bone has remained long bare, the case
may become perplexing. I once scraped a portion
of the cranium which had been some time denuded,
and found that it bled in such a manner, as, in my
opinion, sufficiently to point out the adhesion of the
dura mater, and of course the inutility of employing
the trephine.*
  Where the  extravasation on the  dura mater is
but small, it will probably not require any operation.
A slight hemorrhage from the bone, which may hap-
pen from the anastomosing of the vessels within its
substance, will not, in this case, lead to any injuri-

                                    »
  * In aged persons, and in those in whom the circulation has
been rendered languid by the accident, the mode of distinction
which I have pointed out, may indeed be less conclusive. 
On Injuries of the Head.          -35
ous error. But from what I have observed, I am in-
clined to believe, that even a small effusion of blood
will diminish the hemorrhage from the superincum-
bent bone.
  Mr.  Pott had  an idea, that the bone would perish
when the dura mater was detached for a considerable
space from its inside; and some cases which he has
related, seem to  favour this opinion: but many other
cases to be met  with in  authors, and many which
have occurred to my observation, prove that the
opinion was not  well founded. Indeed we  cannot
suppose that the bone would perish from this cause;
for it still receives blood, not only from the  anasto-
mosing of vessels within its substance, but also from
the pericranium  externally; and the success which
has of late attended the operations  for aneurism  in
the lower limbs,  shows that parts of great bulk and
vascularity will continue to  live when their usual
supply of blood  is very much diminished. If, how-
ever, the dura mater should be detached for a  con-
siderable extent  from the inside of the skull, at the
same time that the pericranium should also be strip-
ped from its outside, I am inclined to believe that a
portion of the  bone would, in that case, die and ex-
foliate.
E 
34          On Injuries of the Head.
                 SECTION III.

       Cases of Fungus, or Hernia Cerebri.

                   CASE XV.
  A MAN, about forty years of age, was knocked
down, and  had a considerable part of the parietal
bone, near the  coronal suture, depressed, by a stone
falling on his head from a high building.  A portion
of bone  was taken out, and the depressed piece ele-
vated. The  patient,  after this, seemed  to  obtain
great relief from the stupor under  which he had till
then laboured.  But the next day,  he became very
restless  and delirious, and frequently endeavoured
to get out of bed. Evacuations were prescribed, and
a blister applied to  his head, by  which  means the
symptoms  were lessened, but did not entirely go
off;   they continued  near  six  days,  only  varying
somewhat in degree. His Strength was  now very
much reduced; and though he became more tran-
quil, he was still delirious, and a coma supervened,
which  increased daily.—On  the  tenth day, upon
uncovering the wound in  order to dress it, a  hernia
cerebri appeared, rising through an ulcerated open-
ing in the dura mater. The tumour at this time was
not  larger  than a  pigeon's  egg; the pia  mater,
stretched over  its surface, was inflamed; and a tur-
bid serum  oozed at its side from beneath  the dura
mater.  On  the following day, the tumour had ac-
quired the size of a  hen's egg, was still smooth on
its surface,  and apparently  ready  to burst. On the
day after, before the time  of dressing, the man died.
—Upon examining  the tumour now,  it was found 
             On Injuries of the Head.          35

larger than before, and of a dark  colour, with an
irregular granulated surface; which appearance seem-
ed owing to coagulated blood which adhered to its
surface, as the part had bled so much, that one half
the cap which the man had worn, was rendered quite
stiff by it. In raising the top of the skull to inspect
the contained parts, the tumour was in some degree
torn from its basis. The pia mater  was in general
much inflamed, and, as well as  the dura mater, was
deficient at the place where the tumour protruded.
A part of this tumour being cut off where it was
lacerated, appeared to consist of coagulated blood of
a fibrous texture.  The brain was now taken out, and
the tumour carefully examined, when it was found
to be of the same  nature throughout, and to have
originated within the substance of the  brain, about
an inch below the surface; but I could not discover
the open vessel from which the hemorrhage had
proceeded.
   The appearances, on dissection, clearly explained
the cause of the symptoms which had taken place,
and rendered it evident, that the disease under which
this man had chiefly laboured,  was inflammation of
the pia mater. The nature of the tumour,  also, was
not less satisfactorily pointed out.  It was plain, that,
in consequence of the brain being injured to some
depth beneath the surface, disease of the vessels, and
consequent  effusion of blood, had ensued; that the
effusion  was for a time restrained by the superin-
cumbent brain and its membranes; but these gradu-
ally yielded to the expansive  force exerted from
within, and  at last giving way altogether, the fluid
blood oozed out and congealed upon the surface of
the tumour.  It appears very probable, that the dis-
ease frequently described by the term hernia cerebri,
consists, as  in this instance, of a tumour formed  by
coagulated blood;  for an organized fungus  could 
36          On Injuries of the Head.

hardly be  produced in  so short a time as that in
which these tumours are usually formed.

                   CASE XVI.
  A carpenter, while at work in a newly-built house,
was crushed by a part  of the wall falling in  upon
him.  His abdomen was bruised, his clavicle broken,
and his head wounded. Beneath the wounded scalp,
the right parietal bone was found fractured and  de-
pressed. He was slightly comatose for many hours
after being brought to the hospital,  yet  answered
rationally to those questions that  were put to him.
As the coma, however, remained,  and his pulse  did
not beat with the freedom that is usual, the surgeon
under  whose  care  he  was admitted,  thought it
right to trephine him.  Accordingly, one perforation
being made, the depressed bone was elevated.  No
blood was found upon the  dura mater, nor did any
thing indicate the propriety of using the trephine a
second time. The patient was largely bled; and sa-
line  medicines,  with  antimony and opium,  were
given. As he complained much of pain in his belly,
fomentations  were applied to this  part, and clysters
administered  occasionally. He  was again bled on
the second and fourth days after the operation.  At
the end of a week the antimony was omitted, on ac-
count of his weakness; and he seemed to get rather
better, until December 7, twelve  days after the ac-
cident,  when  a hernia cerebri  appeared,  rising
through an aperture in the dura mater,  opposite to
the perforation  in the skull.  It increased rapidly in
size,  and exhibited the same appearance  described
in the foregoing  case.—Two  days after  this,  the
patient died.
   On examining the head, the dura mater was found
every where adherent to the skull; but on its  inner 
On Injuries ofthe% Head.          37
layer there was a secretion of pus. The hernia cere-
bri, which had pushed up through an ulcerated open-
ing in the dura mater, was of a fibrous texture, and
evidently formed of congealed blood deposited in the
medullary part of the cerebrum; the containing cavi-
ty being about an inch diameter, and its  parietes
appearing to be the substance of the brain condens-
ed by pressure.  I was equally unsuccessful  here  in
my search after the vessel, whence the blood had
issued.  The ventricles of the brain were  full of a
serous fluid mixed with blood, and a large abscess
was also found in the spleen.—In this case, the men-
tal faculties were  not deranged as  in the former.
Both the symptoms and dissection show the disease
to have consisted in the effects of concussion, with
inflammation  of the dura  mater,  and subsequent
effusion into the ventricles of the brain.
   The opinion I had formed respecting the nature
of hernia cerebri was now confirmed; and I think it
received additional  illustration from the following
case, although the disease was in a different part of
the body.—A patient in the  hospital had a disease
in the head  of the  tibia, from  whence there arose
an unhealthy  fungus,  which Mr. Blicke removed;
and afterwards, the bone was kept bare  by caustic
applications, in hopes that a separation of the diseased
parts would take place. The patient, however, be-
came feverish, and his health was much impaired.
On the cessation of the fever, there suddenly arose,
within the wound,  a fungus-like substance, about
the size of a large apple,  which seemed to sprout
from the bone; it was of a livid  colour, and its sur-
face appeared as if covered with sloughs. I took off
the  tumour,  which  was  nothing  but coagulated
blood,  with the knife; and some blood oozed from
its basis,  but  the  hemorrhage was stopped by the
application of lint.  In a  few hours, however3  a 
38           On Injuries of the Head.

similar  fungus-like  tumour  arose.  As both  the
size and  situation  of the open  vessel  were  un-
known, and  as  the patient could neither  support
the loss of much blood, nor the irritation which
an extensive wound, made in search of the artery,
together with that arising from  the diseased bone,
would infallibly produce, it was judged best to re-
move the limb. This was accordingly done; and
upon injecting water into the popliteal artery, it was
found to be a branch of that vessel which had given
way.
  It seems that Pare, and the surgeons who lived
about his time, often mistook the tumours that arose
out of the cranium, for aneurisms, on account of
their pulsatory motion. M. Louis, in the Mem. de
VAcad. de Chirurgie, torn. V. has well distinguished
the nature and treatment  of those proceeding from
diseases of the dura mater or bone. There may, per-
haps, be tumours of various kinds arising from the
pia mater and brain; but if there are such, I  believe
they have not been discriminated; and the accounts
given of many of them by authors,  are  similar to
those just recited. They have generally been treat-
ed of under the name of fungus or hernia  cerebri;
and if the  effused blood of which they consist, ever
acquired vascularity, they might then deserve that
title: but none of those that I have just noticed were
of an organized structure.—Their formation seems
to proceed from an injury done to a part of the brain
by concussion or contusion, which has terminated
in a diseased state of the vessels, similar to what oc-
curs in apoplexy. The morbid state increasing, one
or more vessels give  way, and an effusion of blood
into the substance of the brain ensues, which, if the
skull were entire, would probably occasion apoplexy,
but, where there is  a deficiency of bone that allows
it to expand, presses the surface of the brain and its 
On Injuries of the Head.          39
meninges through the vacant space. The dura mater
soon ulcerates, and the tumour pushing through the
openings,  now  increases  with a rapidity  propor-
tioned to  that with  which the  hemorrhage takes
place within.  At last, the pia mater, and the stratum
of the brain which cover  the effused blood, are so
extended as to give way,  and the blood oozes out
and coagulates.—Thus, the quick growth,  and all
the other phenomena  observable in these  tumours,
are satisfactorily accounted for.
   The plan of treatment to be adopted with tumours
of the  kind which I have described, is next to be
considered; but  as I have had no opportunities of
acquiring knowledge as  to the treatment of these
diseases, since I became acquainted with the nature
of them, I can only offer  a few general remarks on
this subject.
   Where no bad symptoms pre%ede the appearance
of the tumour, or where they go entirely away upon
its being  freed  from the confinement  of the dura
mater, it may, perhaps, be most prudent not to in-
terfere in the treatment of the complaint: for proba-
bly the hemorrhage  will  cease, and the coagulum
will  drop off in pieces,* or gradually waste away,
and be no more renewed.f All that appears neces-
sary, then, under such circumstances, is to cover the
tumour and sore with some mild dressing, carefully
avoiding all pressure, which both reason and expe-
rience show is likely to be attended with bad conse-

   * See a case in the Edinburgh Medical Commentaries, vol.
i. p. 98, where  the tumour continued to increase for fourteen
days, and had acquired the size of a goose's egg, when it drop-
 ped off in pretty large pieces.  A similar case is related in the
Medical Museum, vol. iv. p. 463.
   f Fabricius Hildanus relates a case in his Fifteenth Obser-
 vation, where the tumour arising from the brain became, in
 24 hours, as large as a hen's egg, and afterwards gradually
 disappeared. 
40           On Injuries of the Head.
 quences. Should the bulk of the tumour, however,
 become inconvenient, or render pressure from the
 dressings unavoidable,  the  practice which present
 experience  has  shown  to be most successful, con-
 sists  in occasionally  paring off the tumour with a
 knife. In this manner Mr. Hill  treated several cases
 with  success.
   But if the tumour continues to increase, and if the
 patient  suffers a train of bad symptoms,  apparently
 arising  from  irritation  and  pressure made on  the
 brain, some further attempt to  relieve him seems to
 be required.  Under these circumstances,  we have
 reason  to suspect  that the coagulum, from want of
 room to protrude,  is enlarged internally;  or that by
 plugging up the  orifice  in the bone, it prevents the
 escape of some fluid collected within the cranium.*
 The  obvious mode of relief here appears to be, to
 enlarge the opening in the bone in proportion to the
extent and increase of the tumour. Many surgeons
have  objected to the  removal  of much of the cra-
 nium, lest protrusions of this kind should ensue; but
it is evident that  these tumours arise from an injury
 and consequent  disease of a part of the brain, the
 event of which must be more fatal if the bone were

  * Mr.  Hill, in relating a case  of  this kind, says, that he
" was  obliged to shave away the tumour, and push a lancet
into its root as often as the stupor and other symptoms showed
that matter was lodged there, by which the patient was uni-
 formly relieved, and afterwards recovered."—(See his Cases
 in  Surgery, p.  91-2.) But very different was the event in two
 similar cases (one is recorded by Scultetus, in his Armamen-
tarium Chirurgicum, Obs. XIX.; the other in the Lond.  Med.
Journal, vol. x. p. 277.), in which repeated attempts were made
 to prevent the growth  of the tumour by compression: one pa-
tient died at the end of a month; the other not until nearly six
months after the accident. In the brain of each there was found,
upon dissection, a large cavity, which had been  formed by the
accumulation of a fluid that could not escape, on account of the
aperture  in the bone being closed by the tumour. 
             On Injuries of the Head.          41

entire. A large removal of bone was formerly a fre-
quent event; but a protrusion of this kind very sel-
dom took place.
  But although, by thus allowing a free escape to
the effused blood, we may prevent the injurious ef-
fects of its pressure on the brain, yet the degree of
hemorrhage may endanger the life of the patient.
  The  quantity of blood  effused will  depend on
the magnitude of the vessels, or on their disposition
to bleed.  As the disease is generally situated not far
beneath the surface of the brain, there is less risk
of its proceeding from the former cause.  If it arises
from the latter, it is  very likely that the distention
caused  by the confinement  of the  effused  blood
would irritate the vessels, and keep up their dispo-
sition to hemorrhage;  therefore the treatment alrea-
dy recommended is likely to diminish it. But should
the quantity of the hemorrhage seem to threaten the
life of the patient, I should think it most proper to
take away the coagulum, and to expose the cavity
in the brain, in order to  learn  whether suffering
some sudden loss of blood to  take place, together
with the exposure of the  bleeding  vessels, might
not produce a beneficial change,  and a cessation of
the hemorrhage.  I am induced to propose this mode
of conduct, from reasoning founded on analogy: for
in other parts of the body a hemorrhage will some-
times continue, notwithstanding a considerable pres-
sure made by a large  quantity of coagulum, toge-
ther with that which the resistance arising from the
closure of the external opening, and that which is
occasioned  by the dressings,  conjointly  produce.
Yet, upon exposing the  bleeding surface, the  he-
morrhage will  cease,  and never afterwards be re-
newed.
  I am still further induced to propose this plan of
treatment, because I do not perceive any other which,
                       F 
42          On Injuries of the Head.
carries with it a probability of success.  The impro-
priety of attempting to restrain the hemorrhage by
pressure has been shown;  ligatures cannot be ap-
plied, and styptics are known, by experience, to be
dangerous.
  I shall extract one case  from the first volume  of
the Memoir es de VAcademie de Chirurgie* to show
that the removal of the coagulum is not likely to be
attended  with  any  alarming  consequences.—A
young man received a  blow on the right  parietal
bone, which occasioned a fracture; some bone was
removed, and a hernia cerebri was afterwards  pro-
duced, which was repeatedly pared down with the
knife.  On the  thirty-fifth  day  from the accident,
the patient having intoxicated himself, while in this
state, slipt his hand under the dressings, and laying
hold of the protruding coagulum, tore it away with
violence. The next day  the surgeon found, that al-
most the whole of what  he  considered as corrupted
brain,  was removed,  and  a vacancy left, so deep,
that he could see nearly  to  the corpus callosum.
From this time forward  the parts went on healing,
until they got quite well; but the patient continued
to labour  under a paralysis of the left side, which
had supervened the day after he received the blow.
  It is obvious, from the nature of the substance of
which the tumour is composed,  that styptic reme-
dies applied  to  its  surface can  have scarcely any
effect in lessening its bulk, and none at all in putting
a stop to its growth; and experience  shows, that
the more active of them  are not only ineffectual, but
highly dangerous. Hildanus, in his Fourteenth Obs.
relates the case of a man who died in consequence of
an empiric having dressed a tumour of this kind
with alum and calcined  vitriol.  And Mr. Hill tells

  * See the  Memoir of Mr.  Du Quesnay, 10th Observation, 
On Injuries of the Head.           43
us (p. 198),  that, after shaving off the protruding
part, he once sprinkled the basis with some blue vi-
triol, and another time  with red precipitate;  but
found that " his  patient had a very bad day  after
each of these;"  no doubt, in consequence of  their
being dissolved by the discharge, and insinuating
themselves  between the  tumour  and  the edges of
the skull, so as to get into contact with the sensible
parts within; for, that it was not owing to their effect
upon the tumour, is evident from its indolence when
he had removed it with the knife.*

  * The foregoing cases explain a particular  kind of protru-
sion, which seems to me to have been  frequently described by
authors, and of which they serve as specimens.  Such occur-
rences cannot be observed without surprise; the suddenness
of the protrusion  scarcely admits the  supposition of the pro-
truded part being organized.  It was never meant by the reci-
tal of these cases to deny, that the surface of the brain, when
exposed and irritated, would throw out a vascular  fungus; it
was only intended to describe a species of those appearances
which had  been denominated fungus or hernia cerebri.  In all
the cases of true fungus cerebri which I had seen when  I first
wrote the foregoing account, the fungus grew so slowly that it
eould not  be mistaken or confounded with the appearances
which took place in the cases  I have cited. Since that period,
I have seen cases in which the fungus grew .much more ra-
pidly, yet none in that degree which would make  it liable to
be confounded  with the appearances described in the present
section.  The curative indications in the true  fungus cerebri
seem to be, to diminish those causes which occasion the brain
to be  thrust upwards against  the bone, and to apply gentle
pressure from without, so  as to give  that degree of support
which the  part ought naturally to receive from the dura mater
and bone. 
44          On Injuries of the Head.
                  SECTION IV.

             Concussion of the Brain.

  AS I am of opinion that the effects of concussion
have not been justly described by authors, and as
the symptoms related by them are not, according to
my experience, those which usually occur, I have
therefore selected two cases out of a great number
that I have seen, in order  to  show what have ap-
peared to me the  common consequences of this in-
jury;  and I shall afterwards offer some remarks re-
specting the treatment of this affection.


                  CASE XVII.
  Harriet Siiverthorn, aged twenty-three years, slip-
ped down stairs, and struck her occiput against some
of the lower steps, by which the  integuments were
divided about half an inch  in length, but the wound
was not deep, nor were the surrounding parts much
bruised. She was taken up senseless, was bled, and
the next morning  conveyed to St. Bartholomew's
Hospital.  When  brought in, she was  comatose;
could not be  made to answer any questions; yet she
drew back her arm when pinched, and seemed very
uneasy when the wounded  parts were pressed upon.
Her breathing was without stertor, but performed
at some interval,  as  if  she did not wish to inspire
until obliged by necessity.   The  pulse, which  was
full and labouring, intermitted every fourth or fifth
stroke.—Eight ounces  of  blood were immediately
taken away, and an opening medicine given, which
procured three stools, after which she was ordered
a mixture, containing aqua ammonias acetatze,  and 
            On Injuries of the Head,          45

antimonial wine.—The next  day [Friday) she was
rational, put out her tongue when desired, and said
she had no pain in her head; her breathing was more
regular, and her pulse free from intermission. (Sa-
turday,) she was still more sensible, and gave some
account of herself;  complaining now  of head-ach,
and general uneasiness. The mixture was continued,
the purging medicine given again, and a blister laid
on  between her shoulders.—(Sunday,) her pulse
was  harder; she was sensible,  but restless; com-
plained of pain in her forehead, sat up  in bed, and
wanted to go home.  Six or  eight ounces of blood
were taken from her  temples, and the mixture or-
dered to be continued as before.—(Monday,) she
was  much more composed; but as she had still some
pain in her head,  a blister was applied  to it.—
(Tuesday,) she had slept quietly during the night,
answered rationally, but with quickness, and eager-
ly desired to go home. As the blisters appeared to
have been serviceable, that on her neck was renew-
ed.—(Wednesday,) she  was  perfectly quiet, and in
every respect  better;  nor had she, after this,. any
complaint worth mentioning.

                  CASE XVIII.
   A Frenchman, twenty-seven years  of age, who
had been many years in England, and  (as  it after-
wards appeared) spoke our language perfectly, had
met  with some accident (but in what manner, 1 know
not), in consequence of which he was brought to
the hospital. He was  then very  comatose,  and ex-
pressed much uneasiness at being roused from  that
state; yet he put out his tongue when bid,  but did
not give a rational answer to questions put  to him,
and his replies were made in his native language.
His  pulse was regular,  strong, and about 96 in a 
46          On Injuries of the Head.
 minute. Ten ounces  of blood were taken from his
 arm;  and after being purged,  the common saline
 mixture, with antimonial powder, was ordered to be
 given. In the night he grew delirious, got out of bed,
 and tore the bandage from his arm; in consequence
 of which he lost a good deal of blood before it was
 perceived. This, however, seemed of use  to  him;
 for he became more tranquil after it, and lay quietly
 dozing till morning. Next day, he was more rational,
 and complained of pain in his head. When I told
him that if he kept quiet,  he would soon be well, he
 said,  he hoped so; and appeared solicitous  to know
what should be done to him. His pulse was only 80,
and not strong. A gentle  laxative  was given, and a
blister applied to his  head.—On the third day, he
was much more sensible,  spoke with clearness, and
mentioned the pain being in the fore-part of his head;
yet, when I asked his age, he told me he was but six-
teen years old.—Tuesday  (fourth day), he appeared
more  excited and wild; his tongue  was  dry, but his
pulse  only 75. Nine ounces of blood were taken from
the temporal artery.—Fifth day, his pulse was  only
70, and perfectly natural; yet he had pulled  off the
dressing from his blisters, and seemed  to  be  very
irritable.—Sixth day, still pain in his forehead, pulse
rather quicker, but tongue not furred. After this he
gradually recovered, without any particular symptom
occurring, and without any other medical treatment.
  It is not likely that, in either of these  cases, ex-
travasation, at least to any considerable degree, had
taken place within the head, since in neither of them
 was there stertor, dilatation of the pupils, or insen-
 sibility. They may, therefore, I think, be considered
as exhibiting the symptoms  which  attend simple
 concussion.  The foregoing cases  were  indeed in-
 stances of but slight  concussion to what the brain
 sometimes suffers, and which proves fatal.  To dis 
             On Injuries of the Head.           47

 play the symptoms which occur in the  worst cases,
 I relate the following instance.


                   CASE XIX.
   W. Thomas, about thirty years of age, fell from
 the top of a brewhouse, a height of at least 80 feet.
 His hand being stretched out,  first sustained the
 shock, by which the carpal bones  were separated,
 and driven upwards, some before, and others behind
 the ends of the radius and ulna, the articular surfaces
 and periosteum  being at the same  time  forced  off
 the latter bones. I mention these particulars to show
 the great violence of the fall. The man's head after-
 wards struck the ground,  as appeared by  a bruise
 on his face:  but the cranium was not injured. When
 brought to the hospital, he appeared almost  depriv-
 ed of life, his body being cold and his pulse scarcely
 to be felt. The gentlemen  then attending,  put his
 feet into warm water, and gave him  an opiate.  '
   After  this he gradually  became  warmer, and it
 was observed that there  was not much dilatation of
 the pupils, and but little stertor in respiration. I saw
 the patient  next morning, at which time  his skin
 was very hot,  and  he  perspired  copiously. His
 breathing was repeated at regular intervals,  but the
 expirations  were made  with  unusual force.  The
 pulse was extremely irregular,  both in frequency
 and in strength;  generally about 140 in a minute.
 His pupils  were moderately contracted, his eye-
 brows drawn into a  frown as  if he suffered  pain.
 When I spoke to him softly, he did not answer. I
pinched his  hand slightly, but he did not move; but
when I repeated this a little harder,  he drew it away
with seeming vexation. He disliked that his eyes
should be examined.  When by speaking loud,  I
roused him, and inquired if his  head ached, he an-
swered, Yes.  I  got him to swallow some opening 
48          On Injuries of the Head.
 medicine,  which  emptied  his  bowels;  and  four
 leeches were applied to his temples; but they ex-
 tracted very little blood, and I thought his pulse
 countermanded any further evacuations.
   In the afternoon,  he appeared better. His pulse
 was more regular, and  his skin of a more natural
 temperature; his pupils, however, were more  con-
 tracted,  and his sensibility increased.  I tried the
 effect of giving him forty drops of tinct. opii, think-
 ing it might diminish sensibility, and keep him quiet
 for some  time,  during which the vascular system
 (which seemed to be particularly deranged) might
 perhaps regain its powers. The opiate increased his
 disposition to sleep,  and he appeared to suffer  less
 pain;  but in the evening, his pulse was more feeble
 and frequent, and his  skin hotter, and quite  wet
 with perspiration. Wine was now given to him, but
 without any apparent benefit; the powers and actions
 of life gradually  diminished, and before morning he
 died.
   On dissection, there appeared every mark denot-
 ing violent inflammation of the brain and pia mater,
 of short duration. The  minute arteries  of the pia
 mater were turgid with blood; in many places there
 was the appearance  called blood-shot,  which  was
 also to be seen in the lining of the ventricles. Dark-
 coloured, and in some places, bloody, coagulable
 lymph filled all the  recesses  between  the  tunica
 arachnoidea and pia mater. On dividing the sub-
 stance  of the brain, all its vessels appeared as if in-
jected  with blood.
   I am inclined to believe that the medical treatment
 of this patient did him niether much good nor harm.
 The means employed seem to have acted on him as
 on a person in health. The opening medicine render-
 ed him cooler, and quieted a little the disturbed  ac-
 tions of the system.  The opiate made  him more
 still, and disposed him  to sleep. 
             On Injuries of the Head.           49

  I leave it to practitioners to consider, whether cor-
dials would have been of any service  in this  case.
Would they not rather, by stimulating the  nervous
system, have increased the disturbance of the sen-
sorium, and, by exciting  the heart and  arteries,
have tended  to aggravate  the inflammation of the
brain.
  I add another case, because it  is remarkable for
the violence of the subsequent inflammatory symp-
toms.  The case was attended by Mr.  Sheppard of
Chew  Magna, who was, at the time it happened,
dressing pupil to Sir Charles Blicke at St. Bartho-
lomew's hospital. To his judicious and unremitting
attention I  cannot but attribute  in a  great degree
the ultimate  welfare of the patient.  The account
which I have drawn  up, is taken from Mr.  Shep-
pard's  notes.

                   CASE  XX.

  David Davis, a robust man, thirty-five years of
age, was admitted into St.  Bartholomew's hospital
on the  21st of November 1799. He had fallen from
a considerable height on his head, and had bruised
and wounded the scalp, but without fracturing the
bone. He was, when brought to the hospital,  so  far
insensible, as not to be affected by slight impressions,
and his extremities  were cold. His  feet were put
into hot water,  and, after  some  time, he became
warm and more sensible, and the pupils of his eyes
contracted as in common. Twelve ounces of blood
were taken from the temporal artery, and a purging
medicine given. On the following day, the pulse
being full and hard, sixteen ounces more of blood
were  taken away,  and the purging medicine re-
peated, which procured several stools, and a blister
was also applied to the nape of the neck.  Notwith- 
50           On Injuries of the tlead.

standing these measures, however, he became  de-
lirious, and his skin felt hot, and he complained of
pain in his head. Twelve ounces more of blood were
therefore taken, and three grains of pulvis antimo-
nialis given every fourth hour.
  November 24. The delirium still continued,  but
the patient lay more quiet: his pulse  was 120,  and
full, therefore twelve ounces of blood were taken,
and as the delirium and strength of the  pulse  still
continued, in the evening the bleeding was repeated
to the extent of twelve ounces. His bowels were  also
emptied by magnesia vitriolata and  senna. After-
wards  he had thirty drops of tinct. opii  given him
at night. He slept some hours in the night, and next
morning his pulse was less hard, and  only 96 in  a
minute; his answers to  questions  were also much
more rational, and delivered in a less loud and quick
tone of voice than before. For during the greater
part of the delirium he had been very unmanageable,
rolling about  in bed and endeavouring to get  up,
and speaking in a loud and fierce manner.  Towards
the evening the symptoms again increased; his pulse
was 120, and harder and fuller than in the morning;
his skin was hot, and lie complained of thirst. He  had
taken purging medicine in the morning, which  had
operated. Three grains of antimonial  powder were
now given every fourth hour, and his feet put into
warm water,  in hopes of procuring perspiration:  ten
ounces of blood were taken from the temporal artery,
and the opiate repeated at night.
  25th. The  patient had slept during great  part of
the night;  his pulse  100; he complained of cold,
though his skin was  hot; and of great pain  in  his
head. More stools were procured, and twelve ounces
of blood were taken  from the temporal artery.  He
now took six grains  of pulv. ipecac, comp. every
four hours. 
On Injuries of the Head.           51
   26th. He had been delirious during the former
part of the night, but had slept towards the morning;
in other respects he was much as before. In the eve-
ning,  as his pulse would  bear it, twelve ounces of
blood were again taken away.
   27th. Pulse softer and  frequent.  He had three
stools from medicine in the evening. The delirium
seemed to have a little subsided, and he was much
inclined to sleep, so that it was difficult to obtain an
answer from him.
   28th* A blister was applied to his head, and  in
the evening his pulse becoming  full, ten ounces of
blood were taken from him.  Two grains of opium
were given him at night.
   29th. He  had slept well but complained  of  his
head, and of difficulty in swallowing, and  in  the
evening had hemiplegia of the right side of his body.
   30th. He had slept but little, the bowels lax,  the
pulse  small and frequent, the  hemiplegia continues.
   We had thus far been endeavouring, by the most
powerful means, to subdue a violent inflammation
of the brain, and  could scarcely be  said to have
accomplished our design, when a new affection call-
ed for attention.  I think it can scarcely be doubted,
that the hemiplegia was the effect of pressure made
by an effusion of fluids, in consequence of inflamma-
tion, operating probably chiefly on the left hemisphere
of the brain, so as to paralyze the opposite side of the
body. Under this persuasion, and without expecta-
tion of  success, I  directed that  two drachms,  by
measure, of strong mercurial ointment should  be
rubbed in on his arms and legs night and morning,
and that five  grains of the pil. hydrarg. with one
grain  of opium, should be given three times a day.
These means were continued for three days without
any striking  amendment being perceived, but  on
the fourth (Dee. 4.) he stretched  out his right arm 
52           On Injuries of the Head.

when required, and was able to swallow without dif-
ficulty.  As  he  was getting better, the  same plan
was persevered in till the 9th, when the mercury had
affected his mouth, and  produced a diarrhoea.  He
now knew all those persons who attended him, and
his state was surprisingly altered. During the inflam-
mation of the brain he had been very unmanageable,
and his replies and expressions were fierce and loud.
Now he was extremely  tractable, and wept when-
ever he  was spoken to. His pulse was very feeble,
and beat but 90 in a minute. It seems right to men-
tion that a few days afterwards, when he was  slowly
recovering, one of the wounds of the temporal arte-
ry gave  way, and he lost perhaps fourteen ounces of
blood before it was perceived. This circumstance
of course made  him weaker, and increased the fre-
quency of his pulse, but it did not much impede his
recovery, which, though  very  slow, was  very per-
fect. Extensive sloughing of the integuments of the
nates had  taken  place, which it does not seem  re-
quisite to mention, but inasmuch as it tends to show
the reduced state to which he had been brought.
Indeed if this patient had not possessed a vigorous
constitution, it  seemed scarcely possible  that  he
could have survived the debility which this disease
and the  treatment conjointly produced.
   The extent of the evacuations, that surgeons are
obliged  to make in inflammations of vital organs, is
such, as would  deter  the unexperienced from pur-
suing them, and must astonish those who have em-
ployed them with success, that they could be borne
with so  little  apparent injury.  It can onlv be ac-
counted for by considering the disease as the stimu-
lus which  keeps up the actions of  the constitution
under such exhausting measures, as would occasion
them to sink but for this excitement.
   The opinions, that prevail amongst surgeons res- 
On Injuries of the Head.            53
pecting the  treatment of concussion, are very diffe-
rent.  Many late writers advise stimulating cordials,
such as wine, and volatile alkali, to be given;  while
others pursue a directly opposite  conduct. Nor do
they agree in the account of the symptoms,  which
they consider as depending on this  species of injury.
Most writers  represent  the  subject, as if the de-
ranged  state of the brain, which  is the immediate
consequence of the shock, continued to the termina-
tion of  the patient's illness or of life;  while,  in the
cases given  by Mr. Pott, the  symptoms appear to
proceed more from the inflammation which ensues,
than from the concussion.
   The whole train of symptoms following a concus-
sion of the brain, may, I think, be properly divided
into three stages.  The first is that state of insensi-
bility and derangement of the bodily powers, which
immediately succeed the accident. While it lasts,
the patient scarcely feels any injury that may be in-
flicted on him.  His breathing is difficult, but in ge-
neral without stertor; his pulse intermitting, and his
extremities  cold. But such a state cannot last long;
it goes off gradually, and is succeeded by another,
which I consider as the second stage of concussion.
In this, the pulse and respiration become better, and
though  not  regularly  performed,  are sufficient to
maintain life, and to diffuse warmth over the extreme
parts of the  body. The feeling of the patient  is now
so far restored, that he  is sensible if his skin be
pinched; but he lies stupid, and inattentive to slight
external impressions. As the effects of  concussion
diminish,  he becomes capable of  replying to ques-
tions put to him in a loud tone of voice, especially
when they refer to his chief suffering at the time, as
pain in the  head,  &c; otherwise, he answers inco-
herently, and as if his attention could not be excited,
or was occupied by something else; he is, hi short, 
54           On Injuries of the Head.
like a man in a heavy sleep. The concussion of the
brain, lastly, produces a state of inflammation of the
organ, and this constitutes the third stage, which is
the most important of the series of effects proceed-
ing from this cause.
   These several stages vary considerably in their
degree and duration;  but more or less of each will
be found to take place  in every instance where the
brain has been violently shaken. Whether they  bear
any certain proportion to each other or not, I do not
know.  Indeed this will depend upon such a variety
of circumstances in the constitution, the injury, and
the after-treatment, that it must be difficult to deter-
mine.
   With regard to the treatment of concussion, it
would appear, that in the first stage very little can
be done.  From a loose, and,  I think, a fallacious
analogy between the insensibility in  fainting,  and
that which occurs in concussion, the  more power-
ful stimulants,  such as  wine, brandy, and volatile
alkali,  are  commonly had recourse to, as soon as
the patient can be made to swallow. The same  rea-
soning which led to the employment of these reme-
dies in the first stage, in order  to recal sensibility,
has given a kind  of sanction to their repetition in
the second, with a view to continue and increase it.
  But  here the practice  becomes  more  evidently
pernicious. The circumstance of the  brain  having
so far recovered its powers, as to carry on the  ani-
mal functions in a degree sufficient to  maintain  life,
is surely a strong argument that it will continue to
do so, without the aid of such means;  which tend
to exhaust parts already  weakened, by the violent
action they induce.
  It seems probable that  these  stimulating liquors
will aggravate  that inflammation which must ensue
sooner or later. The access of it, in the cases which 
On Injuries of the Head.          55
I have related, is sufficiently evident; and its cure is
to be effected by the common  methods. The great
benefit of evacuations was, in those cases, very evi-
dent. Indeed,  it  appears to me, that  there "is no
complaint which  requires such means to be more
rigorously prosecuted, than an inflammation  of the
brain or its membranes.
   In addition to the reasoning which I  have offered
here, I would observe, that surgical books abound
with cases in which suitable evacuations have been
freely employed in concussion, with the best effects;
while the advocates  for a  contrary practice have
rested their arguments upon vague theory, and com-
municate no particulars of their success.
   If the foregoing cases exhibit the genuine marks
of concussion, the administration of cordial medi-
cines, which has been  so much recommended, ap-
pears to be very ill adapted to the relief of such an
injury.
   I have seen so many additional cases of concus-
sion, so exactly corresponding to those  formerly re-
lated, that I am more fully satisfied of the truth of
the representation which has been given of them. I
have in consequence been  led more and more to
wonder, that a contrary plan of treatment to that
which has been so uniformly successful, could ever
have been recommended,  and to conjecture what
cases could have occurred,  in which such opposite
practice must  not have been strikingly prejudicial.
Probably I may point out such  cases; and as I do
not find them described in  books of surgery,  be-
cause they have not been deemed sufficiently im-
portant, it may not be  improper briefly to mention
them.
   A young lady was stooping in a closet, and rising
up suddenly and forcibly she struck her  head against
a shelf.  The blow occasioned extreme pain, but did
not stun her. She went down stairs without men- 
56          On Injuries of the Head.

tioning  the accident, and after  sitting  with her
friends for a short time she fainted. As it was in the
evening she went to bed,  but  could not sleep for
pain hi her head, and the next day her pulse was
very languid, and her extremities cold; she  com-
plained of great pain  when  the  scalp was  slightly
touched, and  said there was a sensation as if cold
water was  dropping on  it.  She took some gentle
opening medicine, which relieved these symptoms,
but she could not sit up for many days, and  it  was a
considerable time before she recovered from the
languor, which the blow had occasioned: but neither
fever, nor failure of sensation, or of intellect,  took
place in the slightest degree.  I have seen many simi-
lar cases, and in one the patient said  his sensations
were such as would induce him  to believe that his
brain was loose, and moving on  the inside of the
skull. All these cases were relieved by slight eva-
cuations, as gently opening medicines, leeches,  or
cupping, though I am inclined  to believe that a
contrary plan of treatment, which has been recom-
mended in concussion,  might have  been pursued
without material detriment.  Cases of this descrip-
tion are to  be  considered  as arising from nervous
symptoms, attendant  upon  slight injuries, rather
than as effects of serious concussion. Mr.  Pott, in
speaking of concussion,  says,  that he never  knew
patients recover from  the immediate consequences
of it, without an imperfection in some sense, or part
of the body, remaining. The result of my own ex-
perience has been very different; and yet I am ready
to believe that such events may not unfrequently take
place, as I know from examination, that the sub-
stance of the brain is  sometimes  lacerated and dis-
organized in violent concussions. I have, however,
examined other cases of  fatal concussions, without
observing any such lesion of the substance of the
brain. 
On Injuries of the Head.           57
   It has hitherto been considered as a desirable ob-
ject, to point out any marks by which we might dis-
tinguish between compression and concussion of the
brain;  but I believe no  such criteria have yet been
communicated  to  the  public.  If we judge of the
symptoms of compression from what occurs in cases
of apoplexy, or from  cases like those which have
been related of the rupture of the middle artery of
the dura mater, (in one of which cases it was evident,
that concussion had no  share in  producing the
symptoms,) we must, I  think, be of opinion, that
pressure on the brain  occasions insensibility par-
tially,  or generally, and in a degree proportionate to
its quantity. In extreme cases, such as I have cited,
the  insensibility is manifested  by every circum-
stance. The pupil of the eye is  dilated, and cannot
be  made to contract even  by  a strong light. The
respiration  is  slow and  stertorous,  and  the pulse
proportionately slow and labouring. There is  no
vomiting, which would indeed  indicate sensibility
of stomach. The  limbs  are relaxed, as in a person
just dead.  No  struggles take  place,  nor signs of
sensation appear during the operation; but  on the
pressure being removed, sensation and intelligence
are immediately restored.  In concussion, the insen-
sible state  is of short duration, and during its con-
tinuance the  body  is generally  cold, and the pulse
feeble and intermitting.  Afterwards the skin  is hot-
ter than usual, the pulse and respiration more fre-
quent; the former often intermits, and the latter has
not the stertor  of apoplexy.* rI]ne pupil of the eye
is not  dilated,  but  rather contracted. The counte-

  * But tbe absence of stertor must not be relied on as a proof
that there is no compression; for Morgagni relates dissections
of apoplectic persons, where the effusion was considerable, yet
no stertor had occurred; and I have seen cases where it took
place only in a very slight degree. 
58
On Injuries of the Head.
nance expresses pain or  uneasiness;  and vomiting
occasionally takes place.  The state of the patient is
like that of a heavy and  uncomfortable  sleep; yet,
being roused, signs, even of intelligence, appear.
  In fractures of the basis of the skull, however, it
must be acknowledged, that the symptoms are often
deceptive. In general the symptoms resemble those
of concussion, yet sometimes a degree  of  insensi-
bility may be observed like that produced by pres-
sure, when no pressure has really taken place.
  I cannot better represent to the reader what I
conceive of the value of the distinctions which I
have made, between the symptons of compression
and concussion of the brain, in ordinary  cases, than
by relating briefly some of the particulars of a case
sent me by Mr. Davies, surgeon of  Tetbury, who
was formerly an industrious and intelligent student
at St. Bartholomew's hospital.  The case also,  in my
opinion, deserves to be recorded for other reasons,
which I shall afterwards mention.
  A young woman  was knocked down by a blow
en her head, and the place where the blow had been
received was denoted by a soft swelling of the scalp.
She lay  in a state  of apoplexy, and appeared like a
corpse.  The  pupils  of her eyes could not be made
to contract by  the approach of a strong light; hei
olfactory nerves were unaffected by the  most pun-
gent odour; her ears were equally insensible to sound;
she  manifested no uneasiness  upon  being  sharply
pinched; her pulse was small and intermitting, and
her  breathing scarcely perceptible;  and a cold and
clammy moisture covered her skin.
  Mr. Davies immediately divided  the  scalp, and
finding the bone fractured, he trephined it. There
was no blood upon the dura mater, but  that mem-
brane was thrust up into the aperture made by the
trephine. The dura mater being divided, about five 
On Injuries of the Head.          59
ounces of blood were suddenly discharged, and the
patient rose up in bed, as if waking with affright.
Her pulse and respiration were soon relieved, and
became natural. A plan of treatment calculated to
prevent and subdue inflammation was strictly pur-
sued, and the patient did well without any remark-
able occurrence taking place.
  From what has been already said it may be infer-
red, that I do not consider the division  of the dura
mater as a slight  evil. It is, doubtless, the duty of
a surgeon, when he has  been urged to trephine, on
account of strong symptoms of pressure, to divide
that membrane,  if it be thrust upwards into the
aperture which he has made. I have said that fre-
quently the blood  is coagulated, or so thickly gru-
mous, that the whole of it cannot be discharged.  In
the present case, however, the promptitude of the
surgeon's conduct enabled him happily to discharge
the effused blood whilst  it remained fluid. 
60           On Injuries of the Head.
                   SECTION V.

         Inflammation of the Pia Mater.*

   THE inflammation of the dura mater, which oc-
casionally succeeds to injuries of the head, has been
well described by Mr.  Pott. Patients labouring un-
der this complaint  are feverish,  have a constrictive
pain in the head, but continue  rational,  and give a
clear account of their symptoms, until matter forms,
or inflammation of the internal parts ensues. This is
what we might naturally expect from  the structure
of the dura mater, the manner in which it is supplied
with blood, and  its vessels  having little connexion
with the brain.  When  the  pia  mater becomes  in-
flamed, as the brain derives a considerable portion
of its blood through the vessels of that  membrane,
the disease  is  instantly  communicated  to the cere-
brum, and deranges its functions.  This derange-
ment varies in its nature and degree, accordingly as
the inflammation of the pia mater is more or less
violent;  as it is confined to  the  surface,  or extends
to the internal parts; as it produces  a  greater or
smaller secretion of fluid which compresses the brain;
or as it is more or less  blended  with the effects of

  * In the former edition, I related in this section cases of
inflammation of the pia mater, in which this disease occurred
distinctly, and terminated fatally, in order to authenticate the
specific symptoms attendant on it, As many of  the foregoing
cases, however, are instances of this disease coming on after
concussion or fracture, and yet occurring as a distinct disease,
and uncombined with symptoms arising from the peculiar na-
ture of the injury, I think a further narrative of cases super-
fluous. 
On Injuries of the Head.           61
concussion. The state of the patient will vary con-
siderably under these different circumstances. If the
inflammation be  violent and general, the patient will
be irrational and disturbed, having his mind strongly
affected by wrong ideas, and endeavouring to act in
consequence of them.  If the inflammation be mode-
rate, and affect the surface only, he will be irrational,
uneasy, restless, and perhaps endeavour to get out
of bed, but without the violence of mania.   Should
a moderate inflammation be blended with the effects
of concussion, he will  have less appearance of irra-
tionality, will lie pretty quiet, and inattentive to slight
impressions, as  appeared in some of the cases rela-
ted.—I am not able to particularize every variety
that may occur  in the  symptoms;  but in all, there
must be more or less derangement  of the powers,
both mental and corporeal, depending upon the de-
gree of inflammation, &c*—The symptoms, which
chiefly characterize the complaint, are those of  an
increase of sensibility; the pupils  of  the  eyes are
contracted; the  patient often withdraws his arm  on
being touched, and his pulse and tongue denote ge-
neral as well as  local inflammation. It  seems of the
utmost importance, that those means which in gene-
ral cure  inflammation,  should be prosecuted very
vigorously at  the commencement of this complaint;
since otherwise, although they may check, they will
not overcome it. Large blood-lettings, brisk purg-
ing, and  extensive  counter-irritation, by  blisters,
ought to  be employed  at the very commencement;
for, if omitted,  the disease will then become esta-

  * An unusual infirmity of the bodily powers is sometimes
observed, accompanied with tremors, low  delirium, and ex-
ceedingly rapid pulse; yet,  on  dissection, a slight inflamma-
tory appearance of the pia mater and brain is all that can  be
discovered. Such a state sometimes occurs after  an abscess
,kas formed in the brain. 
62          On Injuries of the Head.

blished, and the powers  of the body will soon be
too much sunk to admit  of the same active treat-
ment at a later period.
   I have here represented the general effects of in-
flammation of the pia mater when it arises from ex-
ternal  violence.   In other  cases, indeed, where it
comes on, as it were, spontaneously, or without any
powerfully exciting cause (in which case  it general-
ly falls under the care of the  physician),  it has ap-
peared to have  effected the brain but little,  and to
have been very slow in its progress, and inactive in
its nature. In such  cases it has produced a deposi-
tion between the tunica arachnoidea and the pia ma-
ter, or a  collection of serum between the former
membrane and the dura  mater.  Under  these  cir-
cumstances, I have learned that the rationality of the
patient has been scarcely deranged.  And as such a
state of disease  may occur after an accident, I have
thought it right to mention it in this place.
  In the  generality of cases of injury done to the ,
head, the symptoms  of  concussion, compression,
and inflammation are so combined as to appear in-
explicable.  It is only by an  attention to those rare
cases, in which the symptoms of each appear  dis-
tinctly, that we are likely to increase our knowledge
of their specific  effects. I conclude  this review of
the effect of injuries done to the head, by observing,
that whatever may be the nature of the injury which
the brain may have  sustained, still the disorder  in-
duced in that organ must produce a proportionate
disorder  in the functions of the  digestive organs,
and the reaction of  the latter affection must aggra-
vate the former.  Some remarks on this subject are
inserted in the first  volume of these observations.
To corroborate  further the statement  there given,
and to bring  this subject before the reader's mind 
            On Injuries of the Head.            63

on the present occasion, I relate the following case,
which occurred about two years ago.


                   CASE XXI.
  A young gentleman received a severe wound on
the forehead, which laid bare the bone, and stunned
him.  By venesection and the usual treatment, the
immediate  ill consequences of the injury were miti-
gated and  subdued; so that the wound healed, and
he was considered to be convalescent. He was not,
however, well; he had strange  nervous feelings about
his head;  and  after three months he became very
much disordered. Calling at  a friend's house, he
discoursed  wildly, and became so delirious, that they
were  obliged to  confine  him  in bed by means  of a
strait  waistcoat.  Ten ounces of blood were taken
from him. and I was desired to visit him.  His pulse
beat more than 100 in a minute; his skin was hot and
dry; his tongue was furred, but it could not be dis-
tinctly seen; he showed no signs of understanding to
any questions that  were  put  to him; he  rolled his
head  about;  and breathed altogether by  means of
the ribs, without moving the diaphragm. When I
pressed even slightly beneath  the ensiform cartilage,
he seemed to suffer greatly, and became slightly con-
vulsed.  The blood which had been taken from the
arm did not indicate inflammation, and  I was there-
fore induced to consider the symptoms  as arising
from  nervous irritation,  caused, or aggravated, by
disorder of the digestive organs.  As it was impossi-
ble to get  the patient to swallow, we  formed two
grains of calomel and 10 of jalap into an electuary,
by means of a little honey, and besmeared the back
part of the  tongue with it. The same medicine was
repeated after six hours. The  second dose  produced 
64          On Injuries of the Head.

two copious discharges from the bowels, after which
his head was  so much relieved, that when I called
on him the following morning, he was perfectly ra-
tional, and his pulse  was tranquil.  I then question-
ed him particularly respecting  the  kind of pain in
his head; and he told me, that it was not severe, nor
accompanied with throbbing; that it was confined to
the part which  had been wounded, and it was  con-
stant. As  the purgative  medicines had not  begun to
operate till towards the morning, I thought that their
effects  might continue,  and therefore only advised,
that he should take saline draughts in a state of ef-
fervescence, during the day;  and food of an unsti-
mulating  quality.  No  more  evacuations  however
took place from the bowels, and in the afternoon the
patient again became delirious, so that when I saw
him in the evening he  did not seem to understand
any thing  that was said  to  him. He lay, however,
much more quietly than he had done on the preced-
ing evening, only occasionally moving his head to
one side or the other, and then seeming as if he was
looking for some object by  the side of the bed.  The
jalap was  now again given him, with the addition of
one grain  of calomel. The medicine operated twice
in the night,  and  next  morning he was again per-
fectly rational.  We now insured the continuance of
discharges from the bowels, by directing him to take
some common purging  mixtures, if his bowels did
not act  in six hours.  The  delirium did not return,
and the patient soon became as well as he had ever
been since the accident. Yet  still his  digestive or-
gans were not  in a healthy state.  His tongue was
much  furred;  his bowels either costive or purged,
and generally in the latter state; and the secretion of
bile  was  either deficient  in  quantity, or faulty in
quality. He remained in this way for many months, 
On Injuries of the Head.           65
though various kinds of medicines were  given for
his relief. At last a spontaneous diarrhoea  occurred,
and as I was informed by his physician, his bowels
afterwards regained their natural  tranquillity and
functions,
f 
66          On Injuries oj* the Head.
                  SECTION VI.

   Cases of Disease of the Bone and Dura Mater.

   THE diseases  of  the cranium,  and consequent
affections of the dura  mater, have been well describ-
ed by some French and German surgeons.* But as
they have not, I believe, been explained by English
writers, I  shall confirm the accounts which we have
received of them by additional cases; and afterwards
shall offer some remarks on this subject.

                  CASE XXII.
   A man, between thirty and forty years of age, was
salivated for complaints in his head, supposed to be
venereal. There were  two tumours of the scalp; one
a little before the coronal suture, and the other a little
above the posterior superior angle of the left parie-
tal bone. The man's health was greatly reduced by
the course of medicine he had undergone, as well
as  by the disease, which had considerably increased
during the use of mercury. The integuments cover-
ing the posterior tumour had ulcerated; and a probe
could be passed under them, so as to discover a con-
siderable extent of bare and carious bone. The sur-
geon, under  whose care he was admitted  into the
hospital, divided the  integuments,  and perforated
the diseased bone,  which was found separated from
the dura mater. That membrane  also  had a very
morbid appearance, being covered with a soft  sub-

  * Vide Mons. Louis' Memoire, in  the fifth volume of  the
Mem. de l'Acad. de  Chirurgie, and Haller's Disputationes
Chirurgicse. 
             On Injuries of the Head.           67

stance of a dirty reddish colour. On pressing down
the dura mater with a probe, to see if it was detached
to any extent, nearly a table-spoonful of healthy pus
issued from beneath the bone, about an inch behind
the part perforated. The surgeon thought this might
be sufficient to relieve, and therefore deferred making
another perforation. But the man, who had lain stu-
pid, though not irrational, and had subsultus tendi-
num accompanied with great  debility, grew shortly
after delirious; in which state he continued about two
days, when he became convulsed, and died.
   On dissection, purulent matter was found on the
dura mater,  beneath both the carious portions of
bone. The membrane also, which was detached, was
much thickened, so as in some degree to indent the
surface  of the  brain. The pia mater was generally
inflamed;  and a larger quantity of fluid than usual
was found in the ventricles.

                  CASE XXIII.
   An old man was admitted into the hospital for a
complaint of giddiness and pain in his head. Upon
examination, a tumour was perceived over the left
parietal bone, into which an incision was made, and
a good deal of matter discharged. The pericranium
was found to be detached for three inches in length,
and two in breadth.  In the middle of the bare bone,
which seemed to be  dead, and really was so, granu-
lations of a  healthy appearance had sprouted out.
These arose from the  dura mater, and had made
their way through the bone. The patient's health,
which  was  moderately good at the time of his ad-
mission into the hospital, gradually declined;  and,
after about six  weeks, the pain in his head became
particularly  severe. From this time  he became gra-
dually comatose, took no food, and soon died. 
68          On Injuries of the Head.
   On dissection, the dura mater, beneath the cari-
 ous bone, was found detached, and had granulated.
 Much pus lay between the left hemisphere of  the
 brain and the falx; and the whole of the dura mater
 covering the right hemisphere was lined with healthy
 pus, which adhered to its surface, and appeared to
 have been secreted by that membrane.
   The cases of diseased bone, which require perfo-
 ration of the cranium,  have not been sufficiently
 treated of by any  English writer. Mr Pott has,  in-
 deed, noticed the disease and  death  of portions of
 the skull, that succeed to contusions; but he has  not
 sufficiently explained  the  affections  of the mem-
 branes of the brain, which even these diseases some-
 times  occasion.  The  circumstance,  which seems
 particularly to  have  attracted his attention, is  the
 inflammation and  suppuration in the  diploe, which
 proceed from injury done to the bone. The  existence
 of that complaint, however, is easily known;  for
 while there is a fixed pain in that part  of  the bone,
 there is no general inflammation, or but very little,
 of the dura mater. The. disease continues, too, a
 much longer time without producing any  seriously
 bad symptoms, than any disorder of the internal parts
 could do. When matter is formed in the diploe, the
 pericranium will certainly separate from the bone,
 and the external table of the skull will undoubtedly
 perish. In a case so clearly marked, the conduct to
 be pursued is obvious, which is, to remove a portion
 of the external table  with the trephine, so  as to dis-
 charge the matter collected in  the diploe, without
 which no relief can be obtained. I have seen, in seve-
 ral cases, where the operation was performed early,
 that the external table came away within the circle
 of the trephine, the matter was discharged from the
 medullary part of the bone,  and the internal table
remained sound and entire, covering the dura mater.
Granulations soon  arose, and the  patients  got well, 
On Injuries of the Head.           69
with the exfoliation only of a  portion of the outer
table. The mischievous  consequences of delaying
the operation, when once the disease is known, must
be evident; for the matter collected within the bone,
having no natural outlet, will press on every side,
first gradually destroying the diploe, sometimes ex-
tending itself over almost the whole of the cranium,
and at last occasioning the partial absorption of both
tables, so that the skull after death shall be found
perforated with a number of holes, like a piece of
worm-eaten wood. These holes  afford a discharge
to the matter, which not only  oozes  out beneath
the pericranium, but also insinuates itself between
the skull and dura jnater; tiH  at length the  patient
sinks, worn out by the irritation and fever which  this
painful and extensive disease creates; unless, as  it
sometimes happens, he is previously destroyed by
inflammation attacking the membranes of the brain.
  Suppuration of the diploe, and the  death  of a
portion of the bone, are the common effects of inju-
ry done to the cranium; and such a morbid state may
indeed occur at some distance of time from  the re-
ceipt of the injury. But the disease, which the cases
represent, generally arises without an obvious cause.
An affection of the dura mater is almost the necessary
consequence  of such a disease in the  bone. In
syphilis it probably takes place later than in any other
instance; for that disorder attacks the outside of the
skull, which it gradually destroys; the inner table and
the dura mater remain sound till the last. But when,
as in the complaint I am now considering, the whole
bone is involved in disease,  we can no more expect
that the dura mater should remain unaffected within,
than that the pericranium should continue sound
and attached  without; for that  membrane may  be
regarded as  the  periosteum  to the internal table
of the skull. It is well known that, in. general,  the 
70          On Injuries of the Head.

dura mater separates, and becomes  thickened from
a deposition and subsequent organization of coagu-
lable lymph between its layers. This thickening is
sometimes considerable, so as to form a tumour
which causes an indentation in the cerebrum; as hap-
pened in a very remarkable degree in the  case of
the Sieur  le Gallois,  related by M. Louis.* Some-
times the dura mater secretes pus, which being con-
fined within the cranium, produces inflammation of
the brain,  &c. At others, granulations arise from the
irritated membrane, and, making their way through
the bone, form those tumours so well described in the
memoir just  referred to. This took place in one of
the cases  I have related; and  is a  remarkable  in-
stance  of  the power which granulations possess of
removing  bone. The disease,  however, does  not
confine itself to the  part first attacked; for  if  the
irritated state of the  dura mater be not appeased,
thickenings  will  take place in other parts of that
membrane; or the inflammation becoming more  ex-
tended, suppuration may be produced even over the
opposite hemisphere  of the brain, as happened in
both the cases which I have related.
  I do not mean  to say, that in every  case of dis-
eased cranium, even  where both tables  of the skull
are equally affected,  the perforation of the bone is
indispensably  required.  I  know  it often happens
that the bone exfoliates, without any bad effects hav-
ing been produced.
  But surely no surgeon, who perceives the danger
of delay, would hesitate to remove all the dead por-
tion of bone, if symptoms denoting general irritation
of the dura  mater take place.  The best event that
can be  expected, is, that the bone  will at length  ex-

  * See Mem. de l'Acad. de Chirurg. torn. v. It also took
place more  slightly in one of the cases which I have related. 
On Injuries of the Head.           71
foliate without much pain to the patient, or injury
to his constitution. By removing the dead  bone,
and  giving an early and free discharge to any mat-
ter collected beneath it, the irritation which it occa-
sioned will be taken away, the diseased state of the
dura mater will gradually subside, and healthy gra-
nulations arise from its surface; nor will any further
disease occur in other parts of that membrane.  M.
Louis tells us, at the conclusion of the memoir al-
ready quoted, in what manner experience had taught
him to treat fungi  of the dura mater. He  says that
" the whole of the tumour should be exposed, which
" cannot happen till the bony circle which conceals
" its basis, is removed; and that afterwards means
" should be  employed  to destroy the fleshy excre-
" scence."* Although the destruction of the fungus
might be proper for the sake of expedition, and al-
though it can perhaps be attended with no harm, by-
whatever means effected; yet it may not be neces-
sary. Like other animal fungi, it will probably cease
to grow, and soon disappear, when  the  irritation
which occasioned it has been removed.
   In cases of tumours rising from within the skull,
it is of consequence to determine  from what part
they proceed. In general, they will be found to spring
from the dura mater,  and to be  the effect of disease
in that membrane, induced and kept up by irritation.
Surgeons have endeavoured  either to reduce them
by caustic; to restrain them by  pressure; or to take
them off by a ligature or the  knife:  and the excre-
scences have either ceased or continued to grow, ac-
cording  as  the irritation which  gave rise  to  them

  * The excellent effects of such bold but judicious practice
are well shown in a case related in the 9th Paper of Haller's
Disputationes Chirurgicae, vol. i. in which a piece of diseased
bone, six inches and a half in circumference, was removed. 
 72           On Injuries of the Head.

has been removed or not. If the former happened,
the surgeon  has sometimes attributed  undeserved
merit to the means he had employed for the cure.
   Those tumours which come from within the dura
mater, may possibly differ in their kind in different
diseases; and of these I have spoken in a former part
of this essay.
   What I have written must appear very defective,
if it  be considered as regarding the effects of inju-
ries of the head in general. But my intention has
been only to endeavour to illustrate particular points
of practice, by a relation of cases selected from a
considerable number of each kind.
   I shall next relate a case,  in which, though the
brain was not the immediate subject of the injury,
yet it became affected in consequence of it;  and I
think the case deserves to be recorded, not only  on
account of several useful facts and hints relative to
practice which it affords, but also because it may
eventually tend to throw light on the  economy and
diseases of the brain.

                  CASE XXIV.
  A man was gored  in the neck by  a cow.  The
horn entered by the left side of the cricoid cartilage,
and penetrated as far as the vertebras; it then passed
upwards on the bodies of those bones, nearly as high
as the  bottom of the skull; afterwards it came out
behind the angle of the jaw, exposing, and in some
degree injuring the  parotid gland in its passage, and
lacerating the skin of the face as high as the middle of
the ear. In its course it had passed beneath, and torn
the internal carotid artery, and all the primary branch-
es in front of the external carotid artery. The former
vessel was  not, however,  entirely rent asunder, so
that the general course of the artery, and its connex- 
              On Injuries of the Head.          73

 ion with the cranium remained in the usual state. Not-
 withstanding the size of the vessels which had been
 torn,  they did not immediately bleed; the wound
 was therefore closed  and bound up.  The  blood was
 soon observed to flow in  streams  down  the neck,
 nor could any general pressure upon the wound pre-
 vent  hemorrhage. In this  state the  man was con-
 veyed to St.  Bartholomew's Hospital, but he had
 los- a large quantity  of blood before his arrival.
   The patient was laid upon a bed, and before the
 wound was opened, one of the students firmly com-
 pressed the  trunk of the carotid artery against the
 lower cervical vertebra?. We found  upon the first
 inspection of the wound, that this pressure prevent-
 ed any hemorrhage; yet upon the occasional motions
 ef the patient, and upon accidental variations in the
 pressure made on the vessel, the blood gushed from
 the bottom of the wound so suddenly, and in such
 quantities, as to prevent any accurate examination.
 The  man was  very unquiet; he complained much
 of the pressure, and was greatly distressed by a sen-
 sation of suffocation, which compelled him constant-
 ly to  attempt to expectorate. Under  these circum-
 stances our first endeavours were to tie  the more
 superficial arteries; but the tdges of the wound being
 lacerated, the first  ligatures which we endeavoured
 to make tore away portions  of the flesh, and did not
 secure the vessels.
   The situation of the patient  became every mo-
 ment  more desperate; he really seemed choking, his
 extremities became cold, and his pulse was scarcely
 to be  felt: his struggles also, which  could  not be
 controlled, made the pressure on the  trunk of the
aru-ry very precarious. It was deemed necessary to
enlarge the wound to  get at the trunk  of the carotid
arttry, and an incision was made between that ves-
sel and the trachea,  in  a  direction parallel to each
                       K 
74          On Injuries of the Head.
  of these parts.  I  had now the power of passing my
  finger beneath  the trunk of the carotid artery; and of
  effectually compressing  it between that finger and
  my thumb, which was placed opposite to it, upon
  the integuments  of the neck.
    I had now leisure to examine the wound with my
  other hand, and felt that the pharynx had been sepa-
  rated from the vertebrae of the neck, and had fallen
  against the larynx: the irritation of the latter organ
  was probably the cause  of the  sensation of suffoca-
  tion which the patient suffered. There did not ap-
  pear any reason to believe  that  the pharynx  was
  wounded;  for though the patient  was  constantly
  spitting, the  mucus  was not  mixed  with blood.
  Finding that the moment I remitted the pressure of
  the carotid,  the  blood gushed  out from  so many
  orifices, and in such a torrent  from the  bottom of
  the  wound, I resolved to pass a ligature  round the
  trunk of the carotid at  the  part where I  had been
  compressing it, and which was  about an inch below
  its division. This ligature I  thought might be made
  to serve as the tourniquet in amputation, for I could
  with it compress  the artery so as to  prevent the
  wounded parts becoming obscured by blood, and by
  slackening it I might gain information  with regard
  to the situation of the ruptured vessels.
     Should it become necessary at  any time  to tie
  the carotid  artery, I am  convinced that  it may be
  done without much difficulty or danger, even  with-
  out an accurate  dissection of the part. If the inci-
  sion  be made on  that side of the artery which is
  next the  trachea, where no important parts can be
  injured, as  was done  in  the  present instance, the
  finger can then be passed behind the artery so as to
  compress  it.  The vessel being sufficiently bulky
/ and firm, to make its  form and outline distinctly-
  perceptible, a needle may then be passed behind the 
On Injuries of the Head.          75
artery, as near as possible to that  edge of it which
is next  to the internal jugular vein: there can be
little risk of wounding that vessel, or of including
in the ligature the eighth pair of nerves which lies be-
tween them.  In attempting  to secure the qarotid
artery, I passed behind it, in the manner described,
a blunt  hook  with  an eye in the point, and having
previously introduced a ligature into it, I drew back
the instrument and thus inclosed the artery.
  When I compressed the vessel  by  tightening the
knot of  ihe ligature,  I did it slowly,  and with a
watchful attention to  the sufferings of the patient;
for I cannot but suppose  that  had the nerve of the
eighth pair been included, his complaints would have
sufficiently denoted that circumstance.  But the com-
pression of the ligature did not seem to make the
least difference in the general  state of the patient,
whilst it completely prevented  the further effusion
of blood. With a knife and dissecting forceps I then
exposed the  lacerated  vessels,  and  found that the
primary  branches of the external carotid artery had
been torn off from the trunk. By  drawing upwards
the ligature which encircled the trunk of the artery,
I made  the internal carotid tense,  so that  its course
and ruptured state  could be  distinctly  felt.  The
ligature on the trunk  was slackened,  and the gush
of blood further confirmed the  laceration  of the in-
ternal carotid artery.  I had  now  the  alternative of
securing the ligature, which I had already made on
the trunk of  the vessel,  or  of tying the  branches
separately. I preferred the former, and it should be
observed, that the man had now lain ten minutes or
more without any  blood being carried to  the brain
by the left carotid; and during that  period he had
recovered from his extreme faintness, appeared per-
fectly sensible, and  as well as could be expected,
considering that the person had lost so large a quan- 
76          On Injuries of the Head.
tity of blood. The ligature being now made secure,
the wound was brought together by strips of plas-
ter; and  in  this state warm  milk was given  to the
patient to drink, in order to learn what would  be the
effect ,of his efforts to  swallow, and  to ascertain as
far as possible, whether there was any wound  in the
pharynx  or  oesophagus.  The patient swallowed
about a quarter of a pint of this fluid with difficulty,
and with the frequent excitement of coughing.  No
milk however came through the wound, and  I con-
cluded that all the difficulty of deglutition arose from
the unnatural state in  which the muscles of the
pharynx  were placed,  in consequence of their de-
tachment from the vertebrae. These circumstances
happened between 4 and 5 o'clock in the afternoon,
and when I  saw the patient again between 9 ano* 10,
his state  seemed greatly amended.  He had several
times taken warm milk, and the difficulty of deglu-
tition had abated. His  pulse was  now moderately
full and strong, and not very frequent. It therefore ap-
peared, that the  apparently dying state of the man,
which at one time had alarmed us, proceeded rather
from the sudden  discharge of blood, than from the
quantity, however considerable, which had been
lost.  The  patient also appeared  tranquil,  and  per-
fectly rational, and though prevented from speaking
much, he expressed himself satisfied  in this situa-
 tion.
   On the whole I was led to form a favourable ex*
 pectation of the  progress of the case, as far as rela-
 ted to the effects which a  ligature on one  carotid
 would have on the economy of the brain.  I was  next
 morning mortified to learn, that the patient had been
 unquiet  and feverish  during the night; that  he had
 become  delirious; that he  had been several times
 affected  by slight convulsions, which had increased;
 and that^vhen liquids were now given to  him,  they 
On Injuries of the Head.           77
passed through the  wound, and he could  scarcely
swallow any thing.  The pulse of the patient  was
now about 130 in a minute, and hard, and his skin
was hot. He lay inattentive to external objects, but
probably not insensible; for the pupils of  his eyes
were contracted, and when the lids were opened in
order to examine them, he shut them quickly, and,
as it were, impatiently. It had been remarked, that
the left side of the  body was more convulsed than
the right.
   As  we  had  it not in our power easily to give me-
dicine, I introduced a small hollow bougie through
the right nostril into the oesophagus, and immediate-
ly injected half a pint of milk and water, and 60
drops of  tincture of opium; that I  might learn the
effects of that medicine under the  present circum-
stances. The patient shortly after broke out into  a
most profuse  sweat, and the convulsions were qui-
eted by the opium.  The  convulsions,  when  thus
mitigated by  opium, might be described as violent
tremors of the left side of his body, but  the right
 side remained motionless;  to which curious fact  I
 particularly attended.  I placed his  right arm across
 his breast, from which situation it did not afterwards
 stir.  I could not,  however, perceive any distortion
 of the face to the opposite  side, and the  pupils of
 both  eyes were  equally contracted.  When I saw
 the sweat break out  on the taking of opium, and
 the nervous  irritation diminish by its operation,  I
 was then more forcibly struck than I had  been be-
 fore with the similarity of this patient's  situation,
 to that of a person suffering from the effects of con-
 cussion of the brain, some time after the accident,
 when the inflammation often succeeding  to it had
 begun to take place.
    I even questioned if it might not be right to take
 blood from  the  temporal artery, which was  seen 
 78          On Injuries of the Head.

 beating violently.  I thought, however, the  general
 opinion would  be against such  practice,  and I only
 applied a blister to the head. Twenty drops of tine-
 ture of opium were directed to be given to the  pa-
 tient every third or fourth hour, with a view to mi-
 tigate  the  convulsions,  which it  appeared  to do.
 Milk and water was also occasionally given,  in pro-
 portion to the degree  of  perspiration. No remarka-
 ble change of symptoms  took place, but the strength
 of the pulse gradually declined, and at 10 o'clock at
 night he had a severe convulsion fit, and immediately
 after died. His death happened about thirty hours af-
 ter the ligature  had been made on the carotid artery.
   The body  was examined on the  following day.
 The brain appeared to have suffered  a considerable
 degree of inflammation. The vessels  of the pia ma-
 ter appeared  as if they were injected, and in many
 places upon the surface of the convolutions  of the
 cerebrum,  there even seemed an effusion of blood
 producing  that appearance usually termed   blood-
 shot.  There  was a very considerable deposition of
gelatinous substance between the tunica arachnoidea,
 and the pia mater.  The vessels  passing through the
 substance of the brain, though fuller  than common,
 were not particularly turgid. A considerable quan-
 tity of water  of a light brown colour,  and  slightly
 turbid  appearance,  was  found  in the  ventricles,
 whilst the firmness of the  sides  of those  cavities
 sufficiently indicated that the collection had not pre-
ceded the accident. On  examining  the  neck, the
 carotid artery was found to be the only part included
 in the ligature. The superior thyroideal, lingual and
fascial branches of the external carotid,  were torn
 off from the trunk, and the  internal carotid was rent
across, as has been already  mentioned.
  Neither the trunk of the eighth pair of nerves, nor
 the great sympathetic, nor those of the tongue, ap- 
On Injuries of the Head.           79
peared to have suffered injury. The superior laryn-
geal, and the descending branch of the ninth pair,
were the chief nerves injured by the accident. These
circumstances are  mentioned to enable the reader
to form  his own judgment on the probability of the
symptoms which occurred being produced  byr ner-
vous injury or irritation.
  That  the disorder and death  of this man are not
to be attributed to the quantity of blood which he
had lost, appears clearly to me, not only from the
degree of plenitude and power of the vascular sys-
tem which remained, but because I had seen many
patients in the hospital, who had divided most of the
primary branches of the  external carotid artery in
the attempt at  suicide; and  who, after surviving  a
few days,  perished in consequence  of the loss of
blood which they7 had sustained, but with a train of
symptoms very different from those which occurred
in the present instance.
  Some persons may, perhaps,  be inclined to attri-
bute inflammations of the brain to  nervous injury
or irritation.  I have taken notice of all the injury
discoverable  by dissection, and have further to ob-
serve, that we frequently see larger nerves lacerated
in wounds without the production of such symptoms;
and the tranquil state of the patient, till the inflam-
mation  of the brain came on, opposes such an idea.
Upon reflection, I  can form no  other opinion of the
case than that which first struck me, which  is, that
though  the stopping the supply of blood to the brain
did not for several hours produce any apparent de-
rangement in the functions of that organ, yet such
a state was gradually occasioned by it, and which
was attended, like the effects of concussion of the
brain, with inflammation.  It further appeared, that
when the combined effects resulting from the de-
rangement, and the  inflammation were manifested 
80            On Injuries of the Head.

together, the state of the patient much resembled
that of a person who had suffered concussion.  Mi-
asmata which impair and disturb the energies of the
brain, occasion fever and inflammation of that organ;
so that there appears to me nothing wonderful  in
the inflammation which occurred in the present in-
stance.  It is right, however,  to mention,  that the
carotid artery has  been  since  tied in this city, by
Mr. Travers, without such effects as I have descri-
bed taking place.
  Mr. Travers has obligingly communicated to me
the following particulars of this case, which I  here
insert:
  " The case  to which  you refer, I consider to be
" an example of the  disease which Mr. J. Bell has
" denominated Aneurism  by Anastamosis.   It was
" a tumour, resembling  the Nsevus, of a livid co-
" lour, and compressible, projecting from the orbit,
" pulsating formidably,  and gradually working the
" eye out of its socket.  Pressure aggravated the
" pulse, and gave insupportable pain. In examining
" it, I put my thumb on the carotid of the same side,
" and the pulse instantly ceased. Seeing that it grew
" fast, I prevailed on the patient, a woman of eight-
" and-thirty, to allow me to tie the common carotid
" artery, which I  did last May twelvemonth.  She
" suffered nothing more than I have usually  seen
" follow  other  operations  for aneurism, and was
" abroad at the end of a month. The tumour ceased
" to pulsate, but for  some time retained a vibratory
" thrill, which it has since totally lost.  It likewise
" shrunk to about half its former size,  and  became
" solid and incompressible, in which  state it has
" since remained.  I may also add,  that the patient
" was greatly afflicted with pain in the head prior
" to the operation, and  that it has completely re-
" moved that pain.'? 
On Injuries of the Head.           81
   The different states of the two sides of the body,
in the case which 1  have last related, ought not, I
think, to pass without further notice.  Although the
right side could not be positively said to be paraly-
tic, yet, in my opinion, it approached to that state.
   It has been already observed, that a double con-
struction  might be put upon the symptoms; yet as
the inflammation of the brain was equal on both sides,
we might naturally expect the whole body to suffer
equally.  Should the  state  of the right side have
been, as  appears  most  probable, an approach to a
state of paralysis, it must surely be considered as
peculiarly curious. An effusion of blood in the left
hemisphere of the brain would  affect the  opposite
side of the body  in the  same manner, that cutting
off the  supply  of blood to the left side appears in
this  instance to have done.  I forbear to speculate on
this  subject: the fact which I have mentioned seems
to deserve notice, and though at present it must
stand alone, it may receive  future confirmation, and
when thus supported, be applied to the elucidation
of physiology.
   I  have thought it  right to record  this case, not
merely  because it  is curious, but because it affords
some useful practical hints, as to the conduct to  be
pursued when a person has divided the large primary
branches of the carotid artery in an attempt at sui-
cide. It  may  be allowable also to mention, in rela-
tion to this latter subject, the great advantages which
appear to me to arise from  the immediate introduc-
tion  of a small  elastic catheter, passed through the
right nostril, down the oesophagus, nearly  as far as
the stomach, (in the  manner practised by Desault,
in the cure of  a person  wounded by a pistol ball,)
when the pharynx  or larynx are injured.
   A patient in such a state is  not under the neces-
sity of frequently  swallowing nourishment,  which 
82            On Injuries of the Head.

act tears open the wounded parts, and causes inflam-
mation  in them, and produces such a secretion of
mucus as excites almost constant cough, increasing
the disturbance of the wounded parts.
   The  introduction of a small elastic catheter may
be easily accomplished in the first  instance, though
not  without  difficulty, after the sensibility of the
parts has been increased by  inflammation; and from
the benefit I have seen derived from it I should not
hesitate to do it in all cases  of extensive wounds of
the throat. 
SURGICAL OBSERVATIONS
 On the ill Consequences sometimes succeeding
                 to Venesection.

 1  HE public is  much indebted to Mr. Hunter for
a judicious account of the appearance and effects of
the inflammation of the vein, which sometimes suc-
ceeds to venesection. The ill consequences  which
occasionally follow that operation are numerous and
dissimilar; and they, have never I believe been clearly
and collectively stated and  explained. The cases
recorded of such complaints are dispersed in various
periodical publications;  and frequently, the  nature
of the disease appears not to have been understood
by the person who relates its history. In proportion
as I have seen more varieties of these diseases, my
own knowledge of them has become more clear and
simple; and as I believe, I can communicate  useful
information, I have ventured to offer to the  public
the following  observations and opinions. I have
been also incited  to this task, because  the account
in his System of Surgery, which Mr.  Benj. Bell has
given of these complaints, appears to me confused;
and the practice recommended imjproper. I am hurt
to censure the works of any author, but this either
must be done, or injurious error must remain un-
contradicted.
  When from want  of  attention,  or  from other
causes, the wound inflicted in venesection does noi! 
84
On the Occasional
speedily unite, the motions of the arm occasion at-
trition of its sides against each other, and inflamma-
tion  of the wounded, or contiguous parts  is likely
to ensue. I shall give a brief account of these diffe-
rent  complaints, in the order in which I believe they
most frequently happen.
 Oflnflammation of the Integuments, and subjacent
               cellular Substances.
  The inflammation and suppuration of the cellular
substance in which the vein lies, is the most frequent
occurrence. Of this every surgeon must have seen
repeated instances;  they may also have  remarked,
that on the subsidence of this inflammation, the tube
of the vein is free from induration: neither does the
state of any of the  surrounding parts indicate their
previous participation in the disease. The nature of
every excited  inflammation  will vary as the cause
which produced it, and the constitution of  the pa-
tient shall determine; it will  therefore be unneces-
sary to particularly notice the varieties of its appear-
ance.  Sometimes the inflammation will be  more
indolent, and will  produce  a circumscribed  and
slowly suppurating tumour.  Sometimes it will  be
more  diffused, partaking more of the nature of ery-
sipelas:  and sometimes  its violence, and rapid ter-
mination, will evidently distinguish it to be a phleg-
mon.
  If the lancet with  which the patient was bled
should have been bad; if it lacerated rather than  cut
the parts through which it passed; if the constitution
of the patient be irritable; and more particularly, if
sufficient attention be not paid to procure the union
of the divided parts, but  the motion of  the arm be
allowed: the irritation, which the friction of the  op- 
         ill Consequences of Venesection.         85

~posite edges of the wound must occasion, will most
 probably excite inflammation. The treatment pro-
 per to be pursued in this complaint is manifest, and
 distinguished by no peculiarity;  I shall therefore
 postpone what I have to say on that subject, until
 I have noticed the other varieties of these diseases.
     Of Inflammation of the absorbing Vessels.
  The next  frequent complaint which I have seen
is inflammation of the absorbents: it however some-
times accidentally happens, that one surgeon meets
with many cases of a similar nature, so that were he
to judge merely from his own observation, he might
conclude that disease to be common, when the col-
lected experience of others would  determine it to
be a rare occurrence.  I  am inclined to suspect, that
my observation has been thus  partial,  since Mr.
Hunter has not publicly noticed this complaint.  I
think I  cannot give a  better history of the com-
mencement, appearances, and event of this disease,
than by relating three cases, of the circumstances
of which I took an account. It is right, however, to
mention,  that I have  seen two  others, of which I
took no minutes; and which I am unwilling to relate
only from recollection.


                     CASE.
   A lady was bled  in the vena mediana basilica; the
wound did not heal, nor was sufficient attention paid
to preserve the arm quiet.  Eight days afterwards, I
was consulted, in consequence of the patient being
alarmed,  by the  appearance of two swellings; one
was situated about the middle of the arm, over the
large vessels, the other on the  fore-arm, about the 
86
On the Occasional
 mid space between the elbow and wrist, in the inte-
 guments above the flexor muscles. The upper swel-
 ling measured rather more in circumference than an
 egg, the other was of smaller dimensions; they were
 not very painful, they were moderately  firm in their.
 texture, and so  exactly  resembled those tumours
 which form round irritated lymphatics, that no doubt
 could be entertained of their nature.  The  orifice
 made by the lancet was not healed, the  integuments
 for about one fourth  of an inch surrounding it, were
 in a slight degree  inflamed, and  thickened. No in-
 duration of the venous  tube could be distinguished,
 either at this time, or after the subsidence of inflam-
 mation.
   The account which I obtained from  the patient,
 of the attack of this complaint, was, that the wound
 inflamed,  became  painful, and discharged  matter;
 that the gentleman by whom she was bled had dress-
 ed it with salve, but did not restrain her from using
 her arm; that  about  five days after the operation,
 she had felt  pains shooting from the orifice, in lines,
 up  and  down  her arm, and upon pressing  in the
 course of this  pain, its degree was increased. This
account induced  me to examine the arm attentively,
and I could  plainly feel two indurated  absorbents,
leading  to the superior  tumour, but could not  per-
 ceive any extending to  the lower one. The wound-
 ed part  was  dressed  with mild salve;  a bread and
milk poultice was applied to both tumours, and the
arm was supported by a sling, and retained without
 motion  or exertion. The integuments  surrounding
the orifice lost their disposition to inflame, and the
wound  gradually healed; during  five days, the tu-
mours underwent no  evident alteration;  the poultice
was changed to one of  bread, water, and a solution
 of acetate of lead, under which they quickly dimi-
nished and dispersed. 
ill Consequences of Venesection.        87
                     CASE.
  A man about 35 years of age, was admitted into
St. Bartholomew's Hospital, under the care of Mr.
Pott: he had been bled in the country, about a fort-
night before his admission; since that time he had
been extremely ill, and was with difficulty conveyed
to London. The state in which he was admitted, I
shall describe: His  whole arm was greatly swollen,
the  wound made by the lancet was not united, the
parts immediately surrounding it did not seem to be
affected by distinct inflammation; but partook of the
general tumefaction. Two large abscesses had form-
ed, one situated near the inner edge of the biceps
muscle, about the middle of the arm; and the other,
on the inside of the fore-arm. The patient told us
that he been bled, on account of a pain in his side;
that the orifice, instead of healing had festered, that
he  had for a time pursued  his daily employment,
notwithstanding the pain which he suffered; that this,
however,  soon became too  violent to be endured;
the swelling and pain extended towards the armpit,
where the glands became  enlarged. Inflammation
next attacked  the fore-arm,  and after suffering ex-
treme  pain and fever, these abscesses had formed,
and since that time his illness and pain had in some
degree abated. Mr. Pott opened both  abscesses,
and directed  his whole arm to be covered with a
poultice.  The patient was kept in bed, and medi-
cines likely to alleviate inflammation were prescribed.
In about four  weeks, the arm was reduced nearly to
its natural dimensions.  The orifice, through which
he was bled, had united, and the wounds by which the
abscesses had  been opened were nearly healed. The
parts surrounding  them, however,  still remained
thickened, and also all the integuments  on the in- 
88
On the Occasional
side of the arm.  In these  thickened integuments,
three chord-like substances,  evidently absorbents,
were  to be distinguished;  they extended from the
superior abscess, and  again  above this, two were
continued even to the axilla. Two  other indurated
absorbents also were extended from the punctured
part to the inferior  abscess. The  punctured  vein
being attentively examined, was found to be a little
thickened, both above and below the orifice; it  had,
however,  no  connexion with these chord-like sub-
stances, which were superficial, and their appear-
ance, course,  and every other circumstance, clearly
showed them  to be indurated absorbents. The hard-
ness of these vessels,  and  of the integuments had
much  diminished, and  the patient had regained the
strength of his arm, before he was discharged from
the hospital.

                     CASE.
  A poor man was bled,  in one of the bleeding-
shops of this city. His operator dipped some rag in
the blood  which he had taken, applied it to  the ori-
fice, and bound it on the arm with  a tape. The pa-
tient felt  much pain in the wound, even from the
time of the operation,  and  experienced much diffi-
culty in moving his arm. As the rag stuck closely
to the orifice,  he was unwilling to remove it; how-
ever, on the third day, the  violence of the pain in-
duced him to take it  off:  he then found the parts
surrounding the puncture inflamed and  hardened.
The patient had also suffered much pain, which ex-
tended towards the axilla, and  one  of  the glands
there was  swollen.  He anointed the arm  with some
ointment,  but the pain so increased, that he could
scarcely bear  it to touch his side. The integuments
about the  middle of the arm were elevated by a tu- 
           ill Consequences of Venesection.       89

 mour, which was painful when pressed; the base of
 it was not circumscribed, but was gradually lost in
 the surrounding parts. In this situation he request-
 ed my advice.  I gave him some mild salve to dress
 the wounded part; I directed him to keep constantly-
 applied to the integuments, covering the inflamed
 lymphatics, some cloths wetted with the cold solu-
 tion of acetate of lead, to keep his arm completely
 supported by a sling, and to take some gently pur-
 gative medicine.
   This he did, the inflammation gradually subsided,
 and the wound made by the lancet healed.
   It  might be suspected, that in the cases which
 have, been related, the lancet which was employed
 Was envenomed; and that the absorption of virulent
 matter was the exciting cause of  inflammation:  the
 descent of the disease to the inferior absorbents, in
 the two first  cases, opposes that opinion; and  it is
 further invalidated by the observations which I shall
 proceed to offer.  Since the structure and functions
 of the absorbing vessels have become so well known,
 the attention of medical practitioners  has been di-
 rected to their diseases, and much novel information
 has been  acquired.  That which  relates to the pre-
 sent subject, I shall endeavour briefly to state. Phy-
 siology shows  to us, that the absorbents possess
 much sensibility. Practical observation strengthens
 this opinion:  the celerity with which these vessels
 inflame, when  they have imbibed noxious matter,
 and the pain which is suffered in consequence, suffi-
ciently prove this circumstance.  Their frequent in-
flammation, in consequence  of disturbance of the
general constitution, may  be however regarded as
an additional argument. A common cold produces
a painful tumefaction of the absorbent glands;  and
in some fevers, these parts are particularly obnoxi-
ous to disease.
                       M
V 
90             On the Occasional
   There is another  circumstance, which  deserves
attention;  when the absorbents become inflamed,
they quickly communicate this disease to  the  cel-
lular substance, by  which  they are  surrounded.
Most surgeons have remarked these vessels when
indurated,  to appear  like small chords, perhaps of
one-eighth of an inch in diameter; this substance is"
surely  not the slender sides of the  vessel thus sud-
denly  augmented in bulk, but an induration of the
surrounding cellular substance, to which the irrita-
ted vessel  has communicated  inflammation.  The
formation of a common bubo is another instance of
the power, which these vessesl possess, of involving
the surrounding parts in their disease; at first one'or
two glands are found to be inflamed, but they soon
become undistinguishable, in the general inflamma-
tion of the surrounding substance. This inflamma-
tion either is dispersed, or it terminates in suppura
tion: and on the subsidence of the general tumour,.
the originally diseased glands again become distin-
guishable.
   I  now  wish to  show,  that  their inflammation,
in consequence of  local injury, is  deducible from
two causes:  one* the absorption of acrid matter; and
the other, the effect of irritation of the divided tube.
Of the inflammation arising from the absorption of
morbific matter, every one is  apprized; but  that
which is the effect  of irritation, has been  less re-
marked.
   When virulent matter is taken up  by the absor-
bents, it is generally conveyed to the next absorbent
gland;  where, its progress being retarded, its  stim-
ulating  properties  induce  inflammation; and fre-
quently no  evident disease of the  vessel through
which it has passed can be distinguished. The  ab-
sorption of syphilitic and cancerous  matter affords 
          ill Consequences of Venesection.        91

frequent proofs of this assertion. There are, indeed,
some poisons so acrid, that the vessel which admits
them inflames throughout its whole extent; yet  still
the glands are principally affected. When inflamma-
tion of the absorbents happens in consequence of
irritation,  that part of the vessel  nearest the irrita-
ting cause generally suffers most: whilst the glands,
being remotely situated,  partake less of the inflam-
mation. The inflammation is also of a different kind,
and, I think, can be  discriminated:  when it arises
from poison arrested in the part, the gland  is  first
indurated, and a phlegmonoid inflammation follows;
but if irritation be the cause of its enlargement, the
tumefaction  more speedily  takes place, the gland
is more painful in its early  state, but has less  ten-
dency  to  suppurate;  the  enlargement more resem-
bles that of the  lymphatic glands of the neck, which
is the consequence of taking cold.
  When the inflammation arises from  irritation,  it
will be expected, and I believe it will be found, that
the continuity of the vessel will be apparent: but it
does not follow, that  the greatest disease  will be
immediately  adjoining that part which has sustained
the injury. The cases which have been related show
that inflammatory tumours often form in the middle
of the arm and forearm, when the wound of the absor-
bent is at the bend  of the  elbow.  Were it  neces-
sary, I could relate several cases where such tumours
were formed from injuries done to the fingers, or in
consequence of fretting ulcers of the leg. When  they
arise from the  latter cause, it might be  supposed
that some acrid matter had been imbibed;  yet,  I
think, in that case, we should  find  the glands the
principal  seat of the disease. It has been proved, that
the absorbents frequently inflame far below the part
where the vessel has sustained an injury, and where 
92
On the Occasional
the inflammation  could not be  occasioned  by ab-
sorption. These observations I thought it right  to
insert, to illustrate the cases  which have been rela-
ted; and also to excite more general attention to the
diseases of these important vessels.
           Of Inflammation of the Vein.
  After the account which Mr. Hunter has given
of the inflammation of the vein, (in the Medical and
Chirurgical Transactions) no additional information
from me will be expected, nor is it perhaps required.
If the wound of the vein does not unite, an inflam-
mation of that vessel will  probably follow; which
will vary  in  its degree, in its extent, and in the
course which it pursues. One degree of inflamma-
tion may occasion only a slight  thickening  of the
venous tube, and an adhesion of its sides; more vio-
lent inflammation may be attended with the forma-
tion of more limited, or more extensive abscesses;
the matter of which may sometimes mix itself with
the circulating fluids, and produce dangerous conse-
quences: or it  may be circumscribed by  the thick-
ening and adhesion of the  surrounding parts, and
then like a common abscess make  its way to the
surface. When the inflammation of the venous tube
is extensive, it is, indeed, very probable, that much
sympathetic fever will ensue; not merely from the
excitement which  inflammation  usually produces;
but also, because irritation  will be continued along
the membranous lining of the vein  to  the heart. If,
however, the effect of the excited inflammation has
luckily been to produce adhesion of the sides of the
vein, at some  little distance from the wounded part,
the inflammation will here cease; its further transmis-
sion will by the adhesion be prevented. The effect of 
ill Consequences of Venesection.       93
adhesion of membranes, in preventing the extension
of inflammation along their surfaces, is frequently ap-
parent, and has been well explained by Mr. Hunter
on another occasion. In one case, Mr. Hunter ap-
plied a compress on the inflamed vein, above the
wounded part, and he thought that he succeeded in
producing  adhesion, for the inflammation extended
no further. In those cases, where  the inflammation
does not continue  equally in  both  directions, but
descends along the course  of the vein, it is probable
that its extension in the other direction is prevented
by adhesion.
  I have thus briefly  and imperfectly transcribed
Mr. Hunter's opinion,  that the present Essay might
not be altogether  deficient in information  relative
to this subject. I have seen but three cases where an
inflammation of the vein succeeded to venesection;
they,  however, confirm the foregoing  observations.
The vein did not in either case evidently suppurate.
In the first, about three inches of the tube inflamed
both above and below the orifice; it was accompanied
with much tumour, redness, and pain of the cover-
ing integuments,  and  much fever; the pulse was
rapid, and  the tongue furred. After the inflammation
had terminated, and all tumour  had subsided, the
vein  did not swell when  compression was  made
above the diseased part. The  second case was of  a
similar nature, but less in degree. In the third case,
the inflammation was not continued in the course of
the vein towards the heart, but extended as low as
the wrist. I have no doubt, but that adhesion of the
sides of the vein was the cause which prevented the
extension of the disease, equally in both directions.
The nature of a disease being known, the treatment
is commonly evident. The diminution of inflamma-
tion in a vein is to be attempted by the same general
means as in other parts. As the membranous  lining 
94
On the Occasional
of the vein is continued to the heart, and as inflam-
mation very speedily spreads along such surfaces,
unless  prevented by adhesion; the application of a
compress at some distance from the punctured part,
iii order to unite the inflamed sides of the vein ap-
pears to be particularly judicious.
   I am induced  to  suppose, a case may  occur in
which the vein may suppurate, and in which a total
division of the  tube may be  proper practice;  not
merely to obviate the extension of the local disease,
but to prevent the collected pus from mixing with
the circulating fluids.
    Inflammation of the Fascia of the Fore-arm.
  As far as my observation has extended, the next
frequent ill consequence which succeeds to venesec-
tion performed in the arm, is an inflammation of the
subjacent fascia. When  this  complaint occurs, it
perhaps arises not merely from the contiguity of the
fascia to  the  punctured  and irritated parts, but it
is probable that it was wounded by the lancet in the
operation. I hope that the cases which I shall relate,
and those to which I can refer the reader,  will con-
vey sufficient information of the symptoms and ef-
fects of this disease.

                     CASE.
  A man, aged 40, was admitted  into St. Bartholo-
mew's Hospital, under the care of Mr. Pott: he  had
much pain and difficulty of moving his arm, in con-
sequence of inflammation succeeding to phlebotomy.
The wound inflicted in the operation was not healed;
the surrounding integuments were not much infla-
med, but he  could neither extend his fore-arm nor 
            ill Consequences of Venesection.       95

  his fingers without great pain.  The integuments
  of the fore-arm were affected with a kind of erysipe-
  las; when slightly touched, they were not very pain-
  ful, but when more forcibly  compressed, so as to
  affect the  inferior  parts, much pain was suffered.
  The patient complained of pain, extending towards
-  the axilla,  and also towards the acromion,  but no
  tumour of the arm in either direction was percepti-
  ble. A poultice was applied to the arm, opium was
  given at night, and aperient medicines  were occa-
  sionally prescribed. The pain in the arm increased,
  and it was attended by much  fever. After a week
  had elapsed,  a small  and  superficial collection  of
  matter took place a little below the internal condyle;
  this being opened, but little pus was discharged, and
  scarcely any  decrease of tumour or pain followed.
  About ten days afterwards, a  fluctuation of matter
  was distinguished below the external  condyle; an
  incision was here also made,  which penetrated the
  fascia of the fore-arm.  Much matter immediately
  gushed from the wound, the swelling greatly subsi-
  ded, and the future sufferings of the patient were
  comparatively of little consequence. This opening-
  was, however, inadequate to the complete discharge
  of the matter, which had  probably been originally
  formed beneath the fascia in the course of the ulna;
  its pointing at the upper part of the arm, depended
  on  the tenuity and comparative non-resistance of
  the fascia-at that part. The collected pus descended
  to the lower part of the detached fascia, a dependent
  opening  for its discharge became necessary, after
  which the  patient recovered, without any circum-
  stance  being  observed  worth relating.  The  case
  which I have just related, and that in which two large
'  abscesses had formed, attended with indurated absor-
  bents, occurred nearly at the same time at the hos-
  pital, and they both  fell under the care of Mr. Pott, 
 96             On the Occasional
                             i
 In the lectures of that eminent surgeon, I had heard
 dangerous and fatal consequences attributed to the
 injury of  a nerve in venesection, but  I learned no
 other distinction of cases. These cases first excited
 my attention to. this  subject,  and as far as I know,
 such discrimination as that which I now offer to the
 public has not been attempted.
   I have seen one other case  of inflamed fascia, but
 I neglected to take notes of the symptoms; I there-
 fort- can only say, that at the time they appeared so
 clearly to characterize  it? that I entertain no doubt
 of its nature. No inflammation of the vein or ab-
 sorbents appeared, the  integuments were not much
 affected,  but the patient complained  that his arm
 felt as if bound or compressed, and that he suffered
 much pain if he attempted  to  extend it. The, in-
 flammation subsided without  the formation of mat-
 ter; and after much time had elapsed, the pliability
 of the arm was gradually regained. I the less regret
 my deficiency of experience  on this  subject, as I
 can refer  the  reader to the second volume of the
 Medical Communications;  he will there meet with
 two cases, which 1 believe he will acknowledge to
 be inflammations of the fascia; attended, however,
 with some peculiarity of symptoms.
   The first case is related by Mr. Colby of Dor-
rington, in Devonshire;  the other by Mr. Watson.
 The inflammation of the fascia, in the latter case, was
followed by a permanent contraction of the, fore-arm.
From this  case,  I think we  have acquired useful
knowledge: should a similar contraction of the  fore-
arm from  a tense state of the fascia in future  occur,
it seems reasonable to suppose, that it may be com-
pletely relieved  by detaching the  fascia from the
tendon of the biceps, to which  it is naturally  con-
nected.  This, I conclude, was the cause of the per-
fect restoration of free motion, in the case first  rela- 
          ill Consequences of Venesection.        97

ted by Mr. Watson.  On this subject I will not en-
large, but submit the  opinion to the judgment of
the reader.
  The treatment of an inflamed fascia, the conse-
quence  of venesection,  has in  it  no peculiarity.
Doubtless, those general means which are reductive
of inflammation  should be employed. Of local treat-
ment, quietude of the limb, and a state of relaxation
of the inflamed part, will tend to lessen disease; but
as soon as some abatement of inflammation is pro-
cured, the extension  of the forearm  and  fingers
ought to be attempted, and daily performed, to ob-
viate that contraction which might otherwise ensue.
   Of the ill Consequences succeeding to a wounded
                     Nerve.
   In order to complete, in some degree, this Essay,
I  have  attempted to discuss  the  present  subject;
though, I acknowledge, I have no practical informa-
tion to communicate. I believe  these accidents to
be of rare occurrence,  since those of my  medical
friends, to whom I have applied for information, had
never seen a case, the symptoms of which they could
decisively pronounce to arise merely from an  injur-
ed nerve.  Mr. Pott in his lectures used to say, that
he had seen two cases, in which the patients  had suf-
fered distracting pain,  which was followed  by con-
vulsions, and other symptoms which could only be
ascribed to nervous irritation.  He  attributed these
effects to a partial division of the nerve, and recom-
mended its total division as a probable remedy. Dr.
Monro, I am informed, relates similar cases, in
which such treatment has proved successful.  I rely
on the discrimination of these eminent  men, yet I
feel convinced, thai the greater number of surgeons- 
98
On the Occasional
have been deficient in distinguishing these diseases.
A wounded nerve, acting as  a cause, must always
produce specific and  characteristic symptoms  and
effects. I need not insist on the necessity of discri-
mination in these complaints; those who have  de-
scribed the symptoms resulting  from an injured
nerve, have represented them as at all times immi-
nently hazardous,  and frequently  fatal. An opera-
tion is here demanded; from it we have reason to
expect immediate mitigation of the patient's suffer-
ings,  and his future perfect  restoration. Yet  this
operation  in any  other  of the  complaints before
treated of would be unnecessary, and perhaps detri-
mental.
  I shall arrange what I have to say on this subject
in the following  manner:  First, I shall explain what
nerves are subject to injury; secondly, I shall investi-
gate what are the effects likely to be produced by such
an accident; and thirdly, I shall inquire, what means
are most likely to afford relief.
  First, The two cutaneous nerves are those which
are exposed to injury. I dissected  them in several
subjects  with attention,  and  found some irregu-
larity  in their distribution; most frequently  all their
branches pass beneath the veins, at the bend of the
arm;  but sometimes, although the principal rami
still go beneath these  vessels, many small filaments
are detached before them, which it is  impossible to
avoid  wounding  in phlebotomy. As I believe many
surgeons retain  but  an indistinct  remembrance of
these  nerves, and as I have never seen them accu-
rately depicted, in any anatomical book, I thought I
should do an acceptable service, by giving an engrav-
ing of them. I therefore made two drawings of them:
one exhibiting their most simple course;  the other,
their most complicated distribution. These, I con-
clude, are the only nerves liable to injury. It may be 
ill Consequences of Venesection.        99
suspected, that the median nerve might occasionally
be wounded; but its situation, I think,  makes this
opinion improbable. If, however, a doubt should be
entertained  on this  subject, an attention to symp-
toms will soon dispel it.  When a nerve is irritated
at any part  between its origin and termination, a
sensation is felt as if some injury were done to the
parts which it supplies: if, therefore, the cutaneous
nerves  were injured, the integuments  of the fore-
arm would seem to suffer pain; but if the median
nerve was wounded, the thumb and two next fingers
would be affected with pain.
   By referring to the plate, it will be seen, that if
the patient be bled in the vena mediana basilica, the
branches of the internal  cutaneous  nerve are expo
sed to injury; or, if the vena mediana cephalica be
opened, the  branches of the external cutaneous
nerve may be wounded.
   Secondly, I  wish to inquire what are the ills like-
ly to arise from a wounded nerve. Whoever reflects
on the wonderful minuteness of the nervous fibrils,
and considers  their perfect distinctness from  each
other, although connected  by a common covering
of cellular substance, will scarcely imagine a partial
division of a nervous fibril.  If I sought to  express
myself strictly on this subject, I should speak of  a
partial division of a packet of nerves.  But I  shall
use  the commonly adopted language, and call those
chords nerves, which are really composed of multi-
tudes of separate  nerves. I first beg leave to exa-
mine the opinion which  has prevailed, of  a  nerve
being partially divided. Admitting that a nerve be
partially divided, would it not, like a tendon, or any
other  substance, unite?  I think there can be no
doubt but that it would.  I am induced to this opi-
nion, by considering, that nerves of equal size with
the  cutaneous nerves of  the arm are distributed  in 
100
On the Occasional
considerable numbers throughout the body.  In the
many operations performed, and in the wounds daily
occurring, I think  it would be  strange  if a partial
division of a nerve should not happen; yet no pecu-
liar symptoms are observed usually to ensue.  The
pain which some people suffer from bleeding, in my
opinion, indicates an injury done to a nerve.  If the
reader refers to the plate, he will perceive,  that in
some cases it is impossible to avoid dividing branch-
es of nerves in phlebotomy, as sometimes they pass
before the vein.  These branches are so exposed,
that I should  be  surprised if  they did  not many
times suffer a partial division.  Surely, however,  a
half divided nerve would unite  without causing  a
general derangement of the nervous system.   Yet  it
is possible that an inflammation of the nerve may
accidentally ensue, which would be aggravated,  if
it were kept tense, in consequence of imperfect di-
vision.  In the cases related by  Mr. Pott and Dr.
Monro,  I believe, that some days elapsed after the
infliction of the injury, before any alarming derange-
ment of the nervous system ensued.  Inflammation
of the surrounding parts also appeared.  These ob-
servations make it evident to me, that the disease
consists in inflammation of the  injured nerve, in
common with  the other wounded parts;  and this in-
flammation,  I can conceive, to happen with  or with-
out a total division of the nervous chord. I should
consider a case of inflamed nerve as an object  of
great curiosity. Every one, I think, will admit, that it
is likely to  communicate dreadful irritation to the
sensorium; and every one will perceive, that a cure
will probably arise from intercepting its communica-
tion with that  important part.
   Thirdly, I proceed to inquire  what is the most
probable method of relieving the effects arising from
an  inflamed  nerve. The general  opinion is,  that the 
ill Consequences of Venesection.      101
nerve is only partially divided, and that a total divi-
sion would  free the patient from a continuance of
his sufferings. Mr. Pott supposed that the wounded
nerve was situated at one or the other extremity of
the wound which had been made in  the vein; he
therefore proposed to divide it totally,  by enlarging
a little the original orifice.  It is however possible,
that the point of the lancet might injure a nerve ly-
ing beneath the vein. This will be easily understood
by referring to the plate. Mr. Bell directs an exten-
sive transverse incision, to be made through the
original wound; but if the injured nerve be situated
at the upper extremity of the orifice, it will remain
unaffected by this operation.  Mr. Bell also advises
the incision to be continued to the bone; but this
appears to me dangerous and unnecessary.
   If the injured nerve be inflamed, I think it doubt-
ful,  whether even a  total division of it, at the infla-
med part, would  effectually relieve the general ner-
vous irritation which the disease has occasioned. To
intercept the  communication of the  inflamed nerve
with the sensorium, does however promise perfect
relief.  This intention can only be accomplished, by
making a transverse incision above the orifice in the
vein. The incision need not be very extensive, for
the injured  nerve must  lie within the  limits of the
original orifice, and  it  need only descend as low as
the fascia of the fore-arm; for all the filaments of the
cutaneous nerves lie  above  this fascia.  The  vein
which had been opened, and some filaments of the
cutaneous nerves, are all the parts of consequence
which will be divided in this operation.  The prox-
imity of the division of the nerve to the vein,  must
be regulated by the  supposed extent of the disease.
However, as the  extent  of the  inflammation of the
nerve is uncertain, I submit it to the consideration
of surgeons, whether it  may not be adviseable, in 
102
On the Occasional
some cases, to divide either of the cutaneous nerves,
still more remotely from the injured nerve.
  I find little difficulty in detecting the trunk of these
nerves in the dead subject, and I should suppose but
little would occur in the living state; for the com-
pression of the tourniquet would prevent  any ob-
scurity which hemorrhage might cause. 
ill Consequences of Venesection.       103
   General Observations on the ill Consequences some-
          times succeeding to Venesection.

   I think it very probable that these diseases would
 less frequently happen, did not the situation of the
 veins usually opened contribute to their occurrence.
 The common offices of life so constantly demand the
 employment of the arm, that its motion becomes al-
 most inevitable. Unless the orifice made by the lan-
 cet has been  attentively  closed,  the effect of this
 motion will  be to separate the edges of the wound
 from each other, and to prevent their union by the
 first intention. Some slight degree  of inflammation
 will ensue; the continuance of motion of  the arm
 causes a friction of the inflamed surfaces against each
 other, and thus the disease is increased. Under these
 circumstances, if the constitution of the patient be
 irritable, the inflammation will extend itself, although
 it may still be confined to the cellular substance, and
 integuments;  or, perhaps, it may be transmitted to
 that part which has sustained most injury in the ope-
 ration.  The vein, the absorbents, the fascia, or the
 nerve, may  in  that  case  suffer  peculiar disorder.
 Although the injury done by a bad lancet may con-
 tribute  to the production of  disease, yet I  think it
 probable, that a patient improperly bled,  would sus-
 tain no  injury, if me treatment  of the  wound was
judicious;  whilst another, on whom the operation
 had been dexterously and well performed, would be
 liable to these ill consequences, if the proper atten-
 tion to unite the wound was neglected.
   In the account given of these diseases, they have
 been represented as they occurred separately; doubt
 less, in some  cases, they may  be combined. 
104          On the Occasional, £sfc.
  The principal curative indications appear to be,
to mitigate the  inflammation about the orifice,  and
to preserve the  arm supported in a motionless state.
I need not enlarge  this account, by  describing the
modes of appeasing inflammation and irritation, as
they are well known to every  surgeon. 
 
 
   Explanation of the Plate.

A  Vena basilica.
B  Vena cephalica.
C  Vena mediana.
D  Vena radialis.
E  Vena cubitalis.
F  Vena mediana basilica.
G  Vena mediana cephalica.
H  Nervus cutaneus internus.
I   Nervus cutaneus externus.
O 
 
SURGICAL  OBSERVATIONS,
               ON EMPHYSEMA.

JMUCH praise is, in my opinion, due to Mr. John
Bell, for the clear and spirited description which he
has given  of the  state of the lungs in one kind of
emphysema.  The following case is related, to cor-
roborate  his  remarks, and  also  to lead to others
which I am desirous of offering to the public on the
subject of emphysema in general.

                    CASE.
  A poor woman, about forty years of age, was run
over by a mail-coach, one of the wheels  of which
passed lengthwise over  her  back,  and fractured
several of her ribs on the right side. When brought
to the hospital, she breathed  with much difficulty,
and  an emphysema of the  integuments had taken
place. An opening was made through the skin to
let out the air; and the emphysema  did not after-
wards spread. The patient was bled largely; but the
difficulty of breathing had increased to the third day,
at which time 1 first saw her, in company with Mr.
Harvey, under whose care she was. She had passed
the preceding night without  the least sleep,  and
breathed at this time with extreme difficulty; indeed
it seemed  as if she could not long continue the la 
108             On Emphysema.
 bour of such imperfect and distressful respiration.
 It was supposed that one  side of the  thorax  was
 filled with air; and as it was suspected that the oppo-
 site lung might be oppressed by this cause, it was
 agreed to extract the air from the right side of the
 chest. With this view, Mr. Harvey made an open-
 ing into the thorax, in the following  manner: He
 first made an incision, about two inches in length,
 through  the integuments, near the middle of the
 seventh rib, and opposite to its lower edge.  He then
 drew the skin upwards, so as to expose the inter-
 costal muscles which connect the upper  edge of
 this rib to  the one above it.  These he cautiously
 divided, as he next did the pleura.  At the time this
 was effected, I believe the  patient was  in the act of
 expiration; for a blast of air evidently  issued from
 the thorax; and afterwards, whilst  the  integuments
 were  kept retracted, and the aperture in the pleura
 consequently uncovered, the external air continued
 to rush in during the enlargement of the thorax, and
 to be forced out again during  its contraction. But
 when the divided skin  was allowed to descend to
 its natural situation,  and  thus the opening of the
 pleura was covered, no farther passage  of air took
 place; and all that could  then be perceived, was a
 depression of the integuments opposite to the aper-
 ture in the  thorax,  occasioned by the  pressure of
 the  atmosphere,  during  the enlargement of that
 cavity. I had got  ready a  large  injecting syringe,
 and introducing the pipe into the cavity  of the chest,
 I drew up the piston,  and thus  exhausted the air,
till I found I was  stopped from proceeding by the
lung which had risen up  and  applied  itself to the
 mouth of the syringe.  The skin was  then imme-
diately brought down over the aperture in the thorax,
and served like a valve, to prevent  the further in-
gress  of air into that cavity. About ten ounces mea- 
                On Emphysema.              109

sure of air might probably have been extracted by
the syringe. As this quantity of air could have oc-
cupied but a small  space when compared with the
size of the thorax,  it was probable  that the back
part of that cavity was filled with fluids.—Nothing
further, however, was done at this time; and shortly
after the  poor woman fell asleep, and breathed with
comparative ease for nearly six hours. But the dif-
ficulty of breathing again increased during the night,
and at noon, on the following  day, was nearly as
great as ever. Mr.  Harvey and I agreed, however,
that it would not be wrong to inspect the thorax, to
see if the lung had collapsed, or if we could by any
means afford relief  to the patient.  Upon separating
the  adhesion  which had formed between the skin
and subjacent parts, and introducing a finger through
the aperture in the pleura, we found the lung adher-
ing to the inside of that membrane; but upon slightly
varying the patient's  posture, some  turbid  bloody
serum flowed from  beneath the lung. When we had
discharged as much of this fluid as we conveniently
could, the external wound  was closed; but the pa-
tient continued  to breathe with increasing difficulty
till about midnight, when she died.

                   Dissection.
   On examining the  body, no air was  discovered
in the cavity of the chest. The  right lung was par-
tially inflated, and the anterior part of it closely ad-
hering to the pleura costalis, as far as the place where
the opening  had been made. About three pints of
bloody fluid lay in the hollow of the ribs posteriorly,
and about half filled the cavity of the chest on that
side; the surface of it being nearly on a  level with
the  opening  which  had been made to  exhaust
the air. Upon the surface of this fluid, the half-ic* 
 110             On Emphysema.

 flated lung seemed to float.—I looked for the place
 where the lung had  been wounded by  the  injury,
 but cannot say that I could perceive it. It  was,
 however, certainly healed; for the lung bore infla-
 tion without letting the air  escape from it.  The
 pleura was covered with coagulated lymph.  The
 cells of the lung  contained a quantity of fluid, and
 the whole substance of it was of a livid colour.—
 The cells  of the lung of  the  opposite side of the
 chest also contained  more than their ordinary quan-
 tity of fluid; its vessels were turgid, and it was hard
 and thickened in several places; which was probably
 owing to former disease. There was likewise more
 than a usual quantity of turbid serum in the left ca-
 vity of the thorax.
   It seems to me highly probable, that there are
 two states of the lungs in emphysema, one of which,
 indeed, can rarely be proved by examination, since
 the patients in general do well. I have, however, met
 with instances in which patients  affected with  em-
 physema from a wounded lung, died of other injury,
 and thus been able to  ascertain  that the lung had
 not collapsed. I once also met with a proof of this
 fact in a  patient who  survived, and I will relate the
 circumstances of the case.

                      CASE.
   Mr. Crowther requested me to see a poor man
 who was brought into a workhouse with fractured
 ribs, accompanied with a great degree of emphysema.
 The integuments covering the upper part of the left
 side of the thorax and neck, were elevated to a great
 degree by air that seemed confined in one cav ity,
 and  not  diffused in  the interstices  of the cellular
 substance. The integuments of the  face were also
considerably  inflated.  The  pulse  was very  fre- 
On Emphysema.             Ill
quent and small, and respiration quick and difficult.
The extremities were cold. All these circumstances
had taken place so rapidly, and were apparently in-
creasing with so much celerity, that I thought it
right, for reasons which  will be mentioned after-
wards, to make  an opening into the  cavity of the
thorax, which I accordingly did, between the seventh
and eighth ribs, where the digitations of the serratus
anticus muscle meet those of the external oblique.
The external wound was  made  in the manner de-
scribed in the foregoing case.  The lung was in con-
tact with the sides of the chest,  nor  did  it recede
when exposed. Should such an occurrence ever take
place, a surgeon has the means of preventing its hap-
pening to any injurious degree, by instantly closing
the wound. We next made a  puncture through the
distended integuments on the front  of the chest,
about opposite to the collar bone. A blast of air es-
caped, and they subsided to their original level. The
diffused air was expressed in some degree from the
integuments of the face and neck through the same
wound. A bandage was now applied round the walls
of the chest, so as to prevent  their motion and the
escape of air into the cellular  substance, and the pa-
tient was afterwards bled. No more emphysema oc-
curred, and the patient did as well as in a case where
the ribs are merely broken, and the lungs uninjured.
I  cannot satisfactorily  account for the great quick-
ness and difficulty of respiration that took place in
this case, except by attributing  it  to the agitation
of the patient's mind, alarmed by the inflation of his
neck and face. 
lli             On Emphysema.
  I have seen so many cases of emphysema, attended
with very little difficulty of breathing or other inconve-
nience indeed, proceeding in a manner so like cases
of fractured ribs unaccompanied with wounds of the
lungs, that I cannot suppose  patients were in these
cases  reduced to the necessity of breathing with one
lung only.  These  patients indeed were all  treated
in the  manner recommended and practised by Sir
William Biizard. Observing the great pain and irri-
tation which  the constant motion of the fractured
ribs occasioned, he was induced to disregard the
emphysema, and to confine the motion of the ribs
by a tight bandage, in the same manner as when the
lungs  are uninjured:  afterwards  the patients were
largely bled, and Other evacuations were freely made.
This practice he has  since continued  with general
success.  The pressure of the  bandage in  general
prevents the air from escaping out of the wounded
lung,  and  pervading the cellular substance. It will,
perhaps, appear  probable  to  many  surgeons, that,
for this very reason, the air will be likely to insinu-
ate itself between the two pleurae,  and thus occasion
a collapse of the lung.  I do not,  however, see any
good reason for such a supposition. The two pleurae
remain in their natural state of contact;  and there is
no space for the air to pass between  them.  So fre-
quently also are there adhesions between the surface
of the  lung and the sides of the  thorax, that I think,
in some of the  cases  of emphysema which I have
seen,  this circumstance  must  have occurred, and
that if the lungs had receded  from the  sides of the
thorax, the symptoms would have indicated the la-
ceration or stretching  of these adhesions.
  An  idea has generally prevailed among surgeons,
that if the pleura costalis were divided  in the living
subject, the lung would immediately collapse, as it 
                 On Emphysema.,            ilS

is usually found to do  in the  dead one.  But M.
Bremond* has shown by experiments, that not only
when an opening is made into the cavity of the tho-
rax, but even  when some of the ribs are removed,
the lungs still occupy their natural situation, and are
even thrust up into the opening during expiration.
Mr. Norris has also lately shown, by experiments
undertaken -for this purpose, as  well as by observa-
tions on the effects of accidents, that frequently the
lungs do not. collapse when the cavity of the chest
is exposed in the living animal;f and I  have also
had occasion to observe,  on dividing the pleura
costalis in a case of supposed hydrothorax (in which,
however,  no water was found), that the exposed
lung did not collapse; a circumstance which, I think,
ought to encourage us to a more frequent perform-
ance of such an operation.  In  other experiments,
however, the, lungs have been known to collapse; and
the circumstances, on which either of these effects
depends, are not perhaps well understood.
   For these reasons, I believe,  that in most cases of
emphysema succeeding  to broken ribs, pressure by
bandage not only hinders the air from diffusing itself
through the cellular substance, but serves to prevent
it from  escaping out of  the wounded lung, and of
course facilitates the healing of the wound, which
would be prevented by the constant transmission of
air. Its early application,  therefore, will often prevent
a very troublesome symptom,  whilst, at the same
time, by keeping the fractured bones  from motion,
it greatly lessens the sufferings rof the  patient.
   In some cases where the lungs are wounded by
the ribs, the air does undoubtedly get into the ca-
vity of the thorax, as happened in the case of the poov

  * Me moires de l'Acad. des Sciences, 1739.
  /Memoirs of the Medical Society of London, vol. iv. p. 440.-
                       P 
114             On Emphysema.

woman  already mentioned, and as I have  seen  in
other instances.  When the air passes from the
wounded lung into the cavity of the chest, and the
lung becomes in consequence  collapsed,  still the
symptoms and progress of the complaint will differ
from the effect of circumstances which have not been
much attended to. When the wound in the sides of
the thorax allows of the expulsion of air from that
cavity during expiration, and  does not admit air
during inspiration, it is not to be supposed that the
wound of the lung can heal; for the cavity of the
thorax must, under these circumstances,  be filled
from the wounded lung every time that it is enlarged
during inspiration.
   But this state of  circumstances, which is so par-
ticularly injurious, and which  usually  takes place
when the lung has collapsed in the manner described,
it is the business of the surgeon to remedy: and it
may be accomplished  in two ways; First,  by pre-
venting the escape of the air from the cavity of the
chest, in which case the necessity of its being filled
from the wounded lung will, in a great measure,  be
done away.  And as I  know surgeons  have appre-
hended, that if an outlet was not given to  air from
the cavity of the chest, the opposite lung might be-
come oppressed, I beg them to reflect a little on the
state of respiration under these circumstances.
   To examine this subject, let us  suppose the tho-i
rax expanded, and one of its cavities filled with air,
at which time the patient attempts to make an ex-
piration; what will, be the effect? The air cannot re-
turn through the wound in the lungs; and we have
supposed that it cannot escape through that in the
pleura costalis. The muscles of respiration are un-
able then to produce any considerable change in the
dimensions of the cavity, without an exertion pro-
ductive of pain, which it is not probable that they 
                 On Emphysema.             115

 will make; the inactive diaphragm will not be thrust
 up into the hypochondrium as in natural expiration,
 and the ribs will remain nearly  stationary; but in
 proportion to the degree  of the expiratory effort
 that is made, the air may be condensed, and the me-
 diastinum thrust to the  opposite side of the chest.
 But no injury will arise from this pressure,  neither
 can it  happen in  any great degree; for both sides
 of the chest  being  diminished at the same time,  a
 slight  compression of the  opposite lung cannot be
 detrimental, since it helps to express the air from it,
 —the  very effect which is now required; and as that
 lung is pressed inwards by the sides of the throax, it
 will counteract any  great pressure made on the me-
 diastinum. Upon inspiration taking place, the con-
 densed air will expand and fill the enlarged cavity,
 and the mediastinum will regain its natural situation;
 so that the function of the sound lung is scarcely,
 if at all, impeded by the compression which takes
 place on the  opposite side of the chest.
   In whatever state the lungs happen to be when
 they are wounded,  a  bandage, if it can  be borne,
 seems  therefore to me extremely  useful.  By means
 of it, the pain and irritation, which the motion of the
 fractured ribs  must otherwise occasion,  are, in a
 great measure, or entirely, prevented. In that state
 of the  lungs  which  I have first described, the pres-
 sure of a bandage  prevents emphysema,  and does
 no harm; in the other, it not only prevents emphy-
 sema, but does good, by  keeping the collapsed lung
 at rest, and thereby free  from the necessity of con-
 stantly transmitting air.  Patients, however, will not
 always be able to wear a  bandage when one lung  is
 collapsed (particularly if any  previous disease has
existed in the other) as it equally confines the mo-
tion of the ribs on both sides, and as every possible
enlargement of the chest  becomes necessary for the 
IIS             On Emphysema.
 due admission  of air into the lung which still exe-
 cutes its functions. Under these circumstances, if
 the  emphysema  continues (and  its  continuance
 must always denote that the wound in the lung is
 not closed), I should esteem it the best  practice to
 make a small opening into the chest, so that the ex-
 ternal air might have free communication with that
 cavity;  and then the injured lung must remain mo-
 tionless till its wound is healed, and  the mediasti-
 num will, in every  state of the thorax,  preserve its
 natural  situation.
    As almost all the circulating blood must, iu such
 cases, be transmitted through the vessels of one lung,
 if the quantity of that fluid be not greatly diminished,
 the pulmonary vessels will become turgid; a larger
 effusion of fluids will therefore take place  into the
 air-cells and cavity  of the chest, and thus the func-
 tion of  the acting lung will be  materially impaired.
 This reasoning illustrates what experience has al-
 ready determined,  viz. that the preservation of life
 in these cases depends on the most copious blood-
 letting.
    The  case, which I  have related,  clearly shows,
 that the collapsed state of the lung affords an oppor-
 tunity for  the  wounds  of its surface to heal;  and
 when this  desirable event is accomplished,  the air
 which is at that time in the cavity  of the thorax,
 will be speedily absorbed, and the lung will agaii*
 acquire its  former  size and situation.  But  should
 the function of it be more immediately necessary,
 from a diseased state of that on the opposite side, or
 from other circumstances, it may be more quickly
- restored by exhausting the air, in the  manner de-
 scribed. If the cavity of the chest contain a quanti-
 ty of fluids, and it is thought right to extract them,
 it cannot well be done by varying the posture of the
 patient so as to let  them run  out  of  the  opening
•  * 
                On Emphysema.             11V
                                            »
that has been made: the difficulty with which  res-
piration is performed, will render such an attempt
almost insupportable to the patient. It would there-
fore be better to introduce a hollow bougie, or some
such instrument, into the posterior part of the tho-
rax, there connect  it to the syringe, and thus extract
the contained fluids. I need scarcely  add, that the
same method may be employed with  advantage for
the extraction of water from the cavity of the chest
in hydrothorax.
   The great advantage of retaining the lung in a
collapsed state is, if possible, more strikingly shown
when those bodies have suffered a greater degree of
injury than can occur to them from the fracture of
a rib.  I  have seen cases in which bullets have pas-
sed through the lungs, near the root of those bodies,
and where  many  of the large vessels were conse-
quently  torn, in which the blood has been poured
into the  cavity of the chest, has condensed the lung
by its pressure,   and  thus suppressed the hemor-
rhage. The injured vessels might, under these cir-
cumstances, unite; and  the blood being let out of
the thorax, the lung might gradually be restored to
its former  function.  Yet  in the cases which I was
a witness to, the  patients died of inflammation and
fever;  but the particular nature of the circumstances
was unknown  during the life  of the patient; and of
course the  conduct appropriated to  them was not
pursued. The fluid contained in the cavity of the
thorax had  in these cases undergone a degree of
putrefaction previous to the patient's death; which
state required  its  discharge.
   But should  this be attempted in other cases,  it
becomes very essential to keep the thorax filled with
air, lest  the lungs  should become prematurely infla-
ted, the  newly-healed part lacerated, the hemorrhage
renewed, or inflammation induced; and the surgeon 
118             On Emphysema.
would be able, I believe, without much contrivance,
to regulate  the  inflation of the lungs, as circum-
stances seemed to indicate. Surgeons used formerly
to keep canulas in the thorax in these cases, with a
design to give an outlet to fluids;  but such means
might have been beneficial by preserving the lungs
collapsed; and they might have been continued from
being found serviceable, though  the manner  in
which they  became so was unknown. 
SURGICAL OBSERVATIONS.
  On the Operation of Puncturing the Urinary
                    Bladder.

iVl R. HOME, to whom the profession is much in-
debted for many important improvements in practice,
has of  late published some cases of the puncture of
the bladder from the rectum, which, in my opinion,
are of the greatest importance.  They not only exhibit
that operation as more simple and successful than
perhaps was generally believed, but if  the operation
be as successful in the  hands of other surgeons, it
presents an easy mode of relief to a great number of
unfortunate patients, who have generally been left to
die in misery. I mean those who have strictures im-
passable by bougies, and  who are so  irritable that
they cannot bear the application  of caustic, on  ac-
count of the retention of urine  which  it occasions.
In such cases the puncture from the rectum appears
most eligible, because the bladder is contracted, is in
general  irritable, and will not perhaps ascend high
enough to admit of being punctured above the pubes.
  But there are cases in which the operation by  the
rectum cannot be performed, and by frequently meet-
ing with these I have been compelled to puncture the
bladder above the os pubis, and the event of the ope-
ration has been such as would have led me to prefer it
to any other that I had seen practised. The chief cases
to which  I allude are those of enlarged prostates, 
120           On the Operation of
 where the catheter has been forced into the substance
 of the gland, and has torn it considerably; conse-
 quently that instrument enters so easily into the false
 passage as to render  it almost  impossible to make it
 take the right one.  Indeed in cases of stricture, where
 false passages have been made, and the prostate has
 been sound,  the perception of the  bladder from the
 rectum has been so indistinct that I have been de-
 terred  from puncturing it;  and in one case I made a
 division  in the perinreum,  and having  passed my
 finger  beneath the arch of the os pubis a considerable
 way, I could obtain no such distinct perception of the
 bladder as would authorize me to  push in a trochar.
 But  I  punctured it above the os pubis, and drew  off
 a considerable  quantity of urine.   I have therefore
 been led to conclude,  that in some distended blad-
 ders, there is a kind of recession  of them from the
 perinaeum, and that when they become distended
 they ascend proportionally higher into the abdomen.
  In the greater number of cases in  which I  have
punctured  the  bladder above  the  os pubis, it has
been on a sudden call to the hospital, or  some  poor
house; and I  have  had little further concern with the
patient than what related to the performance of the
operation.
  Sometimes I have been in doubt if there was much
urine. in  the bladder, and this circumstance has de-
terred  me from puncturing, except in that situation
in which I could possess an assurance that I felt the
bladder,  and  could puncture  that  viscus: and these
doubts caused me  in some instances to puncture the
bladder with a lancet;  and in  some cases I have not
left any canula in the bladder, in consequence of the
 escape of the urine preventing me  from readily  find-
 ing the opening which I had  made. Several of the
patients died, but in  every  instance the operation re-
lieved  their sufferings;  and I have never seen any  ef- 
        Puncturing the Urinary Bladder.       121

fusion of urine into the cellular substance,  or any
other bad consequence result from the operation; nor
do I think that such events are likely to happen, if it
be rightly performed.  The death of the patients was
fairly to be imputed to the delay of the operation, or
the degree of disease which  previously existed in
the urinary organs.  In several patients who recovered,
the progress of their amendment was similar to that
which took place in the case, which I am about to
relate. I did not, however, preserve any detailed ac-
count of them, for, as I have mentioned, the patients
could scarcely be said to be under my care.  I have
requested the  last gentleman,  with whom I attended
a patient  under these  circumstances, to give me a
particular account of his case, and on the accuracy of
his  narrative I can  place perfect reliance.  This case
I shall relate, in order to have an opportunity of com-
menting on the mode of puncturing the bladder above
the os pubis.

                      CASE.                        «
  A  gentleman, between sixty and seventy years of
age, had a retention of urine from an enlarged pros-
tate gland, which obliged his surgeon to draw off the
urine night and morning. This was done during ten
days, when the difficulty  of introducing the catheter,
which had gradually increased, became insurmounta-
ble.  I was therefore obliged to puncture the bladder,
and  the only place in  which this operation could in
the present instance be  performed,  was above the
pubes.  I therefore made an incision about two inches
in length through the integuments, and between the
musculi pyramidales abdominis,  so that the  lower
part of the wound laid  bare the top of the symphysis
pubis. On introducing my finger into this vacancy I
felt the distended bladder.  The  sensation produced
                        Q 
122             On the Operation of
by pressing against the distended bladder is I think
so peculiar, and so different from any thing else which
could occur in this situation, that if an operator has
once felt it, he will not hesitate in deciding that it is
the bladder against which he presses.  The thickness
and tension of its coats, and its fluid contents are the
chief circumstances from which  this  peculiar feel
seems to arise. When 1 first began to perform this
operation,  I was deterred from using a trochar by a
fear of being misled by  my sensations. I cautiously
punctured  the bladder with a lancet, designing to in-
troduce a catheter through the wound; but the urine
gushed out so violently, and the bladder became con-
tracted  so  suddenly,  that I could  not  discover  the
wound which  I  had made; yet under these circum-
stances,  the urine  passed from the aperture in the
bladder, through  the external wound,  and was  not
diffused  into the cellular substance.  Indeed neither
observation nor reasoning would induce me to sup-
pose that such an occurrence is  probable, whilst there
is a free  external opening. The apprehension seems
to have arisen from the extensive diffusion of urine,
in cases where  the urethra has given way.  But in
such  cases, the  urine is actually  injected into  the
cellular substance, and with great force, by the blad-
der, in consequence of the channel out of the body
being closed up. If the external wound in this opera-
tion were to be closed, and the exit of urine prevent-
ed  by this means, then it is probable that the urine
would be forced to pervade the cellular substance. It
may be asked, if urine is in  any way likely, accord-
ing to the  common  phrase, to insinuate  itself into
the surrounding cellular substance?  I  should think
not. The operator should be  cautious not to make
any  separation of the bladder from the back part of
the symphysis pubis, that there should not  be even
a cavity into  which the  urine  might gravitate.  He 
         Puncturing the Urinary Bladder.      123

should also leave the external wound free and open.
The first effect of the operation will be an inflamma-
tion, which will consolidate the surrounding cellular
substance, and prevent the ready  impulsion  of urine
into it. The stimulating qualities of the urine will aug-
ment this inflammation,  and thereby increase the ef-
fect. Indeed the stimulus of the urine often occasions
a sloughing of the surface of the wound, which how-
ever makes no alteration in the general circumstances
of the case. In later operations I acquired more con-
fidence,  and  a  belief that  I could distinguish the
bladder from any thing else by its feel; and  one case
which occurred  tended  further to embolden me in
the performance of it. Being called on a sudden to
relieve a patient, who had had his urethra lacerated,
and  being urged to puncture the  bladder  by several
gentlemen who were  present, and who were certain
that a considerable quantity of urine was detained:
though I could not feel the  bladder distended above
the pubes, I consented,  as the patient was in immi-
nent danger,  to  perform the operation,  and having
punctured the bladder with  a trochar, four, or five
ounces only of urine  were  discharged.  However a
large  quantity of urine gradually flowed through a
canula which was introduced. The patient died, and
was  examined,  when  the cause  of this  occurrence
became apparent. A large cyst made by the protru-
sion of the internal coat of the bladder, had beenformed
between  the bladder and the  rectum, which contained
the greatest quantity of the retained urine. The ori-
fice, by which this cyst communicated with the blad-
der,  did not exceed  in dimensions the  barrel of a
common quill.  It also appeared that, though the blad-
der itself could not in this case be said to have  been
distended,  yet the  front of it only was wounded  by
the trochar, and the back part was uninjured.
  To return from this digression to the operation in 
124            On the Operation of

the case which I was relating:  after I had, by an in-
cision between the pyramidales muscles, enabled my-
self to pass my  finger along the  upper part of the
symphysis pubis, so as to press against the distended
bladder, I introduced a common trochar of the middle
size, in a direction obliquely downwards.  There is
an advantage, as  Sabatier, in his Medicine Operatoire,
observes, in introducing an instrument in this direc-
tion, for it accords with the axis of the bladder, and
is  therefore not  likely to injure the opposite side of
that organ.  When I found that the instrument had
penetrated the cavity, I withdrew the stilet within the
canula, and then pushed the canula obliquely down-
wards, so that about two inches of it were introduced
into the bladder. On withdrawing the stilet of the
trochar, the urine gushed out with great force, but I
prevented its escape,  by placing the thumb of my left
hand against the mouth of the canula, and then intro-
duced through  it in  the same oblique direction,  a
middle sized hollow  elastic catheter, till it met  with
resistance by touching the  bottom of the bladder.
After the urine  was  discharged, the canula of the
trochar was  withdrawn  over  the elastic  catheter,
which was  left  in its  situation, and the end which
came out of the  wound was bent downwards towards
the pubes, and attached, so as to be kept motionless,
to a circular bandage put round the body of the pa-
tient. The wound, which was funnel-shaped, being
wide  externally, and  gradually contracting to the
bladder,  was covered with linen, spread over with
spermaceti salve. The urine flowed not only through
the catheter, but by the sides of it. A slight inflamma-
tion occurred round the wound, such as would doubt-
less tend to consolidate the surrounding cellular sub-
stance.  The surface of the wound in this case did
not even slough, at least in any evident degree.  Four
days after the operation the patient got  up, and walk- 
Puncturing the Urinary Bladder.     125
ed about his chamber, and feeling himself comforta-
ble and well,  he did  not  go to bed again ml night.
At the end of a week some few drops of urine came
through the urethra, and the quantity thus discharged
daily increased.  At this time as the catheter seemed
to be clogged up with mucus, it was withdrawn, and
another was introduced with perfect facility.  In about
three weeks,  as the urine came pretty freely through
the urethra, the catheter was  withdrawn, and the pa-
tient voided his urine by  the natural channel.  In six
weeks the external wound was perfectly healed, and
the patient was as well as before the retention of urine
took place.
   Since the publication of the preceding case, I have
many times performed the same operation, and with-
out observing any thing  contradictory to the state-
ment which  I have given. I shall briefly relate  the
particulars of one of the cases.

                      CASE.
   A  gentleman, who came  from the country, was
seized with retention of urine, and the medical man
to whom he first applied for relief was unable to draw
off that fluid. Before I made any attempt,  I first in-
troduced a bougie, which I think, ought in all cases to
be done, in order to examine the state of  the parts
prior to the introduction of more rigid and injurious
instruments.  It passed into the prostate, but could
not be made  to proceed further. A small sized cathe-
ter much curved, or bent upwards towards the point,
was next introduced, which entering the bladder, the
urine discharged. Upon  attempting to withdraw the
catheter, I found that I could not do it without em-
ploying considerable force, so firmly was it compress-
ed by  the neck of the bladder.  I  examined the pros-
tate per anum,  and did not find that gland materially 
126            On the Operation of
enlarged, so that I conclude the difficulty of intro-
ducing altd withdrawing the instrument arose from an
enlargement of what Mr.  Hunter called the valvular
part of the prostate, and Mr. Home describes as its
third lobe. Being fully aware of the improbability of
my being able to introduce a catheter night and morn-
ing to  draw off the urine, in this case, I employed
for that purpose, at my next visit, a flexible varnished
catheter, and left it in the  bladder. This gave pain to
the patient,  and did not long remain in the cavity of
the bladder; I was  therefore under the necessity of at-
tempting to draw off the urine twice a day with the
common catheter.  I succeeded in doing this for seve-
ral days, each time encountering a difficulty in intro-
ducing the  instrument, which was surmounted by
keeping  the point of the instrument closely in  con-
tact with the upper part of the canal; and I continued
to experience considerable difficulty in withdrawing
the instrument after the escape of the urine.  One
morning, however, I was  unable to accomplish the
introduction of the catheter,  and felt myself obliged
to puncture the distended bladder. The operation
was performed as in the preceding case.  A month
elapsed before  the patient voided  any urine by the
natural channel. The quantity of that fluid which was
discharged through the urethra when he wanted to
make water was at first small, and gradually increased
in another fortnight to about four ounces.  After this
evacuation,  the plug being  removed from the  tube
inserted at the  pubes,  six or eight ounces of urine
were discharged from it; it therefore appeared, that
the bladder had but very partially regained its power
of expelling the urine.  When this operation  is per-
formed, we can know with some degree of accuracy
when the bladder has fully regained its powers;  and,
consequently, when we ought to remove the tube.
The patient was very anxious to return into the coun- 
        Puncturing the Urinary Bladder.      127

try, and I knowing the great impediment that existed
to the expulsion of the urine in his case, dared not to
remove the tube; nor has  it appeared proper to do it
since that time. He has now kept the tube in his blad-
der, 1 believe, more than two years. He has lately com-
plained much of the badness of the varnish with which
the tubes are covered; and it is greatly to be regretted,
that in this country, no one has the art, or takes the
trouble, of varnishing these catheters as they are done
in France. 
128
           ON THE TIC DOULOUREUX.

   As the public attention has been of late excited to
 that painful affection of the nerves, called Tic Dou-
 loureux, I shall in the next place relate a case of that
 disease, which  lately came under my care, because
 it seems to me to  elucidate the  nature of the disor-
 der, to  demonstrate the degree and kind of advantage
 which is likely to result from the division of the trunk
 of the nerve,  and also to illustrate some circumstan-
 ces in  the anatomy and physiology of the nervous
 system, of which I have not as  yet met with any
 satisfactory explanation.


                      CASE.
   A  lady  became gradually affected with a painful
 state of the integuments under and adjoining to the
 inner edge of  the  nail  of the  ring finger of the left
 hand. No injury to the  part was remembered which
 could have brought on this disease. The pain occur-
 red at irregular  intervals,  and was extremely severe
 during  the time of its continuance, which was for a
 day or two, when it usually abated. Accidental slight
 injuries always occasioned great pain,  and  frequently
 brought on those paroxysms,  which however occa-
 sionally occurred spontaneously, or without any evi-
 dent exciting  cause. In all these particulars the dis-
 ease correctly  resembled the Tic Douloureux of the
 nerves of the face.  As the pain  increased, the disorder
 seemed to extend up the nerves of the arm.  After
 the patient had  endured this  painful affection for
seven years, she submitted to have the skin, which
was the original seat of the disorder, burned with
caustic.  This  application gave her intense  pain,  and 
              On the Tic Douloureux.          129

on the healing of the wound she found her sufferings
rather augmented than diminished  by  this experi-
ment. After four more years of suffering she con-
sulted me, when the circumstances of the case were
such  as to render an operation indispensably neces-
sary.  The pain of the part was intolerable, and it ex-
tended all up the nerves of the arm;  and this general
pain was so constant during the  night, as to deprive
the patient of rest.  The muscles of the back of the
neck  were occasionally affected with spasms.  The
integuments of  the affected arm were much hotter
than those of the opposite side, and sometimes the
temperature was so increased as to cause a burning
sensation in them. Under these circumstances,  I did
not hesitate to divide  the nerve of the finger,  from
which all this disorder seemed to originate. I laid it
bare by a longitudinal incision of about three quarters
of an inch in length, from  the  second joint  of the
finger,  and divided  it opposite to that joint,  by  a
curved  sharp  pointed bistoury which was conveyed
under it. I  then took  hold of the nerve with a pair
of forceps, and reflecting  it downwards,  I removed
a portion of it half an inch in length, that the possi-
bility of a  quick reunion  might  be prevented.  The
wound was brought together by sticking plaster, and
it  united  by adhesion: but the upper  part  of the
wound, opposite to the upper end of the nerve, be-
came slightly inflamed, and was very painful;  how-
ever the appearance of inflammation gradually went
off in the course of three weeks. After the operation
I pinched the originally affected integuments sharply
with my nails, without causing any sensation; but if
in so  doing I moved the finger, then pain was felt.
I found it difficult to convince the patient that the
skin at that part  was actually devoid of sensation, for
she still continued to feel similar sensations to those
which formerly  occurred,  though  in a  much di- 
130          On the Tic Douloureux.
minished degree: but she became gradually as per-
fectly convinced as any medical man could be,  that
these sensations arose from the irritated  state of the
end  of the nerve, above the place where it was di-
vided. The  painful affection of the nerves of the
arm  still continued, though considerably lessened in
violence; however, it was sufficiently severe to make
the patient apprehend that  little permanent benefit
would arise from the operation. This pain continued
occasionally about four months, with varying degrees
of severity, but the temperature of the skin was not
hotter than that of the opposite side, as it  had been
before the operation.  At  the  expiration  of three
months, the patient  ascertained that the integuments
at the end of the finger actually felt when  any thing
was  applied to them, and this proved a new source
of alarm.  More than nine months have now elapsed
since the  performance of the operation,  and the ge-
neral pains in  the nerves have become  very trivial;
but the sensation of the integuments at the end of the
finger has during that time  gradually increased, and
the  skin has now its natural sensibility, so as accu-
rately to  distinguish the tangible properties of any
body applied to it.  If also the originally affected part
be compressed slightly, painful sensations resembling
those which formerly occurred take place.
   The observations of Dr. Darwin relative to ocular
Spectra, and the experiments of Mr. Home on the
contraction of divided nerves (contained in the Croo-
nian Lecture, inserted in the Philosophical Transac-
tions for the  year 1801) have given a kind of demon-,
stration  that there  is a  subtile  and mobile  matter
superadded to  the visible fabric of nerves, and sanc-
tion the use of the  yet novel terms of the  irritability
and  irritable  actions of nerves, and  1  shall therefore
employ them in the few subsequent remarks which
 I have to offer. 
On the Tic Douloureux.         131
   The case above  related appeared to me to merit
publication, because I believe it is not a common oc-
currence for the tic douloureux to happen any where
but in the face.  In the instances related by Mr. Home
in his Croonian lecture, the disease was the effect of
an injury done  to the thumb; and it is reasonable to
suppose that it  would not have taken  place without
a predisposition to it in the constitution of the pa-
tients.  It is also not unfair to conclude that the dis-
ease thus occasioned was of a more general  nature,
and  less confined  to the  extreme branches of the
nerves,  and therefore less susceptible of cure by an
operation.  The case, which I have related shows, as
indeed might  have been  concluded a priori, that
though the source of the irritable state of the nerves
in the tic douloureux may be  cut off by an opera-
tion, yet that the general irritable  actions of those or-
gans, which had been excited, and had continued for
a long time, would not immediately cease,  though
they might, as happened in  this  instance,  gradually
subside.
   The speedy  return of sensation, which is both ac-
curate and acute in the  present case, must  surely be
deemed  a curious  circumstance.  It cannot be attri-
buted to a reunion of the divided nerve, since so large
a portion of it  was  removed; for I believe  in simple
divisions of the nerves by accident, sensation is slow
in returning. It must, I think, be admitted, that sen-
sation in the present instance took place through the
medium of the communicating branches of those or-
gans, and probably its speedy renovation was the ef-
fect of their unusually active or irritable state.
   Nerves strikingly resemble arteries in their modes
of communication;  sometimes they conjoin even  by
considerable branches,  such as  must  be  manifest,
in common dissections; but they  communicate irj
surprising  numbers- by their minute  ramifications 
132         On the Tic Douloureux.
This circumstance is not perhaps so familiarly known
to professional men, since it cannot be perceived un-
less in the course of a very  minute dissection, and to
understand how numerous these communications are,
the representations given by the German authors, of
their delicate and  laborious dissections, may be  ad-
vantageously consulted.*
  The  communications  of nerves seem also not to
have excited much attention  amongst physiologists;
at least I have not met with any probable conjecture
concerning their use  I shall therefore take the liber-
ty of mentioning as briefly as possible, what has oc-
curred to me on that subject.
  The  opinions of Mr. Hunter respecting a subtile
matter inhering in the brain and nerves, and diffused
throughout the body, are, I believe, generally admit-
ted,  though variously expressed.  Now if  the brain
and  nerves  be supposed in those animals  who pos-
sess  them, to be  the chief if not the sole organs for
the preparation of this subtile matter, then  it appears
as necessary that the nerves should communicate, as
that  the arteries should do  so.  For if the continuity
of the trunk of either of these organs were destroyed,
the parts, which its branches supply, would  perish
were it not for their communication with the minute
branches of other adjacent trunks.  It is probable that
one of the advantages derived from important organs
being supplied from plexuses of nerves is, as has been
suggested  by Soemmering, that  such essential or-
gans should never want that animation and influence,
which  they  derive from  the nerves,  even should
casual obstruction  take place in some of the trunks
leading to such a plexus.  But parts less essential to

  * See Meckel's Representation of the Nerves of the Face,
©r Frotscher's of the Cervical Nerves, in Ludwig's Opera
Minora, or Walther's Plates. 
On the Tic Douloureux.
133
life, equally require that such interruption of the ner-
vous energy  should be  guarded against. Have we
not a plexus formed in the axilla, prior to the distri-
bution of nerves, to the upper extremities?  do not
the sacral nerves form a plexus, in order to form the
ischiadic or  posterior crural nerve?  and may not
the same circumstance be affirmed with  respect to
the anterior crural, and obturator nerves,  since they
arise from the  complicated  union of the  lumbar
nerves, with a branch of the first sacral nerve? The
reticular communications of the minute nerves may
not only serve the purpose which has been suggested,
but, as appears from the  present  case,  the actions
which  take place in the extremities  of the nerves
may, by them, be propagated to the sensorium, and
thus produce sensation.  Whether,  in the present in-
stance, the original painful actions of the extremities
of the nerves may again recur,  and be continued
throughout the communicating branches to the sen-
sorium,  the  future  progress of the case will deter-
mine.
   The lady, whose case I have related, died about
four years after the operation, of disorder of the  di-
gestive organs, to which she was habitually subject.
Indeed, from what I have since seen of cases of Tic
Douloureux,  I am induced to believe, that this dis-
order is as much constitutional as either gout or rheu-
matism. I have  known patients afflicted with it  get
well, either spontaneously, or in consequence of the
administration of medicines which were likely to re-
lieve or counteract nervous irritability. 
134
  ON THE REMOVAL OF LOOSE SUBSTANCES
            FROM THE KNEE  JOINT.

  I shall next relate a case  in which some of those
loose substances that  are frequently found  in the
knee-joint were  removed by an operation; because
I think the case  contains many  interesting particu-
lars, and because it will afford me an opportunity of
offering a few observations on the necessity and mode
of performing such an operation.  Mr.  Hey  has of
late  recommended a bandage to keep these  bodies
stationary, and has related several instances of its ef-
ficacy, and of course of its  preventing the necessity
of undertaking  a  serious and  uncertain  operation.
When loose substances exist in the  knee-joint,  and
are lodged on either side of the patella, they produce
but  little inconvenience; but when they slip under
the  ligament of  the patella,  and become interposed
between the condyles of the  os femoris and the tibia,
they impede progression, and cause pain, and so much
injury as to bring on inflammation in the joint. If the
extensor tendons,  the  patella and its ligament, can,
by  Mr. Hey's  bandage,  be kept steadily   pressed
against  the  corresponding  parts of the joint,  then
these bodies must remain stationary on one or other
side of the patella, and the patient will be exempted
from the inconvenience and injury which their mo-
tion in  the  joint  occasions. Under these circum-
stances  the necessity for an operation  is obviated;
but  in the case  which I am about to relate the ban-
dage was  of no  avail,  for reasons which will appear
in the relation.  It  is not improbable  also that though
these bodies  may  occasion  much irritation  at first,
yet that the  joint becoming accustomed to their sti- 
•
             On the Removal of, $£?c.          135

mulus may afterwards  be less affected  by their pre-
sence, which circumstance ought to be adverted to
and ascertained before an operation be undertaken.


                      CASE.
  A  man, about  forty years  of age,  having fallen
from a ladder, and  injured his knee, suffered after-
wards a  good deal from  inflammation in the joint.
The joint became  much better,  but never perfectly
recovered;  and after a year had elapsed he slipped in
walking, and again  injured his knee. From this time
he became sensible of  the presence of two movable
bodies in the joint, which incommoded him consi-
derably.  They frequently, in  walking, got between
the condyles  of the os femoris, and the crucial liga-
ments, giving him  great  pain at the time, and pro-
duced heat and inflammation of the knee afterwards.
He bore this inconvenience for  several years, till at
length, coming to  London, he resolved to submit to
the operation for their removal if it were recommend-
ed. When I  saw him there was a considerable quan-
tity of synovia in the joint, the knee was hotter than
that of the opposite limb, and in this state he said it
usually was.  There was no difficulty in bringing the
two loose substances to the inner side of the joint;
and it required only to put that part in a  depending
position, and those bodies descended by their gravity^
through  the fluid,  and were easily fixed in the situa-
tion to which they had fallen.  I could bring them on
the inner surface of the internal condyle  of the os
femoris,  which is  of  considerable  extent, and  by
placing the points  of my finger  so as to  describe a
portion of a circle, I could  prevent them from pas-
sing again into the cavity of  the joint although the
limb  might be moved, and the  patient press firmly
against them with his finger, as if he meant to  push 
•
136            On the Removal of

them into the joint.  Yet when my fingers, which thus
confined them  were  removed,  the slightest touch
caused them to disappear, and to glide with velocity
into the general cavity of the joint.
   This is the  situation, and the  manner in which I
think these bodies can be  most conveniently and cer-
tainly fixed. The inner surface  of the internal con-
dyle of the os  femoris  presents an extensive and
nearly plain surface, which terminates in front and at
its upper part by an edge  which forms a portion of a
circle.  If the points of the finger be firmly pressed
upon this edge so as to form a kind of line of circum-
vallation round  these  bodies,  they cannot pass into
the joint in this direction,  nor can they recede in any
other, on account of the  tense state of the  internal
lateral  ligament. Here these substances are near the
surface, and may be distinctly felt; and there is nothing
to be divided in order to expose them, but the inte-
guments, fascia, and  the  capsule of the joint.  Mr.
Cruikshank says,  that Mr. Hunter  preferred  re-
moving these  loose bodies at the upper part of the
joint, as there, the bag which contains the synovia
has less of  the nature  of the capsule. Mr. Ford, in a
case which required the operation (and which is re-
lated in  the Medical  Observations and Inquiries,)
extracted the  substance  on the outer edge  of  the
patella;  and if the substance is large, it may undoubt-
edly be extracted in this situation.  In the case, which
I am going to relate,  it would have been impossible
to fix the loose substances in any other situation than
that which  I have described, and in my opinion that
situation must in  most cases  be preferable  to any
other, for the reasons which I have mentioned.
   I did not hesitate to undertake the removal of the
bodies in the  present case, as they could be so se-
curely fixed. For the patient had tried bandages with-
out any advantage, which  perhaps was owing to the 
            Substances from the Knee.         137

quantity of fluid in the joint preventing them from
acting in  the manner mentioned above.  His suffer-
ings were very considerable, and the necessary restric-
tion in exercise extremely inconvenient. I thought it
right to reduce the inflammation of the joint as much
as possible, prior to the operation, and with this view
directed the application of leeches, and of linen kept
constantly damp with Goulard's wash: some  aperient
medicine  was also  given.  By  these means, in  the
course of three days, all the fluid was removed from
the joint, and it was as cool, and free from pain and
inflammation as the other knee; but when I endea-
voured to get these bodies into the situations in which
I had formerly  fixed  them,  I  found all my efforts
were  in vain. There was  no fluid for them to  de-
scend through, and though  one  of them could be got
into the situation which we wished, we could  not,
after trying nearly an  hour and an half, succeed in
getting both  of them upon the  condyle of the os fe-
moris.  I was therefore  obliged to let the patient walk
about a little, that some more fluid might be effused
into the joint, and then I could  bring them both into
the same situation, and fix them as readily as before.
   The operation was done  in the following  manner.
Sir Charles Blicke,  who assisted me, pressed the in-
teguments of the knee gently  towards the  internal
condyle, and then applied his finger in the manner I
have  described, round  the circular edge of the bone.
I also drew the integuments gently towards the inner
ham-string, and divided them longitudinally, imme-
diately over the loose substance, to the  extent of an
inch and an half. This withdrawing of the integuments
from their natural situation  was designed to prevent a
direct correspondence in the situation of the  external
wound, and that of the  capsule of the joint; for when
the integuments were suffered to regain  their natural
position, the wound in them was nearer to the patella, 
138             On the Removal of
than the wound which was made in the capsule. The
fascia which covers the joint  being exposed by the
division of the integuments, it was divided in a simi-
lar  direction, and  nearly to the same extent.  The
capsule was now laid bare, and I gently divided it to
the extent of half an inch, where it covered one of the
hard substances, which suddenly slipped through the
opening, and by pressing  gently upon the other,  it
also came  through at the  same part.  The bodies,
which were thus removed,  were about three quarters
of an inch in length, and half an inch in breadth.
They had a highly polished  surface, and  were hard
like cartilage.  The fluid contained in the joint was
pressed towards the wound, and about two ounces
of" svnovia were discharged. I then drew the wound
of the integument gentty towards the patella, pressed
the two sides together, and closed it accurately with
sticking  plaster, enjoining the  patient to  keep the
limb as free from motion as possible.
  No inflammation took place in the knee, either on
that day, or the following;  but  on the  second  night
after the operation  the patient suffered a good deal of
pain, and in the morning the joint felt hot, and was
distended with fluid as it had been before  the  ope-
ration. I  now  removed the dressings,  and found
the wound was closed;  but I felt very apprehensive
lest, the inflammation of the joint continuing, the
collection of fluid  should also increase, and byr dis-
tending the capsule, cause  the wound  to open.  Hav-
ing already seen in this  case the beneficial effects of
evaporating washes, which by diminishing the heat
of a part check its tendency to inflammation, I was de-
sirous of reapplying them.  In order to prevent these
applications from loosening the  sticking-plaster, and
causing the exposure of the wound, I made use of an
expedient,  which  I have frequently employed,  and
which from its utility I think deserves to be mention- 
Substances from the Knee.         139
ed. After having supported the sides of the wound in
their situation by adhesive plasters as at first, I put
over them a piece of iinen, which extended beyond
them in  every direction.  This linen was  made to
adhere to the surrounding skin, by  smearing over
the edge with a solution of sealing-wax in alcohol, and
afterwards  varnishing;  the linen  over  with  the same
solution.  The alcohol having evaporated,  and the
sealing-wax remaining, no liquid could penetrate and
detach the sticking  plaster. This is the same varnish
with which some parts of electrical machines are coat-
ed, and its power of remaining unaffected by  moist-
ure and moderate warmth is well known.
   Folded linen kept damp with  laudanum and water
was now applied, in the proportion of an ounce of the
former to a  quart of the latter.  This wash I  prefer,
for the purpose above mentioned, to Goulard's wash;
for the precipitated powder contained in the latter is
apt to fill the interstices of the linen, and prevent its
imbibing the  wash, so that the requisite evaporation
does not go on. These applications quickly diminish-
ed the heat of the knee, and the quantity of fluid con-
tained in the joint speedily decreased.  The wound
was daily dressed, and in a week was firmly healed;
and in a fortnight the patient might be said to be well.
He has since the operation walked as much as he was
accustomed to do, and has not found the least incon-
venience.
   I have since the publication of the preceding case,
seen one of the same kind, so curious on account of
the number of loose  bodies contained in the capsule
of the knee-joint, that it seems to deserve being men-
tioned.  I do not exaggerate, when I say, they must
much exceed  a hundred in number, and feel like shot
of various sizes, distending the capsule on either side
of the patella.  There  is  no fluid in the joint,  nor do
they  prevent  the patient from  taking ordinary ex
ercise. 
140
ON THE TREATMENT OF ONE SPECIES OF THE
               NMVI MATERm.

  I SHALL relate two cases, and say a few words on
the treatment of this complaint, which is a congenital
deformity, consisting of a cluster of enlarged vessels,
filled, and  occasionally  distended  by  the  influx of
blood from numerous surrounding arteries. The de-
formity  to which  1 allude is so well known, and so
frequent an occurrence,  as to preclude the necessity
of any description. Mr. John Bell has of late pro-
posed an ingenious theory of its formation, and  has
denominated it an aneurismal enlargement of  the
vessels,  in consequence  of their anastomoses.  There
can be  no  doubt that the repletion, distention,  and
consequent enlargement of the dilated vessels depend
upon a kind of inflammatory action of the surrounding
arteries;  for, if that  be  wanting, the mark ceases to
enlarge, and if present, it increases in size in propor-
tion to the degree of  inflammatory action. In  many
cases these  marks having increased to a certain de-
gree,  cease to enlarge; they then remain stationary, or
gradually diminish, till  they almost disappear. This
occurrence  is not so frequent as to induce surgeons
to expect such an event, or to prohibit, in conse-
quence  of such expectation, their removal.  For, if
they continue to enlarge, the operation must be com-
mensurate to their size. The consequences of their
bursting are alarming and vexatious. It is not, how-
ever, my intention to  speak  of these affections in
general, but only  to state what, perhaps, may in some
instances be done with success, when the removal of
the unnatural structure cannot be accomplished.  For 
On the Treatment, fcfc.          141
this  preternatural enlargement of vessels  is not al-
ways cutaneous. I have seen it occupying the whole
substance of the cheek, neither appearing beneath the
skin nor the  membrane of  the mouth: I have met
with it in the  orbit of the  eye, and have found  it
covering the whole of an extremity, or  nearly one
half of the trunk of the body.  If any means can be
pursued, under such circumstances, to  check the
progress of the complaint,  they surely deserve at-
tention. I was  lately so fortunate as  to succeed  in
such endeavours,  in cases,  the relation of which is
my chief object at present.

                      CASE.
   A child about two months old was brought to St.
Bartholomew's hospital, with this unnatural enlarge-
ment of vessels, distributed  every where beneath the
fore-arm, from the wrist  to the elbow.  In a short
time it  had swollen to that degree,  that the circum-
ference of the affected fore-arm was twice the size of
the other. The vessels were large and contorted; and
to give the reader an idea of their appearance, I may
mention that the child's mother affirmed that theyr re-
sembled the entrails of a pig,  with which she had
either been frightened or disgusted  during her preg-
nancy.  The skin was of a dusky hue, and had not its
natural smoothness of surface. The heat of this fore-
arm was much greater than  that of the corresponding
sound one.  Pressure forced the blood out of the ves-
sels, and for the  time  diminished  the bulk of the
limb,  and made it of  a  paler colour. The  child's
mother lives at Turnham Green, where Mr. Graham,
an ingenious surgeon, who was for a long time a stu-
dent at St. Bartholomew's hospital, also resides.  I re-
quested this gentleman to  take charge of the case,
and  try the effect of the following plan of treatment, 
 142           On the Treatment of

 which it seemed to me right to institute. First, I was
 desirous of ascertaining whether  a  permanent  and
 equal pressure would not prevent the distention and
 consequent  enlargement of the turgid vessels; se-
 condly, whether reducing  the temperature  of the
 limb would not diminish the inflammatory  action,
 upon which their repletion seemed to depend. These
 two intentions admitted of being readily accomplish-
 ed. A many-tailed bandage of sticking plaster seemed
 adequate to  effect the first, and wetting the limb with
 water the latter.  These measures were judiciously
 carried into  effect by Mr. Graham; the pressure  was
 first made slightly, and afterwards more forcibly, as
 the part seemed to bear it without inconvenience. A
 roller was applied over the  plaster, and kept wet,  if
 the limb felt hotter than natural, so as to regulate its
temperature. The  success of these measures exceed-
ed our most sanguine expectations. The size of the
limb gradually diminished, and its temperature  be-
came natural.  After  six  months,  Mr.  Graham re-
moved the bandages, which it was not necessary to
continue any longer.  The limb was  in some degree
wasted, from pressure and disuse, but it soon gradu-
ally reacquired its  natural size.  After  the bandages
had been left off for a month, I saw the child. The skin
was  pale, and  had a slightly  shrivelled appearance.
The contorted vessels felt like solid  chords inter-
posed between it and the fascia of the fore-arm.

                     CASE.
  A child had this unnatural  state of  the vessels in
the orbit of the eye. They  gradually  increased in
magnitude,  and extended themselves into the upper
eye-lid, so as to  keep it permanently closed.  The
clustered vessels also projected out of the orbit, at the
upper part,  and  made the integuments protrude, 
the JVavi Materni.
143
forming a tumour as large as a walnut.  Of course,
the removal of this disease did not appear  practicable.
I was consulted on  this case by  Mr. Hurlock, to
whom I related the success of the former experi-
ment. Pressure to any  extent  was here evidently
impossible: but the  abstraction of heat,  and conse-
quent diminution  of inflammatory action might be
attempted. I recommended  that folded  linen,  wet
with  rose  water,  saturated  with  alum,  should  be
bound on to the projected part, and kept constantly
damp. Under this treatment the disorder  as regularly
receded as it had before increased. After about three
months  it had  gradually sunk within the orbit, and
the child  could open its eye. Shortly afterwards all
medical treatment  was discontinued, and no appear-
ance of this unnatural structure remains.
   A third case of a very extensive mark of this de-
scription,  covering the back and shoulder, got well,
as I am informed, by the same treatment.  I have
not, however,  been able to learn the particulars. It
appears  to me probable, from the foregoing  cases,
that if the preternatural distention of the vessels could
be  prevented, the blood  would coagulate in  them;
and thus this unnatural contexture of vessels,  being
rendered impervious, might become obliterated.
   Since the publication of these cases, which is more
than four years ago,  I  have seen many  instances of
such  affections,  and they have ceased to grow, and
afterwards shrunk, and been no longer objects of any
Consequence when treated in the manner that I have
described. I have only in one case been  called upon
to perform an operation for the removal of the swell-
ing, which had attained a very considerable magni-
tude before I was consulted respecting its treatment. 
144
        ON HEMORRHOIDAL DISEASES.

  MR. HEY of Leeds,  in his highly valuable Ob.
servations, describes his  mode of  treatment of the
procidentia ani, and that chapter of his work appears
to me to  deserve  particular  praise, because I have
not found the same treatment recommended by other
writers; and because, from the  accounts of the pa-
tients themselves, it has relieved  them  from very
great inconvenience and suffering.  Wishing to cor-
roborate the  statement there given,  and to add my
mite of observation on the practice that is best adapt-
ed for the relief of such diseases, I may  mention, in
the first place, that my attention to this subject was
particularly excited,  even during my apprenticeship
to surgery, from witnessing  the  sufferings of  those
who underwent what I may  call  the  natural cure of
piles. When these organized bodies are large and
numerous, they impede the expulsion of the fasces,
and  the straining consequent to  this  impediment
everts the bowel.  When, at length, the patient is un-
able to restore the parts to their natural situation, the
piles mortify and drop off, and then the bowel retires,
leaving the patient considerably relieved from the dif-
ficulty and pain attendant on the  expulsion of the
faeces. The editor of Mr. Pott's work says, that Mr.
Pott was remarkably successful in removing hemor-
rhoidal excrescences, by ligature;* in some cases such
means may doubtless be proper;  yet it has appeared
to me,  that tying  hemorrhoidal excrescences is pro-
ductive of all  that temporary distress which is ob-
servable in what  I have termed their natural  cure;

  * See sir James Earl's edition of Mr. Pott's Works, vol. iii. 
            On Hemorrhoidal Diseases.        145

and as there is a general disorder in the functions of
the alimentary  canal  in all such cases, the irritation
occasioned by  the  ligature aggravates this habitual
disorder,  and  produces sometimes very  alarming
symptoms.
   With these facts  before me,  I was led to examine
the structure of those piles which had been removed
by a ligature, or which I accidentally met with in the
dead subject; and I found them to be merely fleshy
substances,  possessing no  vessels  of considerable
size, nor  such  as should deter us  from cutting the
excrescences away. It is now  twenty years  since I
first  began to remove them freely with the knife or
scissars, and I have never met with any circumstance
to deter me, whilst  the relief of suffering,  which the
operation  has afforded to some, and the scarcely to
be expected, and complete cure which it has effected
in many, has been highly gratifying.  Piles have been
supposed  to be owing to a dilatation of the hemor-
rhoidal veins, and that these veins are sometimes en-
larged, is evident from anatomical examination, and
from cases which occasionally occur in  practice.  In
a recent  attack of an  hemorrhoidal affection, some-'
thing occasionally protrudes from the anus,  which
when punctured emits a continued stream of blood,
as a vein does when opened. When the blood ceases
to flow, the protruding part should  be replaced, and
maintained in its natural situation.
   The origin and formation of internal piles, is,  I
think,  similar to those which  are  external.  When
from  irritation  about the  rectum,  an external pile
forms, a swelling suddenly occurs  beneath the thin
skin, near the verge of the anus, and the part is heat-
ed and painful.  If the skin be divided, the swelling is
found to be caused  by effused blood; and if the clot
be removed, there is  no stream of blood emitted as
from a vein.  If the wound be small, blood  again cof-
                       T 
146         On Hemorrhoidal Diseases.
lects beneath the skin, and the swelling is reproduced.
If the bowels  be regulated,  so that the state of irri-
tation, which is the cause of these productions,  be
mitigated or removed, and if the slightly painful and
heated swelling be cooled by evaporating washes, the
effused blood is frequently absorbed, and the distend-
ed skin  appears loose and pendulous.  On the con-
trary, if the irritation  continues  from  there  being
some permanent disease on  the inside of the bowel,
then the effused blood becomes  an organized sub-
stance, and a permanent external pile is formed. The
orifice of the anus is often surrounded by tumours of
this kind, which,  however,  do  not require to  be  re-
moved,  and are only indicative of internal irritation.
In like  manner blood is  effused  beneath  the  bowel
just above the sphincter,  and forms an  internal pile.
If it be divided, coagulated blood may be removed
from beneath it, with the same events as occur  in ex-
ternal piles. The effused blood is  sometimes absorb-
ed, and the pile disappears;  but,  more  generally, it
becomes an organized substance, and  increasing in
bulk, whilst others also form, they are productive of
those inconveniences that have been represented.
   Though the eversion of the bowel may, in  many
cases, be attributed to the efforts  made to overcome
the mechanical resistance, which  these  tumours op-
pose to  the expulsion of  the faeces; yet the eversion
is not, in general, to be solely attributed to this  cause.
It arises also from an irritable and striving action of
the bowel, which produces a kind  of intus-susception.
Thus plaits of the bowel often descend in an irritable
action of the part during the expulsion of the  faeces.
I have  known many cases of the following descrip-
tion. A person having some disorder of the bowels,
and  having an urgent call to void the faeces, has suf-
fered afterwards great pain  for a number of  hours.
The next evacuation has been attended with similar 
On Hemorrhoidal Diseases.         147
 cohsequences,  and thus the patients have continued
 for a considerable time, ignorant of the cause of their
 sufferings. On introducing the finger,  I have dis-
 tinctly felt,  and fairly replaced a fold of the bowel,
 and the patient has been immediately relieved from
 all  uneasiness;  and by repeating the same act,  when
 required, and  keeping the bowels-regular by a mix-
 ture of castor oil and mucilage, w ith cinnamon water,
 theyr have suffered no uneasiness subsequent to the
 alvine  discharges, and in a short time this faulty ac-
 tion of the bowel has entirely ceased. But if a patient
 remains  ignorant of the cause of his sufferings, and
 does not adopt this mode of relieving them, the fold
 of  the bowel becomes irritated and thickened by the
 pressure of the sphincter muscle; it enlarges and be-
 comes in form adapted to this unnatural situation,
 and thus we often meet with folds of the bowel form-
 ing hemorrhoidal  tumours. When  a pile,  or any
 hemorrhoidal tumour becomes inflamed and swollen,
 it has a tendency to draw down more of the  bowel,
 and increase the disease.
   The eversion of the bowel thus  produced  from
 hemorrhoidal  affections,  must be considered  as  a
 different case from that  procidentia or prolapsus ani,
 which  takes, place  independently of such affections,
 and it is to the treatment of the former only that this
 paper relates.
  In the first volume of these observations,  I  have
 mentioned,  that to me, all kinds of irritation in-
 ducing local diseases in the lower parts of the  bowel,
 appear to be the effects of a general disorder in the
 functions of the alimentary canal; and that the cor-
 rection of the general affection is essential to the cure
 of the  local disease. If the bowels can be got to re-
 gularly carry down and discharge the residue of the
 food once in twenty-four hours, the  straining, from
costiveness,  and that irritable and repeated action at- 
148         On Hemorrhoidal Diseases.
tendant on purging, both of which must be injurious
to the  local disease, will cease to aggravate it* The
patient should bathe and  anoint the protruded parts
with ointment, and carefully replace them above the
gripe of the sphincter. Under these circumstances
hemorrhoidal tumours, and the procidentia ani often
become of so little inconvenience, as not to induce a
patient to wish for a more radical relief.
   But, if from the  magnitude or number  of these
hemorrhoidal tumours, such an opposition should be
created to the expulsion of the faeces, that the bowel
is forced down  at every attempt to discharge them; if
from the inflamed and ulcerated state of hemorrhoidal
tumours, they7 keep  up an irritable action of the parts
tending to maintain  and aggravate the disease, then
an operation seems to be required.
   I shall now describe, in the briefest manner possi-
ble,  the  treatment and mode of operating which I
have found  most successful in these diseases.  First,
it seems essential, prior to undertaking any operation,
to get the bowels  into the habit of regularly evacu-
ating the refuse matter of the food daily, and the liver
regularly secreting a due proportion of healthy bile.
2dly, The bowels ought to be  perfectly cleared be-
fore the operation; and this may be accomplished,  by
giving to the patient such a dose of medicine as has
been found, by experience, to be likely to answer this
purpose without inducing a continuance of irritation
and  purging.  The bowel  being everted to the ut-
most by the efforts used in evacuating the faeces, and
the parts cleansed by bathing  with tepid water, the
piles should be taken hold of by a double hook, of a
breadth corresponding to the length of the pile, and
when drawn upwards from the  bowel, it may be re-
moved by a pair of scissars. A protruded and thick-
ened plait of the bowel  may be seized  in the same
way;  but I think it  is better to use the bistoury in 
On Hemorrhoidal Diseases.         149
removing it, because the depth to which the scissars
may cut is uncertain.  The  incision made by the
knife resembles two curved lines joined at each ex-
tremity.  The length of the incision should, both for
the removal of piles and that of plaits in the bowel, be
longitudinal, in the direction of the bowel.
   If,  therefore, there be  a transverse fold of  the
bowel of considerable extent,  I think it best to take
away  two  elliptical portions in the long axis of  the
rectum,  rather than attempt more completely to re-
move it by a wound made in another direction.
   The hemorrhoidal tumours being removed,  the
wounds  should be suffered to bleed as long as they
are disposed to do so, and afterwards the parts should
be completely replaced  by  means of the finger, pre-
viously^ anointed.  As irritation is a principal cause of
hemorrhage from the small vessels,  and as that is
likely to be occasioned by any part of the bowel be-
ing lodged within the  gripe  of the  sphincter, and
compressed by that muscle, this part of the operation
should be particularly attended to. The patient should
now be speedily placed  in an horizontal position, the
nates should  be exposed, and the  parts surrounding
the anus should be frequently bathed with cold water,
to check inflammation and consequent hemorrhage.
   Frequently from the apprehension of the vexation
and trouble of a subsequent  hemorrhage, the sur-
geon  is desirous,  after  an  operation,  of tying every
vessel that  could  possibly pour forth blood; yet after
the patient is put to bed, and becomes warm, parti-
cularly if there be any circumstance causing local ir-
ritation in the wounded parts,  hemorrhage even to a
considerable degree ensues.  The wound is  opened
and bathed, and often no vessel  is discovered bleeding,
or requiring a ligature.  Diminishing the temperature
of parts is one of the most potent means which we pos-
sess of lessening inflammatory action,  and this seems 
150         On Hemorrhoidal Diseases.
 to be best accomplished by the continual evaporation
 which is going on when parts are frequently wetted.
 Formerly I met with much trouble from hemorrhage,
 particularly on account of the blood effused  into the
 rectum, creating an uncontrollable propensity to dis-
 charge it per anum; and in this act the wounded parts
 became again protruded and injured.  Since, however,
 I adopted the mode of treatment which 1 have describ-
 ed, 1 have witnessed no inconvenience of this kind.
 In general, the patients feel very comfortable, and the
 anus seems as if there were  no disease.  When  the
 parts have been for some time tranquil, and the risk
 of hemorrhage has ceased, the parts need no longer
 to be bathed or exposed.
  The patient should be restricted  in his diet: the
 food should be of the most nutritive quality, and such
 as is likely to leave the least residue, but the quantity
 should be as small as possible, because it is an object
 to keep the  restored parts  undisturbed for as long a
 time as possible. If the opening medicine, which has
 been given with a view to clear the bowels,  before
 the operation, should be likely to  affect them after-
 wards, some opium maybe administered to prevent it.
  Under these circumstances I have known patients
 lie for eight or ten days undisturbed, and during that
time the wounds, it is probable, had nearly, if not en-
tirely, healed, as the subsequent discharges from the
bowels  were effected without hemorrhage,  or  the
descent of any part. However, as these patients have
a disordered state of the digestive organs,  sensations
seemingly requiring some alvine discharges for their
relief, will induce us to give some  opening medicine
long before  that period. Experience in the  case of
our  patient  should have previously  taught  us, by
what dose  of medicine we might calculate, with some
degree of certainty, to procure one sufficient and lax
motion, which should be parted with by the patient 
           On Hemorrhoidal Diseases.         151

with as little effort as possible.  It is better that the
patient should not attempt to evacuate the  contents
of his bowels till his sensations become urgent. When
a sufficient discharge has taken place, if any thing has
descended, it  ought  to  be carefully replaced  as  it
was after the operation.  A small dose of laudanum
may be given  to  stop  any further  effect  from the
purgative medicine.  Now, though such operations,
conducted  on the plan which I have described, have
been productive of the beneficial effects which I have
represented in the beginning, it is wrong to promise
too much to patients in general, because the irritable
and disordered state  of the digestive organs, which is
habitual, and which  has produced the disease,  may
keep up a disordered state of rectum afterwards, and
occasion new diseases to form of the same nature. 
152
        ON FISTULA IN THE PERINEUM.

   TOWARDS the conclusion of the second part or
 volume of these observations, when speaking of the
 effects of diseases of the urethra, I  had designed to
 insert a chapter explanatory of some circumstances
 relative to those abscesses and  diseases, which fre-
 quently take place, and lay the foundation for fistulas
 in perinaeo. In consequence of my being much hur-
 ried by business  at that time,  it was omitted,  yet
 thinking that its publication may be useful, I insert
 it at the conclusion of the present volume.
   It is well known, that  abscesses  form in the  vi-
 cinity of the urethra, when it is in an irritable state,
 but there are some circumstances  relative to  their
 progress, which perhaps have not been generally  or
 sufficiently attended to. When matter forms  in the
 course of the membranous part of the urethra, or in
 the neighbourhood of the bulb, it does not produce
 inflammation of the skin, or  break  like a common
 abscess; on the contrary, the skin is but little affected,
 and as  the matter  increases  in quantity,  it appears
kept down as if it were collected beneath a fascia.
Under these circumstances it in  general comes for-
wards, in the course of the spongy substance of the
urethra, and bulges out in the middle of the scrotum,
forming  there a tense  protuberant swelling. I have
sometimes known  the  matter make its way  back-
wards, and present  itself between the thigh and but-
tock,  a little below the rectum.  These circumstan-
ces indicate,  that there is a fascia spread beneath the
skin of the perinaeum, over the subjacent parts; yet,
I think,  the  limits of this fascia  can scarcely be  as-
 certained by dissection. 
On Fistula in the Perineum*.        153
   The knowledge of its existence appears to me of
importance  in explaining many occurrences  which
take place about these parts, though its density and
strength varying in different persons, the facts  which
I am endeavouring to represent will vary in degree
in different cases.
   The abscesses of which I  am speaking are  often
simple, no urine having escaped from the urethra to
give rise to  them,  though sometimes after they have
been opened, urine  is found  to  pass  through the
cavity  of the abscess in a greater or less degree.
   These  abscesses ought of course to  be treated as
collections of matter beneath fasciae in general; they
should be opened at an early period, to  prevent their
enlargement. A free opening is proper, because the
skin being only slightly diseased,  and having a great
propensity to heal, will sometimes prevent the free
escape of anyr matter or urine, which may be in the
cavity  of  the abscess. The cavity will  then become
distended and enlarged, perhaps in a  direction be-
tween  the rectum and the thigh,  requiring another
opening to be made in that situation: yet, in general,
I  have not  found it  necessary to  divide the  skin
throughout  the whole front of the  abscess.
   The complicated  sinuses, which form in  some
cases of fistulae  in  perinaeo,  do not appear to me to
arise from  such simple cases, but from the uretnra
ulcerating in many parts.  Anatomical  examination
has  shown  this  to be fact in several cases which I
have inspected.
   The ulceration, or giving way of the  urethra, is, I
think,  generally understood to be the  consequence
of a stricture affording so complete an obstacle to the
passage of the urine, as to  occasion the canal  to in-
flame,  ulcerate, or slough above the impediment,  It
•is very evident that this is not unfrequently the case,
yet  I  do not believe that surgeons in general, are 
154        On Fistula in the Perineum.
sufficiently impressed with the knowledge of the fol-
lowing fact, that the urethra may ulcerate in various
parts from  irritation, even whilst there is a sufficient
channel for the free exit of the urine.  The following
cases are related in proof of this fact:

                      CASE.
  A gentleman  had been attended for a typhoid fe-
ver for between a fortnight and three weeks. A clys-
ter  was ordered for him; but the person who was de-
sired to administer it, could not readily introduce the
pipe; and,  on examination,  it was discovered  that
there was a  considerable induration, discolouration,
and swelling of one buttock,  by the side of the anus.
On this account I was desired to see the patient, and
the appearance of the part  instantly induced me to
say, that some urine had escaped from its  natural
channel, and  caused the inflammation  which  had
been productive of these peculiar appearances.  The
powers of the patient's mind were weak and wander-
ing; yet, when I asked him in a loud voice, whether
he had any difficulty in voiding his urine? he replied,
"Oh,  I told you,  it was my first grievance." Yet I
saw him void his urine freely, and in a  moderate
sized stream.  Perceiving that there was fluid beneath
the thickened and discoloured integuments, I divided
them, and discharged a considerable quantity of pu-
trid matter, urine, and sloughs. The patient became,
for a time, much  better, and  urine  passed freely
through the wound;  yet he afterwards  gradually
sunk,  and died.  In this case, the urine must  have
escaped from  its natural channel very  high up, and
have been forced into the cellular substance connect-
ing die bladder and the rectum, producing that pe-
culiar inflammation, which probably occasioned the
typhoid fever.
* 
           On Fistula in the Perinaeum.         155

                       CASE.
   A similar occurrence happened to a patient whom
 I had previously attended on account of strictures in
 his urethra, and which had been so far relieved,  that
 a moderate sized  bougie could be  passed  into the
 bladder, and he voided his urine freely in a moderate
 sized stream. He had for some months discontinued
 the  use of bougies previously to the event which I
 am  going to relate. He was seized with a  kind of
 low fever, but his attention seemed to be directed to
 the seat of his disease, so that it became remarked at
 an early period, that the integuments of the buttock,
 by  the side of the rectum were inflamed.  The simi-
 larity of this case to the preceding one induced me to
 make an incision through the skin and subjacent sub-
 stance to some  depth, when a  considerable quantity
 of fetid matter and urine gushed out. I saw this pa-
 tient void his  urine, which he did with apparent free.
 dom, and in  such  a stream as I have described. He
 was relieved  by having an outlet given to the urine
 and  matter, which  continued to pass freely  through
 the  wound; yet he afterwards  gradually sunk,  and
 died. To my great regret, I was prevented from ex-
 amining the parts after death, in both of these cases.


                      CASE.
  A patient who had suffered  for more than a  fort-
 night with slow fever, in which his intellects were so
 impaired, that he communicated no information to
 his medical attendant respecting the nature of his dis-
 order, was observed to have a swelling near his left
 groin, which  was supposed to be a common abscess.
 This disease increasing, and showing no tendency to
 break, after a few days,  I was desired to see the  pa-
tient. The swelling then was as large as an  orange, 
156       On Fistula in the Perinaum.
but oblong, extending from the groin clown the front
of the scrotum. The colour and  induration of the
skin,  in such cases, are in  general so peculiar, as at
once to impress the opinion, that effused urine has
been  the cause  of the inflammation and abscess.  I
without hesitation cut through the  thickened integu-
ments, and  discharged  about six  ounces  of putrid
pus and  urine.  A quantity of sloughy cellular sub-
stance soon afterwards protruded through the wound,
which gradually separated  and came away. The pa-
tient's intellects soon became clear, all fever left him,
and he soon regained his usual state of health.  In this
case,  1 conclude, that the urethra had given way on
its left side, in front of the fascia, which covers and
binds down the  parts beneath the skin  of  the  peri-
naeum, and in the vicinity of the abscess.  I mention
this opinion to lead us to form a probable conjecture
as to the cause of the urine becoming  diffused, in
some cases, beneath  the integuments of the pubes
and abdomen.
   When circumscribed abscesses form,  it is pro-
bable, that the quantity of urine which escapes from
the urethra is small, and that by its irritation it occa-
sions  adhesion of the surrounding cellular substance.
In the case just related, the quantity must have been
sufficient to have occasioned the death of a consider-
able quantity of cellular substance. When the urine
is diffused, and  injected into the  cellular substance
extensively,  scarifications  afford but an ineffectual
outlet to it.  The practice  most appropriate to  these
cases would be, at as early a period as possible, to
make a wound down  to the aperture in the urethra,
so that whatever urine may escape  from  the  canal
should run freely out of the wound, and  be no longer
forced to pervade the cellular substance.  Yet it is dif-
ficult, nay, perhaps in some cases impossible, to know
where the urethra has given way; and one object which 
          On Fistula in the Perinaum.         157

I had in view in relating these cases, was to induce
others to reflect, and to endeavour to ascertain, by
experience, how and  where  we ought  in  different
cases,  to make such wounds as will afford  free dis-
charge to the urine,  and prevent the horrible effects
of its becoming extensively diffused through the cel-
lular substance. Our conjectures respecting the situ-
ation of the aperture, will be much assisted by the
history of the case. If the swelling and inflammation
began at the top of the scrotum, near the pubes, it is
probable, that the diseased aperture of the urethra is
in front of the  perinaeum; if it began on one side, it
is probable, that the opening of the urethra is on that
side.  Were surgeons fully aware  of the nature and
urgency  of  the case, and bold enough to do what is
required of them;  that is, to cut through the swollen
and inflamed parts, till they exposed the tube of the
urethra, I am convinced many lives might be saved.
If the integuments of the perinaeum be affected, it is
probable, that the aperture in the urethra is as far, or
farther back than that part; yet respecting this  point
we may err, it frequently happening that the  aperture
in the urethra is far back, and  yet the integuments of
the perinaeum may contain no urine, the fascia, which
I have spoken of, preventing that fluid from  affecting
them.
  I shall briefly relate two more cases to exhibit other
varieties  of these diseases.
                      CASE.
  A gentleman, who was  more than seventy years
of age, but of a  strong constitution, who had never
found  any difficulty in voiding his urine  till a few
days before the occurrence, which I am about to re-
late, and  who  actually did void it freely  in a full
stream, after his urethra had given way, so as to al- 
158         On Fistula in the Perinaum.
low of the escape of a considerable portion of the
urine, was suddenly seized with shivering  and se-
vere indisposition. The patient did not complain of
any thing being wrong about the scrotum, or urinary
organs, till about two days,  when he mentioned that
his testicles were swollen.  When  I saw him, the
scrotum  and integuments of the penis  were much
distended and mortified on  the  surface  in several
largs irregular black patches.  The distention of the
scrotum  was not merely occasioned by urine, it was
emphysematous  also from air extricated  by putre-
faction.  The integuments of the perinaeum   were
scarcely affected.  The patient said that the swelling
had begun from behind, and on the  left side. I  con-
cluded, that in this case, the urethra had given way
in the perinaeum, and that  the urine had passed in
the course of that canal, between it and the fascia,
which I  have spoken of,  till it arrived  at the loose
cellular  substance of the  scrotum which  it readily
pervaded. I know this to have been the fact in some
similar cases which  I  examined  after  death; and I
conclude it to be  owing to the resistance of a fascia
spread beneath the skin, that the integuments of the
perinaeum are not affected, even though the urethra
has given way beneath them. As the object of sur-
gery is  to make an external wound opposite to the
orifice in the urethra,  I pursued a practice in this
case which I had found successful in several others
of a similar nature,  and which  I was  led to adopt,
from discovering that the aperture in the urethra was,
in some cases which I examined, much farther back
than the  part where the urine first appeared to  have
pervaded  the cellular  substance of the scrotum.  I
made a wound about two inches and a half in length,
thr4%h the integuments and subjacent cellular  sub-
stance of the perinaeum and back part of the scrotum,
in the direction  of the urethra, but more to the left 
           On Fistula in the Perinaum.        159

side.  The wound need not extend farther back than
the bulb, and should, I think, come forwards so as
to divide the integuments of the  back part  of  the
scrotum, where the swelling  first takes place. The
object of this wound is to lay bare the fascia of  the
perinaeum, and the operator may now feel the groove
which intervenes between the spongy  substance of
the urethra and the crus penis. Now/in cases of this
description, I have  proceeded to divide the  fascia,
which is spread  over these  parts,  so  that I could
more  distinctly pass my finger into the groove which
is formed between them, and  gently elevate the fascia
from off the spongy  substance of the urethra. I  did
so in the present case, and was anxious that the  pa-
tient should void his urine, that I might see if it came
through the wound which I had made, but he was
unable at that time to discharge any. However,  af-
terwards when he made water, it continued to pass
freely through the wound in the perinaeum.
  Having formerly  been perplexed with regard to
such cases as I have last described, and having now
operated in many similar instances, with the same
event; that is, with a perfectly free discharge being
afforded to the urine which escapes from its natural
channel, I thought it might be useful to publish one
of them, and I will add another of a different kind, to
show the necessity and propriety of our endeavouring
at  once to  give a free discharge to the urine,  by
making  an external  wound,  which communicates
with the aperture in the  urethra. 
16©         On Fistula in the Perinaum.
                      CASE.
  A gentleman, of seventy years of age, was affected
with a kind of intermittent fever,  for which  he was
attended by  a physician, from whom he concealed
that he  had any disease  of his urethra.  After some
weeks, however, the patient informed him one morn-
ing, that he  had a slight swelling  of one testis. On
this account I was desired to see the  patient, who re-
sided a little way from London.  The swelling of the
scrotum at that time was not larger than a large ap-
ple; it was situated at the back part of the bag, and
on the right side, and its appearance was very demon-
strative of its nature; I urged the patient, but in  vain,
to permit me to divide the skin, but he said he would
allow no operation to be done, unless in consequence
of the opinion of other surgeons in consultation.
  I found that he had for  the greater part of his life
been in the frequent habit  of passing bougies for  him-
self, and that he was uncertain of his ability to intro-
duce even a very small one. As no  consultation could
be held on his case, till the following day, I called on
the patient in the evening,  taking with me an extremely
small flexible varnished catheter, hoping that I might
be able to pass it, or if I  should fail,  that I might be
allowed to give a free exit to the effused urine. At
that time, however, I found the whole scrotum uni-
formly distended to a very great size, and the integu-
ments of the penis  so swollen and projecting, that it
was impossible, without an operation, to discover the
orifice of the urethra. The patient having appointed
other surgeons to attend on the subsequent day, was
resolved to abide the result of their opinion, before he
would submit to any wound being made. On the en-
suing day,  several large  irregular  mortified  patches
had formed on the  integuments of the scrotum and 
           On Fistula in the Perinaum.       161

penis, and the patient was so sunk and confused in
his intellects, that an operation was, I believe, deemed
useless by all present, except myself.  I knew the pa-
tient was in other respects healthy, and I had many
times seen the whole skin slough off from the genitals,
and the patients survive and do well. As, however,
an operation was the only resource, it was performed.
We drew the patient's legs and thighs out of bed,
and turning him on his face,  the perinaeum presen-
ted itself in such a manner as to admit of my per-
forming the  operation.  The integuments  of the
perinaeum were now greatly swollen, which circum-
stance  I had not observed before.  I  made a wound
in the direction of the one made in  lithotomy, and
cut through between two and three inches of cellu-
lar substance cedematous with urine, before I could
touch the bulb of the urethra, or other parts  situa-
ted beneath them.  I raised the tumid integuments
from off the subjacent parts with my  finger, but
still  no urine flowed.  I then endeavoured to pass
my finger by the side of the bulb towards the pros-
tate,  in  the direction of the  urethra; and in a few
seconds, about three pints (as  I should guess)  of
highly putrid  urine, mixed  with  purulent matter,
was  suddenly and  forcibly' projected. Being now
assured that the bladder could readily discharge the
urine through  the external  wound,  I cleansed and
dressed the parts. The patient got into his bed with-
out assistance, and expressed, with vivacity, all that
comfort and relief which every  one  experiences
from the evacuation of a much distended bladder.
The  mortified  patches of skin separated, yet suffi-
cient remained to  give a covering to the genitals.
Great quantities of mortified cellular substance came
through the apertures left   by  separation  of the
superficial sloughs. I was able  to  introduce a very
fine elastic catheter, and by enlarging its size, week-
                       X 
162       On Fistula in the Perinaum.
ly, the urethra regained its natural calibre in all it's
parts; so that the patient voided his urine in a larger
stream, and with  more freedom and force than he
had  done for for  fifty preceding years. It  seems
right however to add,  that after  two  years, the
stream having again diminished he  had recourse to
bougies, and met  with opposition  from the  stric-
tures which  had contracted again during that in-
terval. 
 
 
SURGICAL OBSERVATIONS
ON
TUMOURS,
AND ON
LUMBAR ABSCESSES.
        BY JOHN ABERNETHY, F. R. S.

Honorary Member of the Royal Medical Society of Edinburgh, and of the Medical
      Societies of Paris, Philadelphia, &c. Assistant Surgeon to St. Bar-
       tholomew's Hospital, and Teacher of Anatomy and Surgery.
Y 
1 
SURGICAL  OBSERVATIONS.
An Attempt to form a  Classification of Tumours
     according to their Anatomical Structure.


 1  HE observations which I have had an opportu-
nity of making in St. Bartholomew's Hospital, on
the various tumours which  occur in the human
body, have been so numerous, that I have almost
felt myself under  the necessity of forming some
classification of those diseases. This classification I
have attempted according to their anatomical struc-
ture, which allows,  at the same time, of a corres-
ponding  arrangement of those  practical remarks
that have been  promiscuously  collected. I have
long felt  so sensibly the advantages resulting from
an orderly  arrangement  of this extensive subject,
that I have taught  it for some years in my Lec-
tures  in  the  manner  exhibited in the  following
pages. I am far, however, from being satisfied with
the method which  I have adopted;  but it  is the
best that I  have been able to devise; and, at least,
it has this  utility,  that it admits  of  a number of
important cases being arranged in a  perspicuous
manner, and prevents that obscurity which a total
want of order necessarily  creates. 
166        A Classification of Tumours.

  My  motives  for  laying  this paper before the
Public are; first, a  conviction,  that  an extensive
knowledge of this  subject, such  a knowledge as
would lead to an attempt  at classification, and to
ascertain the peculiarities which characterize the
different species of tumours, can only be obtained
by  those who have very  ample opportunities of
observation.  But  it is  probable  that,  when the
subject in general has been surveyed, and its  parts
pointed out, those parts  may be discriminated and
examined with  accuracy and advantage, by per-
sons who have not had  opportunities of contem-
plating the whole.  2dly, The minds of medical men
having of late been laudably excited to investigate
the nature of cancer, in hopes of discovering some-
thing  serviceable in that  dreadful disease, it be-
comes right to remark, and  it will  appear  from
the following account, that  there  are  many  local
tumours and ulcers, as intractable in their nature,
and destructive  in their progress, as cancer, which
are liable to be  confounded with that disease, but
which ought  to be  distinguished  from it, before
any progress  can be made in this difficult part of
medical science. The society for the investigation
of  the  nature of cancer have inquired  about the
anatomical  structure of that disease, and  about
other  disorders which have a resemblance to it.
In  the present paper I have attempted to reply to
such interrogations, as far as my knowledge enables
me. It appears to me, that, in order fully to investi-
gate  any subject with advantage,  a  great deal of
collateral knowledge is required, which serves like
light shining from various places,  to illum'inatc
the object of our researches.  I am  not without
hopes ihat this paper will tend to point out the
required  distinctions,  and furnish such collateral
knowledge. 
           A Classification of Tumours.        167

   In  engaging in a new undertaking, I am likely
 to expose my  own deficiencies of information; and
 by  adopting a new  and perhaps  injudicious ar-
 rangement,  and employing  new and  perhaps unfit
 terms, I may lay myself open  to criticism and cen-
 sure. I am  not unwilling,  however,  to  encounter
' these risks,  when I have it in  view  to bring a diffi-
 cult and interesting subject  fairly before the public;
 in hopes that, by exciting  the attention and  en-
 gaging the  labours of many persons,  it may, at
 length, acquire that perfection of which it is sus-
 ceptible, and which could never be brought about
 by  the exertions of a few individuals.
   The subject of tumours occupies a considerable
 space in the works of the ancient writens on medi-
 cine. They  seem, however,  to have considered the
 subject, rather with regard  to its name than its na-
 ture; for we find a great variety of dissimilar dis-
 eases collected, I cannot say arranged, under the
 same general title. The error  has descended to us,
 and even in Dr. Cullen's  Nosology we find dis-
 eases of arteries, veins, glands, tendons, joints, and
  bones, brought together under one order, and de-
  signated by  the same  name of  tumours.  Some
  of  these also  are merely enlargements  of natural
  parts; whilst  others are entirely new productions,
  having  no existence in the  original composition of
  the body. We have, I  believe,  sufficient know-
  ledge of the nature of these diseases to class them
  more scientifically; and as this has not yet, as far as I
  know,* been done, I shall  endeavour to supply
  the deficiency.

    * Plenck published, 1767, a work intitled '< Systema Tu-
  raorum," which I have not seen, but I conclude that it does
  not resemble the present attempt; since no arrangement,
  like that which  I have made, is  to be met with in the Ency-
  clopedic Methodique. 
165       A Classification of Tumours.
   In  the  definition which  I  mean  to give  of tu*
mours,  I  shall trespass as much against  the usual
import of the word, as nomologists have hitherto
done  in their classifications against the nature of
the disease. For 1 shall restrict the  surgical signi-
fication of the word "Tumour" to  such swellings
as aii^e from  some new production, which made
no part  of the original composition  of the body;
and by this means I shall  exclude all simple en-
largements of bones, joints, glands, &c. Many en-
largements of glands are however  included in the
definition, as they are found to be  owing to a tu-
mour growing in them, and either  condensing the
natural structure, or causing  the absorption of the
original gland.  Sometimes also the disease  of the
gland seems to produce an  entire  alteration  of
structure in the part; the natural organization being
removed,  and  a  new-formed diseased structure
substituted in its stead. In either of  these cases the
disease of the gland is designed to  be included  in
the definition;  and the  practical remarks  which
follow will equally apply to the same kind of  dis-
eased structure,  whether  it  exist  separately by
itself, or occupy the situation of an  original  gland.
The structure  of  tumours is also  a part of mor-
bid anatomy  which  deserves to  be examined;
since  (as it did not come within the scope of the
undertaking) it has  not been fully discussed by
Dr. Baillie in his very valuable treatise on that  sub-
ject. Yetas he has given representations of glandular
parts enlarged by a diseased structure of an entirely
new formation; so I shall have the advantage of re-
ferring the reader to his accurate  and expressive
representations of some of those appearances which
it  is my purpose to describe.  There is an observa-
tion of this judicious and accurate  writer which I
shall take the liberty of inserting,  since it  justly 
A Classification of Tumours.        169
appreciates the degree of utility of investigations
like the present: he observes, " that the knowledge
of morbid structure does not lead with certainty to
the knowledge of  morbid actions, although the
one is the effect of the other; yet surely it lays the
most  solid  foundation  for prosecuting such  in-
quiries with success.  In proportion, therefore, as
we shall become acquainted with the changes pro-
duced  in the structure of parts  from diseased ac-
tions, we shall  be  more likely to make some pro-
gress towards a knowledge of  the  actions them-
selves, although it must be very slowly."
   The  incipient state of tumours  will naturally
first engage our attention;  and  those, which per-
haps form the best example and illustration of the
subject, are such as  hang into  cavities from the
membranous surfaces which form their boundaries.
The cause of tumours having a  pendulous attach-
ment attracted the attention of Mr. Hunter, who
made the  following remarks  on the formation of
one on the inner surface of the peritoneum, as is
related by Mr. Home in the Transactions of a So-
ciety for the  Improvement of Medical  and Chi-
rurgical Knowledge,  Vol. i. p.  231. "The cavity
of the abdomen being opened there appeared, lying
upon the peritoneum, a  small portion of red  blood
recently coagulated; this, upon  examination, was
found connected to the  surface  upon which it had
been  deposited by an  attachment  half an inch
long, and this neck had been  formed before the
coagulum had  lost its red colour."  Now had ves-
sels shot through this slender neck,  and organized
the clot of blood, as this would  then have become
a living part, it might have grown to an indefinite
magnitude, and its nature and progress would pro-
bably have depended on the organization which
it had assumed. I have in my possession a tumour, 
 170       A Classification of Tumours.

 doubtless formed in  the manner Mr. Hunter has
 described, which  hung pendulous from the front
 of the peritoneum, and in which the organization
 and consequent actions have been so far completed,
 that the body of the tumour has become a lump of
 fat, whilst the neck is merely of a fibrous and vas-
 cular texture.  There  can  be little doubt, but that
 tumours  form  every  where  in the same manner.
 The coagulable part of the blood being either acci-
 dentally  effused,  or deposited in consequence of
 disease,  becomes afterwards an  organized and
 living part,  by  the growth of the  adjacent vessels
 and nerves into it. When the  deposited  substance
 has its attachment by a single thread, all its vascular
 supply must proceed through that  part; but  in
 other cases the  vessels shoot into it irregularly at
 various parts of its surface. Thus an unorganized
 concrete  becomes a living tumour, which has  at
 first  no perceptible peculiarity as to its  nature;
 though it derives a supply of nourishment from the
 surrounding parts, it seems to live and grow  by its
 own independent powers; and the future  structure,
 which it  may acquire,  seems to depend on the ope-
 ration of its own vessels. When the organization
 of a gland becomes changed  into that  unnatural
 structure which is observable  in tumours, it may
 be thought in some degree to contradict  those ob-
 servations: but in this case the substance of the
 gland is the matrix in  which the tumour is formed.
  The structure of a tumour is sometimes like that
 of the parts near which it grows. Those which are
pendulous  into joints, are of a cartilaginous or
 osseous fabric;  fatty tumours  frequently form in
 the midst of adipose  substance, and  I  have seen
 some  tumours growing from the palate, and having
a slender attachment, which in structure resembled
the palate.  Sometimes, however, they do not  re 
A Classification of Tumours.       171
semble in  structure  the  parts  from which they
grow. The  instance just mentioned, of the pendu-
lous  portion of fat growing from the peritoneum,
will serve as a proof: the vessels, which had shot
into it, made the tumour  into fat, whilst the neck
was of a fibrous and vascular structure. I have seen
osseous  tumours unconnected with bone or peri-
osteum; and indeed, in general, the structure of a
tumour is unlike that of the part in which it is pro-
duced. Therefore we seem warranted in concluding,
that in many cases the nature of the tumour de-
pends on its own actions and organization; and
that, like  the embryon, it merely receives nourish-
ment from the surrounding parts.
   If, then, the coagulable part of the blood be from
any cause effused, if the adjacent  absorbents  do
not remove it,  and the surrounding vessels  grow
into it, the origin of a tumour may be thus formed.
It may be right to reflect a little on the causes which
may occasion a deposition and consequent organi-
zation of the coagulable part of the blood;  as such
reflections throw light on the nature and growth of
tumours, and lead to the  establishment of princi-
ples,  which are applicable to tumours in general.
The deposition of the coagulable part of the blood
may be the effect of  accident, or of a common  in-
flammatory  process,* or it  may be the consequence

  * It will  probably be useful  to illustrate this  subject by
the recital of a case:—
                      CASE.
  A medical practitioner bruised the upper part of his thigh
against the  pummel of a saddle, in consequence of his horse
starting. The bruise and slight inflammation attendant on
this accident  soon disappeared, but after some months, he
perceived a small tumour, which gradually increased, till it
acquired a considerable magnitude, He came to London, and 
172       A Classification of Tumours.
of some diseased action of the surrounding vessels
which may influence the organization and  growth
of the tumours.
  In the former  cases, the parts surrounding the
tumour may be considered  simply  as  the  sources
from which it derives its nutriment, whilst it grows
apparently by its own  inherent powers,  and its
organization  depends upon actions begun and ex-
isting in itself. If such a tumour be removed, the
surrounding  parts, being sound, soon heal, and a
complete cure ensues.  But if a tumour be re-
moved, whose existence depended on the disease
of the surrounding parts,  which are still left, and
this  disease be not altered by the  stimulus of the
operation, no benefit is obtained: these parts again
produce a diseased substance, which has generally
the appearance of fungus,  and, in consequence of
being  irritated by the injury of the operation, the
disease is in general increased by the means which
were designed  for its cure. It appears therefore
that  in some cases of tumours, the newly formed
part  alone  requires removal, whilst in others the
surrounding  substance must be taken away, or a
radical cure cannot be affected.
  There  is yet another circumstance deserving
attention, before I proceed to the particular consi-
deration of the subject; which is, that a  tumour
once formed, seems to  be  a sufficient  cause of its
own continuance and increase. The irritation, which
it causes in the contiguous parts, is likely  to keep
up that increased action of vessels which is neces-
sary to its supply; and the larger it becomes, the

had it removed. It was an adipose tumour, and had a distinct
capsule inclosing it, formed by the condensation of the cellu-
lar substance in which it had grown. 
A Classification of Tumours.         175
more does it stimulate, and of course contribute to
its own increase.
    Suppose  then  a tumour  to  have formed, and
increased; it will  continue to grow and  to con-
dense the surrounding cellular substance, and thus
acquire for itself  a kind of capsule. Tumours are
more closely or loosely connected to the surround-
ing parts; which  circumstance seems  to  depend
upon the  degree of stimulus which they occasion,
and the inflammation which they thus excite. This
irritation  perhaps  may be the cause why some tu-
mours, which are  slow in their first increase, grow
rapidly after they have acquired a certain size.
   These preliminary observations will  be referred
to, when  the different kinds of tumours  are  de-
scribed. When the history of different kinds of tu-
mours is  spoken of, there will be frequent neces-
sity to advert to the effects of  medical treatment
upon them;  it therefore seems right to premise a
few words upon that subject.
   It  can  scarcely be doubted that when tumours
form and  grow, there exists an increased state  of
action in  the adjacent vessels, and the  first  cura-
tive intention in these diseases will therefore  be to
repress as much as possible this  unusual exertion
of  the vessels, which gives  rise to the formation
of a tumour, and, by its continuance, causes its in-
crease.
   I know of no local measures  to diminish an in-
creased or inflammatory action of any part of the
body more rational in theory, or, more  efficacious
in practice, than those of taking away the two great
causes of  animal actions, the blood and heat of the
disordered part. The former is generally accom-
plished by means of leeches applied in its vicinity,
which should be repeated as circumstances indicate;
and the latter, by the application of folded linen, 
174        A Classification of Tumours.
 wetted with sedative lotions, by which a continual
 evaporation and constant abstraction of heat is kept
 up from the surface of the skin. The effect of this
 last mode of treatment is much more considerable
 than at  first sight might be supposed.  It operates
 on parts far  beneath  the  surface. As  heat is so
 transmissible  a substance,* so in  proportion as
 the temperature of the skin is diminished by eva-
 poration, it derives heat  from the subjacent parts,
 and thus are  their  morbid  actions  lessened.! If
 by such means  the  growth of a tumour be sus-
 pended, another curative indication naturally arises,
 which iis to  promote  the  absorption  of the new
 formed  substance.
   This  indication  is  generally attempted  by the
 use  of stimulants, such as frictions with mercurial
 ointment, pressure,  and electricity,  or by  means
 which also excite some counter irritation, as rube-
 facient   plasters,  solutions  of  salts,  blisters,  and
 issues.   Both  reason  and experience equally  de-
 monstrate the  impropriety of using the stimulating

  * Though  this expression may not be  correct,  the idea
 which is  designed to be conveyed by it, will, I believe, be
 understood.
  t The regulation  of the temperature of diseased parts,
 seems to  bean imporant object in the treatment of local
 diseases; and it is very possible, that by producing evapora-
 tion from the surface we may chill them. Patients, therefore,
 ought to be apprised, that our object in the use of evaporating
 washes, is merely to prevent an unnatural degree of heat. It
 is not necessary  that the washes should be applied cold to
 accomplish this object. A chilly sensation imparted to a por-
 tion of the skin may affect the whole surface, and  produce
 that affection which we call a cold. In many cases, a bread
 and water poultice seems to me the best application we can
 employ,  both with a view to abstract superfluous heat, and
on account of its soothing properties. It is indeed a local warm
bath, and, like the bath, it induces a gentle perspiration from
the surface. 
A Classification of Tumours.       175
plan till the disease is first tranquillized, and in a
degree subdued. It is  reasonable  to  expect that
stimulating measures will increase the actions,
which are going on  in the diseased part; and ex-
perience proves that diseases are  often increased
by  those  very means which, had  they been em-
ployed at a proper time, might have effected their
cure. This may be elucidated by a fact which  is,
I believe, generally known and admitted, that if a
blister be applied for the cure of a pleurisy before
evacuations are made use of,  and the activity of
the disease be thus checked, it aggravates the dis-
ease; if afterwards, it speedily effects  a cure. If a
tumour or any local disease be for a time benefit-
ed  by stimulating  discutients, and the diseased
actions recur in it with a degree of activity; it is
better to desist from this latter plan of treatment,
and adopt again the former one,  till the disease is
by  such means rendered inactive.
  I am so well convinced of the necessity of at-
tending to the time and circumstances in which
these remedies are applied in order to give them
their real efficacy in the cure of local diseases, that
I have been induced to dwell longer on this subject
than may perhaps to some seem  necessary.
  When  a blister is made permanent, or a seton
or  issue is made in the vicinity of a disordered
part, it is in fact producing a new but curable dis-
ease, in  order to detract  from an  old one, over
which we have less control. But here the same ob-
servations apply.  We should not  produce a new
disease till the active state of the original one is
diminished,  and till it  is, as it  were,  rendered
dormant;  for otherwise the irritation of the intend-
ed remedy will rather tend to the aggravation than
the cure of the disorder; it will  also  increase  the
febrile disturbance  of the constitution, by adding 
 176       A Classification of Tumours.

 to the causes of irritation. It should also be borne
 in mind, that the  intended  remedy is a  disease of
 our own creating; and, if it'be a painful one, that
 it may,  by disturbing the  constitution, do  more
 harm in this way to the original disease than good
 by  its counter-irritation.
  Such are the  local means of treating tumours,
 as  well  as  other  local diseases,  and  to  these I
 shall  have occasion to refer. I cannot speak of the
 general means  usually employed  to operate  on
 these disorders  without entering into a long, and,
 I think, an unnecessary discussion.
  In  attempting a classification of tumours, I shall
 suppose  that they may be made  to  constitute an
 Order in the class of  local diseases in nosology;
 and the meaning of the word may be restricted, in
 the manner suggested, to substances of new for-
 mation, which made no part in the original struc-
 ture of the  body;  the  order may then be divided
 into genera, and the first  genus may be denomi-
 nated from its  most obvious  character, (that of
 having a firm and fleshy feel,)  Sarcoma, or Sarco-
 matous tumours.
   This  genus contains many species,  to  a de-
 scription of which I next  proceed.  The first of
 which I shall treat, being  apparently composed of
the coagulable part  of the  blood, rendered  very
generally vascular by the growth of vessels through
it, without having any noticeable peculiarity in their
distribution, may therefore be called


     Common Vascular, or organized Sarcoma.

  The names by which I have distinguished the dif-
ferent species of sarcoma have been  objected to,
because they are  derived  from internal cireum- 
          A Classification of Tumours.       177

stances, and not from any information, which can
be acquired prior to an operation. I have not, how-
ever, been able to devise any better mode of deno-
minating  these tumours:  for all  the species must
agree in  the external characters, those of an in-
crease of  bulk, and a fleshy feel. If,  however,  an
arrangement of tumours were once made, so that
the history of each species could be particularly
remarked, we might perhaps  be able, from this
circumstance, to form a probable opinion of the
nature of the tumour, and of the  mode of treat-
ment which  it would require; and, by adverting
to the  structure of the removed tumour after  an
operation, we  might determine whether it would
be right to remove or leave the contiguous  parts.
It is designed, then, to include under this title  all
those tumours which appear to be composed of the
gelatinous part of the  blood, rendered more or less
vascular by the growth of vessels through it.
  The vessels which  pervade  this  substance are,
in different instances, either larger or smaller, more
or less  numerous:  they are distributed in their
usual arborescent manner, without any describable
peculiarity of arrangement. This kind of tumour
seems to be the most  simple in its nature; many,
perhaps all, of the varieties of tumours, were  at
first of this nature. The  fatty tumour lately men-
tioned was doubtless  at  first a common vascular
substance; but the vessels secreted fat in the body
of the tumour, whilst  the neck underwent no such
change.
  They are such tumours, then, as are  organized
throughout, but without distinguishable peculiarity
of structure, that are meant to be considered under
this title.  This structure is met with not only  in
distinct tumours, but likewise in the testis, mamma,
and absorbent glands.  In the testis I have seen the 
178       A  Classification of Tumours.
vessels, very numerous and small, dispersed through
every part of the tumour. In the mamma they seem
to be rather large than numerous, and  the  organi-
zation appears less complete.
   When this kind of tumour has attained a consi-
derable size, the superficial veins appear remark-
ably large; on which account, together with their
curiously meandering course beneath the skin, they
cannot fail to attract attention. Perhaps the weight
of the tumour compresses  the deeper seated veins
and obliges the blood to return in larger quantities
through those nearer the surface; or perhaps these
vessels  undergo a  kind of sympathetic enlarge-
ment;  for they do not appear to  be  distended  by
the blood which they contain.
  These tumours are generally dull in  their sensa-
tion; enduring even  a rough  examination by the
hand, and electric shocks, without becoming pain-
ful. I suspect that it is this kind of sarcoma, which
sometimes, though rarely, suppurates; but as, when
that  event takes place,  even partially, the rest of
the substance is, in general, speedily removed  by
absorption, I have  had no opportunity of ascer-
taining this circumstance.
  These tumours generally grow till the skin is so
distended that it  ulcerates, and  exposes the new-
formed substance; which, being as it were obliged
to inflame,  and not  being able to sustain disease,
sloughs and falls out; sometimes portions seem to
be detached, and come  away without sloughing.
In this manner is the disease occasionally got rid of;
but such is  the constitutional irritation attending
this process, and the disgusting frjetor and frightful
appearance of the part, that the  surgeon generally
recommends, and  the patient submits to  its  re-
moval at this juncture.
  As cases will probably convey more information 
A Classification of Tumours*       179
in less words than description or narrative, and as
they identify the  kind of disease which  is meant
to be described, and inform, as it were by example;
I design to  relate  one or more cases of each kind
of tumour, and thus curtail as much  as  I can mv
description of them.
                     CASE I.

   A woman, between forty after fifty years of age,
 was admitted into St. Bartholomew's Hospital, on
 account of a considerable tumour which had grown
 on the inside of the knee, and had  so concealed
 the tibia, that it could not be felt. She remembered
 it when of  the size  of an egg, but could give no
 information to  our enquiries, whether in that state
 it was fixed to the  bone,  or moveable upon it. It
 measured two feet in circumference, and had been
 gradually increasing between three and  four years.
 The veins were  large, and formed an appearance
 like network on  the surface.
   As the tumour advanced in size  it had gradually
 prevented her moving about till it entirely confined
 her to  her bed. In this situation it was not painful
 till within half a year before her admission into the
 hospital; when, from the sense of distension of the
 skin, and the inflammation induced  in that  part,,
 she became restless and feverish, and lost her flesh
 considerably. At length, the skin ulcerated, and the
 exposed tumour inflamed and sloughed at different
 times,  so as to  leave a cavity in it  of the size of a
 pint bason. From the sides of this cavity there was
 poured forth a most  copious and fetid  discharge:
 she had  frequently  lost  blood from the vessels
laid open  by ulceration  or  sloughing; and, on
her admission  into  the hospital,  she had a  con-
                    2 A 
180       A Classification of Tumours.

firmed hectical fever, through weakness and irriga-
tion.
  The state of the patient's health, the magnitude
of the tumour, the uncertainty of its origin, (for it
was supposed to have arisen from a diseased bone,)
made amputation appear the only means  of  pre-
serving life.  Upon  an examination of  the ampu-
tated limb, which was  previously injected, this tu-
mour was found  to have no connection with  the
bone or joint upon which it lay. The lower part of
the tumour was covered by a  thin capsule, made
apparently of condensed cellular substance, and it
was  loosely  connected  to the parts on which it lay;
but on the surface of the tumour next  the skin the
capsule firmly adhered to it in consequence of the
inflammation which had taken place. The substance
of which the tumour  was composed  appeared to
have been  originally of a coagulable  nature, and
the vessels which ramified throughout  it, appeared
to be rather large than  numerous:  yet this ap-
pearance might have arisen from an imperfect in-
jection.
   This single case is  sufficient to convey all the
 general information  on this subject, which I  have
 obtained. It is unnecessary to add parallel instances,
 and I am unwilling to load the account with mi-
 nute particulars, lest they should obscure the  prin-
 cipal facts. Probably from the want of knowledge I
 may have included, without discrimination, many
 varieties in  this species of tumour; and, perhaps,
 further observations will furnish more specific dis-
 tinctions in these diseases. The subject is but be-
 gun; and the difficulty of the  investigation will, I
 hope, apologize for the small advances  which I
 have been as yet able  to make. 
            A Classification of Tumours.       181


                Adipose Sarcoma.

   This is a very common species  of sarcomatous
 tumour,  and is formed most  commonly  on the
 front, or  back part of the trunk of the body,  and
 sometimes in the extremities.
   Although it is generally formed in  the midst of
 cellular and adipose  substance, there  can  be little
 doubt that its origin is like that of other tumours;
 that, in the first instance, it was coagulable  lymph,
 rendered  vascular by the growth of  vessels  into it,
 and that  its future structure was the consequence
 of their arrangement and  actions. That  this  Was
 the  case  in the pendulous tumours mentioned in
 the  preliminary observations (page 170) seems to
 be certain.
   The distinct  origin  of  such tumours is made
 sufficiently evident, by observing, that they have
 always a thin capsule  of common cellular substance,
 which separates them from  the contiguous parts.
 This capsule seems merely to be the effect  of that
 condensation of the surrounding cellular substance,
 which the  pressure  of the tumour occasions. As
 the  growth of adipose  tumours is regularly and
 slowly progressive; as  nothing like inflammation
 in general accompanies  their increase; their cap-
 sules afford a striking instance of an  investment
 acquired  simply by  a slight  condensation  of  the
 surrounding cellular  structure,  unaffected  by  in-
 flammation. The capsule,  which is very thin,  ad-
 heres but  slightly to the tumour: and the principal
 connection  appears to  be  by vessels, which pass
 through it to enter the substance of the tumour.
 These vessels are so  small and" the  connection so^
slight, that no dissection is required  to separate it;
for when the tumour  is to be removed, the hand of 
182       A Classification of Tumours.

the operator can be easily introduced between it
and its investment, and it is thus readily turned out
of its capsule.
   The vessels  of adipose tumours are neither
large nor numerous; they are readily torn when the
separation alluded to is attempted, and they scarce-
ly bleed after it  has been  effected. It is natural to
suppose when the greater part of a  large tumour
has been detached, and no vessel of consequence
has been divided, that some principal nutrient ar-
tery will afterwards be met with; and this suppo-
sition  produces  an  unnecessary hesitation on the
part of the operator. There is indeed no species of
tumour that can be  removed with so much  cele-
rity, with such  apparent dexterity,  or with  such
complete  security  against  future  consequences,
as those of an adipose nature. In some instances,
however, when inflammation has been induced, the
capsules even of these tumours are thickened, and
adhere so as not to be separable without difficulty
from their surface.  To certify this  remark I may
mention the case of a man  who had an adipose tu-
mour  growing beneath the skin of the nates, in
which the pressure from sitting occasioned inflam-
mation, and this kind of tenacious adhesion of the
capsule to its surface. This circumstance made the
separation of the skin from off its surface difficult,
when the extirpation of the tumour was undertaken;
but, after that was accomplished, the base of the
tumour was  lifted up and  removed with great  fa-
cility, and almost without the use of the knife. The
under part of this tumour had not a regular sur-
face,- but  projected in portions so as to have a  ta-
bulated appearance; a circumstance which is not
unfrequent, and  which deserves to  be mentioned.
From the occurrence of inflammation likewise these
tumours sometimes adhere to the contiguous parts: 
A  Classification of Tumours.         183
of which circumstance the case which I  am about
to relate affords a curious example.
  I have known several fatty tumours growing at
the  same time, in different parts of the body of the
same person.
  I shall take the  liberty of giving an account of
the  extirpation of a very large tumour of this kind;
as the  case  is particularly interesting, and shows
that the circumstances usually met with are unal-
tered by the size of the tumour.


                    CASE II.
    A  healthy  middle-aged man  had a  tumour
formed apparently  beneath  the fascia of his thigh,
which  he remembered when it was no bigger than
an egg. It had increased by a regular and slow pro-
gress,  in  little more than four years,  to a  very
great magnitude, such as may be easily supposed,
when it is told, that  it weighed, after removal, be-
tween  fourteen and fifteen pounds. It had been at-
tended with no  pain during its  increase, and was
now only inconvenient by its bulk.
  The surgeons who first  saw this patient would
not undertake any  operation, feeling an uncertainty
as  to the nature and connections of  the tumour;
though they all agreed that, when the  skin gave
way, there was but little chance of the poor  man's
surviving the consequences of such an exposure.
Considering from the history  of the case, that the
tumour must have  been  removeable in the  first
instance; believing, from its freedom from pain and
irritation, that it was of no malignant nature, and
that an operation was only alarming from its mag-
nitude; I recommended the patient to see the most
eminent surgeons  in London, before he returned 
 184       A Classification of Tumours.

 in  despair to the country, from whence he  had
 come for relief.  Mr. Clin- gave him more  direct
 hopes of success than he received elsewhere,  and
 he went into St. Thomas's Hospital to submit to
 the operation.
    When  Mr.  Cline  had divided  the  skin  and
 fascia of the thigh, the  tumour was easily turned
 out;  but it  had  unfortunately acquired a liga-
 mentous adhesion to the orbicular ligament of
 the hip,  which  could  not  be separated without,
 in  some degree, injuring  that part. This attach-
 ment appeared to be about half an inch in breadth
 and about one-fourth of an inch in length. The
 cause and nature of this firm attachment to  the li-
 gament  of the  hip, seems the only circumstance
 peculiar  to this case,  or  requiring explanation.
 It appears to me easily accounted for, by supposing
 the tumour to have compressed  and irritated that
 part,  and thus to have occasioned an adhesion, at
 first of a glutinous nature, but which afterwards
 becoming organized,  had  assumed  the structure
 of  the parts, from whence it proceeded. In like
 manner tumours growing  near, and compressing
 the surface of bones, frequently occasion a degree
 of exostosis.
    No hemorrhage followed the removal of the
 tumour.  The wound at first appeared  disposed to
 do  well;  but the patient became feverish, and it
 did not unite by adhesion. There were also  some
 symptoms indicating inflammation about the hip-
joint.  The man, however,  surmounted these dif-
 ficulties,  and, after  some months, was  discharged
 from  the Hospital.
  There were two circumstances in  the operation
 attended  with danger;  one,  the size of the wound,
 which could hardly be  expected  to unite by  adhe-
 sion,  on  account of the  irritation which, from its 
A Classification of Tumours.
185
extent, must  be created; the other,  this unlucky
attachment to the ligament of the joint.  It is to be
lamented, that a disease, so readily removable in
its commencement, should have  been suffered to
acquire a magnitude, which alone was a source of
danger.
  Since the publication of the first edition of these
observations, I have seen an  abscess form in  the
substance of an  adipose tumour. Earthy matter
was also  deposited on the sides  of the cavity which
had contained  the" pus. I have also  seen osseous
matter deposited within the  substance  of an  adi-
pose tumour.


               Pancreatic Sarcoma.

  The next species of sarcomatous tumour, which
I shall describe, resembles in appearance the pan-
creas, and, on that account, may  be named (if the
etymological import of the word be not  considered
as prohibitory) Pancreatic Sarcoma.
  This new-formed  substance  is made up of ir-
regularly shaped masses;  in  colour, texture,  and
size resembling the larger masses which compose
the pancreas.  They appear also to  be connected
with each other, like the portions of that gland, by
a fibrous substance of a looser  texture.  This kind
of sarcoma,  though sometimes formed distinctly
in the cellular substance, more frequently occurs
in the female breast, perhaps originating in lympha-
tic  glands;  and, as cases of  this kind  sufficiently
illustrate its nature and progress, and appear more
interesting in proportion to the importance of the
parts  concerned, I  shall select some instances of
it, in this part, to show those circumstances which
seem most important in the  history of this species
of sarcoma. 
I8o       A Classification of Tumours.

   I  shall, however, first relate a case of this dis-
eased structure occurring in the lymphatic glands
beneath the  lower jaw, and afterwards speak of its
progress, when it takes place in or near  to the fe-
male breast.

                    CASE III.
   A  man  came to St. Bartholomew's Hospital
from Oxfordshire,  with  three diseased lymphatic
glands, each of the size of a  very large plum. They
were situated beneath the  basis of the jaw, upon
upon the mylohyoideus muscle. They resisted the
attempts which  had been made to discuss  them;
and had not been removed  fiom an apprehension
that a dangerous hemorrhage would take place in
the operation. The  glands  had gradually, though
very slowly, attained their  present magnitude, for
the disease  was  of  fifteen  years' duration. The
surrounding  parts were  not affected. Sir Charles
Blicke undertook and accomplished  the removal
of the diseased gland,  the structure of which was
exactly such as  has  been described.  This case is
related in the first place, as  it shows  most clearly
the usual characteristics of this species of diseased
structure; which are those of slowly increasing, of
not being prone to inflammation,  or tending to
suppuration.
   It may not be improper  to mention, though it
is  irrelevant to the present subject, that, in the ope-
ration, the external maxillary artery was unavoida-
bly divided. It did not, however, bleed immediately
after the operation, so  that  this circumstance was
not perceived; and  the edges of the  wound were
brought  together by  one  suture, and accurately
and firmly closed by sticking-plaster. Shortly after-
wards the patient felt a sense of choking,  which 
          A Classification of Tumours.       187
                                    1
increased to a state almost of complete suffocation.
Indeed  it seems probable that this might  really
have happened before any one could have  come
to his  assistance, had  not some  of the  plasters
fortunately given way, and afforded some discharge
to the blood: for a very great quantity of coagulated
blood had collected  within the wound, and com-
pressed the  trachea and pharynx to  a greater de-
gree than would readily be believed by those who
had not witnessed the fact. This circumstance is
mentioned to show the impropriety,  when there is
any chance of hemorrhage,  of closing wounds so
strictly by sticking-plaster, as to allow no exit to
any blood that may be effused;  and  it is particu-
larly unsafe in circumstances similar to those of
the  foregoing case.  If the  hemorrhage  be but
small in quantity, and the  escape of  the blood be
prevented,  it separates the  sides  of the wound
which  should lie  in close  contact, and  thereby
prevents their immediate union; and, if  it be con-
siderable,  it deserves to be remarked, that,  so far
is the compression which the confined blood must
make on the arteries, from which it was poured,
from stopping the bleeding, that it seems to be a
stimulating  cause, exciting an hemorrhagic action
in the vessels. This  remark  is  manifested by the
present, as well as by many other cases in surgery.
  This kind of sarcoma frequently  forms amidst
the mammary gland, a little above,  and  on that
side of the nipple, which is  next  to the arm. Its
appearance would lead one to suppose, that it was
a lymphatic gland, which  is usually  found in that
situation, converted into this structure; but some-
times it seems like  a distinct tumour.  It is the
appearance  of the capsule which  invests  the tu-
mour, that has led me to form these opinions. 
188      A Classification of Tumours.

   These  tumours lessen in bulk if judiciously
treated; but if they cannot be entirely dispersed,
they increase gradually:  and when they have at-
tained some considerable size, they are generally
removed, from apprehension of the consequences
which they  might produce, if they were suffered to
remain. If the tumour be indolent, and if it increases
slowly, the parts surrounding it, and the glands in
the axilla are not affected. But some tumours formed
by this kind of diseased  structure, which do  not
unfrequently occur in the breast, are, contrary to
the ordinary properties of such diseases, of a very
irritable nature, occasioning severe and lancinating
pain, and  producing an inflammatory  state  of  the
skin which  covers them, so that it  becomes adhe-
rent to their surface. They also irritate the  absor-
bents leading to  the  axilla, and produce enlarge-  .<,.il
ment of their glands. From  these circumstances I
suspect that  these tumours  may be frequently
considered as cancers.  These extremely irritable
tumours do not generally attain any considerable
magnitude; they are reduced in  size by the treat-
ment  which has  been mentioned, but  increase
again,  when it has been desisted from.  Sometimes
a tumour  of this nature, which was irritable in the
first instance, becomes  indolent after  the activity
of the disease has been checked  by proper local
applications, but  in other cases the irritability of
the disease recurs. The pain is lancinating, and so
severe  as to  make the patients feverish, grow faint
frequently, and lose their muscular strength. When
the axillary glands become affected, one  generally
swells  at first, and is extremely tender and painful;
but afterwards the pain abates, and it  remains  in-
durated: another  then becomes affected, and runs
through the  same course.  I  remember an instance
where  many of the glands attained  a considerable 
           A Classification of Tumours.       189

magnitude. The case was considered as cancerous,
and the tumour, which was of the structure that
has been described, and also some of the diseased
glands, were  removed, but several were left, and
the patient did well.
                   CASE IV.
  A young woman, who lived with me as  a ser-
vant, suffered for more than two years severe pain,
and considerable constitutional indisposition, from
a tumour of this kind, which had caused inflamma-
tion and enlargement of three of the axillary glands.
Being assured that it  was not carcinomatous  from
its diminution under surgical treatment, I waited in
hopes that some beneficial chartge would sponta-
neously take place;  but, at  last, by her request,
and with  the coinciding opinion  of  Sir Charles
Blicke,  I removed the original tumour, leaving
the diseased  glands  in the  axilla. The source of
irritation being taken away, the glands gradually
subsided, and the patient soon grew  fat, and be-
came, and remained  remarkably healthy. I  have
known many similar cases.
  When the  above account was written, I was
unacquainted with those facts recorded in the first
volume  of these observations,  which show that
considerable tumours of the breast and neighbour-
ing parts, which resist all  locally repellent  mea-
sures, may be dispersed in  many instances readily,
by correcting a disordered state of the  digestive
organs. I  have no doubt,  but  the  occasional fits
of pain  and languor, which  were  experienced  in
the case  just related, were  the  effects of irritabi'
lity of constitution, and might have been relieved,
and prevented, by means that  would have given
tone and tranquillity to the  system. 
190       A Classification of Tumours.
                   CASE V.
  A lady, about twenty-seven years of age, had  a
tumour between the breast and the axilla, which had
gradually increased during a year and a half to the
size of a goose egg. Its growth had been accom-
panied with  occasional fits  of pain.  She had  a
much  furred tongue, and  costive bowels. As no
discutient remedies had checked the progress of
the tumour;  and, as some apprehensions that its
nature might be malignant were entertained, I was
requested to remove it.
  After I had done so, on dividing the tumour, its
structure was found to be of that  kind which  I
have described in this section; which induced me,
for the comfort of the patient, to assure her, that
the disease was not cancerous, and therefore not
likely to return. The patient resided in  the coun-
try, and when she left town, I exhorted her to be
very attentive to her diet, and to the regulation of
the functions of her digestive organs. After twp
years, she came from the  country much alarmed,
by a good deal of thickening irritation and redness,
which had taken place in the  parts wounded in the
operation;  all of which, however, soon subsided,
under  the application of a  bread and water poul-
tice  during  the night, and  the use of alterative
doses of mercury.  In another  year she returned
again frightened by the occurence  of  a swelling,
attended  with  uneasiness, on  the side  opposite to
that on which the operation had been  performed.
The swelling was situated between the breast and
the axilla, parallel and contiguous to the margin
of the pectoral muscle. It was as  big as a small
walnut; and, I have no doubt, was  caused by the
tumefaction of an absorbent gland. It was dispersed 
          A Classification of Tumours.       1 y 1

by the same treatment that had been instituted for
the  irritation which had taken  place about the
wound. About three years have  now elapsed, and
though she  has  been  occasionally  alarmed  by
pains,  yet no other manifestations of disease have
appeared.
  As I have preserved no notes, and do not per-
fectly  recollect any  case,  of  a  tumour  of  this
structure occurring in a distinct form, unless some
of those about the breast may be so considered; and
as I wish to show that all these diseases occur
distinctly as well  as in  glands, I shall, as an in-
stance  of a  pancreatic appearance  in a distinct
tumour, refer the reader to the curious case pub-
lished  in  London by  Dr. Bouttatz, of Moscow,
of a tumour which grew beneath the  conjunctiva
of the  eye, and protruded it  between the eyelids.
The tumour was  seven inches  long  and three
inches and a half in circumference, and weighed
two  pounds  and a half. The structure, which  is
represented in a plate, answers  correctly  to that
which  I have denominated pancreatic;  and  it  had
also the ordinary characters of this diseased struc-
ture, which are those of slowly and regularly in-
creasing,  not being prone  to inflammation,  nor
tending to suppuration. The tumour, as might be
naturally supposed,  was  closely  connected with
the tunica  conjunctiva against which it pressed,
but the base of it was  easily elevated from  the
cornea which still retained its natural transparency,
and the patient regained his  sight on its removal.


                Cystic Sarcoma.
  The next species of sarcomatous tumour, as  it
contains cells or cysts, may be  named  Cystic Sar-
coma;  and  this species will be found  to compre- 
192       A Classification of Tumours.

hend varieties. This species sometimes occurs as
a distinct tumour, but  is  more frequently met
with in the testis and  ovary.  In one kind of dis-
ease of the testis, the part is perhaps enlarged to
six times its natural size, and  consists of a con-
geries  of cells, containing a  serous fluid; their size
is that  of currants or grapes, but of an oval figure.
The sides of the cysts are so  vascular as to  be
made red by injection; and sometimes the injec-
tion is  even effused and tinges the contents of the
cyst. Dr. Baillie has favoured us with an elegant
and  correct representation of this  disease, in his
Series  of Engravings  intended to illustrate  the
Morbid Anatomy of some of the most  important
Parts of  the  Human  Body.* I have  known thiss
alteration of structure the consequence of a blow
received  on the  part;  but,  in  general,  it occurs
without evident  injury.  The firm or sarcomatous
part of an ovary affords a good specimen of the
structure I am describing; the cells are here much
larger, and are so vascular as to  be made quite red
by injection.
  To  show that this structure  is not peculiar to
these parts, I may mention the  following case: a
tumour was taken  from the face of a  boy by Sir.
Charles  Blicke, which, when divided, was found
to consist entirely of an assemblage of cells filled
with a watery, yet coagulable fluid.
  In the testis,  cysts  are not  unfrequently found
containing a kind  of  caseous  substance. In this
case too, the sides of the cyst  are vascular.  The
cysts are generally large, and  sometimes there is
but one.  I have  called the substance caseous, be-
cause  it resembles cheese in consistence, and  in
colour; being of a yellowish cast, and of an unctd-
* Vide Fasc. 8. Plate 8. Fig. 2. 
A Classification of Tumours.
193
ous appearance; but it is not at all unctuous to the
touch. It may be proper to mention, that this case-
ous substance is sometimes irregularly distributed
throughout the vascular substance  of a diseased
testis, without being confined in distinct cysts. I
believe this kind of sarcocele is particularly un-
yielding to medical treatment.
              Mammary Sarcoma.
  There is a species of sarcomatous tumour, which
indeed I have not frequently met with, but which
so strikingly resembles the mammary gland in co-
lour and texture, that, wishing to distinguish it on
account of the following  case, I have  named  it
Mammary Sarcoma.
  I have seen this substance (which is white and
firm, and has a similarity  of appearance through-
out) in the  midst of adipose tumours;  but my
attention was not particularly excited to it till the
following case occurred.


                   CASE VI.
  A moderately healthy middle-aged woman came
from the country  to St. Bartholomew's Hospital,
on account of a tumour of the size of a very large
orange, which had grown gradually on the front
of her thigh: it  lay beneath the  integuments and
above the fascia. It was removed  by an operation,
and  the  integuments covering the tumour were
also taken away, as in the removal of the  cancer-
ous breast. The sides of the wound were brought
together by  sticking plaster, and, at first,  seemed
disposed to  heal;  but afterwards a considerable
induration of the surrounding parts  took place. 
194       A  Classification of Tumours.
and the wound degenerated into a malignant ulcer,
which spread extensively, and was incorrigible by
any medical means employed. As the ulcer spread,
so, in the same proportion, did the hardness of the
parts which surrounded it. The pain and fever so
exhausted the patient, that in  about  two months
she died.
   This tumour, the appearance of which was ex-
actly of the kind that has been described, seemed
to have  no distinct  capsule, but to be  gradually
lost in the surrounding  parts.  The whole of the
diseased part seemed to have been removed, yet
it is probable that the contiguous parts had  a dis-
position  to disease,  which was aggravated,  and
rendered  more  malignant, by  the  injury  of the
operation.  Could  the circumstances  have  been
foreseen,  it might  have  been  right  to  have re-
moved  the parts surrounding  this  tumour more
extensively, as suggested in one of the preliminary
observations.
   There is a  similar kind of diseased structure,
but of a softer texture, which is frequently  found
as a distinct tumour, or in glandular parts perhaps;
which might with propriety  be considered as a
variety  of the  same species of sarcoma. It has
the same  uniformity of surface,  but  it is  not
always of a white colour, being occasionally of a
a brownish or reddish tint. I have seen a substance
of this kind forming a  tumour surrounding and
compressing the oesophagus, and causing a con-
traction of that tube. I have seen this kind of sar-
coma in glandular parts, in which the progress
and event of the case did not indicate  the disease
to be  of a noxious nature. The general result of
my observations, however, has induced me to be-
lieve,  that this diseased structure is prone to dege-
nerate into an intractable ulcer, which will com-
municate its disease to the surrounding parts, and 
          A Classification of Tumours.        195

I have therefore placed this species of sarcoma
between  those which seem to possess no malig-
nity, and those  which follow, and which are of a
very destructive nature.
  I add  the relation of a case which occurred at
St. Bartholomew's Hospital, since the publication
of the former edition of this paper.
                   CASE VII.
   A woman about fifty years of age, had a turnout
growing beneath the skin of the perinaeum, that by
the side of the rectum, and that which is external
to the labium. It was about seven inches in length,
about two in breadth, and descended as low as the
middle of the thigh.  Sir Charles Blicke removed
it, by dividing the skin  on either side of the tu-
mour lengthwise, at the upper part of it. He then
dissected out the upper part of the tumour, which
was thin, from beneath the divided  integuments,
and brought the parallel edges of the skin together
by two sutures. The tumour, when removed, being
divided,  appeared  firm,  white, and  smooth, and
strikingly resembling the mammary gland. It had
no distinct capsule. The integuments adjoining to
the tumour inflamed, and indurated, and ulcerated,
and a very large and  foul sore was formed.  The
patient's  health became greatly deranged,  so that
little or no hopes were entertained of her recovery.
However, after a time, the disease ceased to spread,
and at the end of about three weeks began to amend.
The  constitution  became tranquil in proportion,
and the sore slowly healed.
                  2C 
196       A Classification of Tumours.
             Tuberculated Sarcoma.
  The next species of sarcoma, which I  have to
describe, may be named Tuberculated Sarcoma.
It consists of an aggregation of small, firm, roundish
tumours, of different sizes and colours, connected
together by a kind of cellular substance. The size
of the tubercles is from that of a pea to that of a
horse-bean, or sometimes larger; the colour of a
brownish red, and some are of a yellowish tint. In
Dr. Baillie's plates there is one of the tuberculated
liver,* which expresses the appearance of this kind
of sarcoma as well as can possibly be done by an
engraving.
  The instances  which  I  have seen  have been
chiefly in the  lymphatic gknds of the neck. The
tumours  have ulcerated;  have become  painful
and intractable sores; and have destroyed the pa-
tient.  The disease appears to possess a very malig-
nant nature.
                  CASE VIII.
  A remarkable case of this kind occurred in St.
Bartholomew's Hospital in 1797. A man between
forty and fifty years of age had a large tumour at
the side of his neck, beneath the platysma myoides.
It measured about eight inches in length, and four
in breadth.  It was hard and irregular on the sur-
face, seeming like a cluster of diseased lymphatic
glands.  It was extremely painful, and had greatly
impaired his health. He affirmed that it had not been
* Vide Fasc. 5. Plate 2. 
         A Classification of Tumours.        197

more than six months since its  first appearance,
and in the course of this time, numerous small tu-
mours of similar density and structure had grown
beneath the skin all over the trunk of the body, but
chiefly on the neck and  abdomen.  The  skin and
the front of the tumour in the neck had ulcerated,
and  become a painful phagedenic  sore; and  the
patient died with hectic  fever, in about six weeks
after his admission into the hospital. The structure
of all  the tumours  was alike, and such as has been
described: the body was examined by the students
of the hospital, who said that there were no tubfer-
cles on the viscera, as there commonly are in cases
of this disease.—As this disease is  uncommon, it
may   not be  improper to relate  another case on
which I  was consulted in the  course of the last
year.


                   CASE IX.
  A  gentleman  had a tumour in the lymphatic
glands of the axilla, which he had taken  notice of
about a month, and  which was supposed  to be
of a  scrofulous nature. I was consulted as to the
propriety of his going to the sea-side. The tumour
was of the size of an egg, and its surface was irre-
gular from  the projection of numerous  tubercles.
This  circumstance struck me, and led  me to en-
quire if he had no other little tumours in the skin.
He told me there was one in the groin,  which ap-
peared on examination to be a distinct  tubercle;
and on  further enquiry, I found that the  glands
above the collar-bone, by the  side  of  the  neck,
were  in some degree affected.  I  had no doubt of
the nature  of the disease, and told the physician,
that,  in my  opinion, it would  terminate fatally. 
 198       A Classification of Tumours.

 After about a  fortnight, when I saw  the  patient
 again, these tubercles had  multiplied all over the
 skin, both in the front and back  part of the body;
 they were hard and painful, and  gave him the sen-
 sation as  if he was lying on a number of hobnails.
 The disease in  the glands, both below and above
 the collar-bone,  had greatly increased, and the arm
 was very  oedematous. The disease progressively in-
 creased; the skin seemed to peel off in thin sloughs
 from the  surface of the enlarged glands in  the ax-
 illa; but  no sloughing or ulceration had taken
 place in the tumour when the patient died, which
 was about five weeks  after I first  saw him. On exa-
 mining the body, the  tubercles every where had
 the appearance   which  has  been  described;  and
 many similar tubercles were found on the  surface
 of the lungs, heart, liver,  spleen,  omentum, and
 mesentery. The absorbent glands of the mesentery,
 and the other internal absorbent glands were, how-
 ever, unaffected.
  Since the above account was written, I examined
 a body in which such tubercles  were found very
 generally  scattered beneath the  skin. The patient
 was said  to have died of a cancerous uterus, and
 the cervix was  in a state of ulceration. The whole
 uterus was diseased, and the parietes were an inch
 in thickness. The disease, however, was not carci-
nomatous. From this case, as well  as from  others,
which are related, it appears, that the same  disor-
der of the general health  may produce local dis-
eases of a dissimilar appearance or nature.*

  *  Since the publication  of the former edition, I have seen
a case, which is to me so singular, that I wish briefly to men-
tion  it. A gentiemen had  a spot in the skin, opposite to the
inferior angle of the scapula.  It had the appearance of one of
those spots  called petechia. It enlarged, thickened, and ul- 
A Classification of Tumours.        199
           Pulpy or Medullary Sarcoma.

   The sarcoma which is  next to be described is
generally found in the testis, and is  distinguished
by the name  of the soft cancer of that part. The
term cancer  is objectionable, because  it  conveys
an erroneous idea of its  nature,  for this disease,
though perhaps equally destructive, will be shown
to be unlike cancer in  its nature and progress.
   The tumour, in those cases of the  disease which
I  have  most frequently met with,  has been of a
whitish  colour, resembling, on a  general  and dis-
tant  inspection, the appearance of the  brain. The
disease  is  usually of  a pulpy  consistence;  and I
have, therefore, been  induced  to  distinguish it  by
the name of  medullary sarcoma. Although I have
more frequently met with this disease of a whitish
colour, yet I  have often seen it of a brownish red
appearance. WThich is  most common I cannot de-
cide: the structure and feel of both  are the same,
and  their progress  is  also similar; they are there -

eerated.  The ulcer became foul and intractable, and   the
patient came to London with  his health much disordered,
apparently from local irritation. The axillary glands became
affected, and enlarged to a considerable size, and suppurated.
Smaller spots resembling petechias came out in various parts
of his body. He took medicines with a view to regulate and
improve the functions of  his digestive  organs, which were
much disordered. His general health improved,  and under
this change the original ulcer greatly amended in its appear-
ance;  the spots remained  stationary; the parts in the axilla
became so far sound, a* to make it nearly certain that they
had been affected only by common  irritation, and not by a
specific disease. This tranquil state lasted about  six weeks,
when the  original ulcer became worse; and by the aggrava-
tion of that  disease, without any increase of the others,  his
powers became  exhausted, and  he died. 
 200      A Classification of Tumours.

 fore to be considered as varieties  of one species.
 The shortest way in which  I can  communicate a
 knowledge of  this disease, and  render those re-
 marks which  I have to make on it  intelligible, will
 be, by relating a case in which it proceeded to a very
 considerable extent before it destroyed the patient.


                    CASE X.
   A tall  thin healthy-looking man, of about forty
 years of age,  had, about fifteen  years before, a
 swelled  testicle from a gonorrhoea; the epididymis
 remained indurated. Six years afterwards it became
 enlarged, and a hydrocele at the same  time formed.
 Half a pint of water was discharged by a puncture,
 but inflammation  succeeded the  operation,  and
 this testis became very large. An abscess formed,
 and burst in  the front of the scrotum, and the
 testis subsided in some degree. Mercury was  em-
 ployed to reduce it, but without effect. The part,
 however,  was indolent, and  gave  the patient no
 trouble but from its bulk.
   About  a year afterwards  a  gland  enlarged in
 the  left groin  (the same side as  the  testis): ano-
 ther then became swollen  in  the right groin, and,
 in the course of two years, several  glands in each
 groin had obtained  a very considerable magnitude.
 At this period he was admitted into  St. Bartho-
 lomew's  Hospital,  under the care  of Mr. Long.
 The testis was, at this time, between four and  five
inches in length, and about three in  breadth; it re-
sembled  its natural form, and was  indolent in  its
disposition. The spermatic chord was thickened,
but not much indurated. Four or five  glands were
enlarged in the groin on both sides, each of which
was of the size of a very large orange; and, when 
          A Classification of Tumours.       201

observed together, they formed a tumour of very
uncommon shape and magnitude.
   They gradually  increased  in  size for several
months, till at last the skin appeared as if unable to
contain them any longer. It became thin, inflamed,
and ulcerated; first  in  the left groin,  and exposed
one of the most prominent tumours. The exposed
tumour inflamed and  sloughed  progressively, till
it entirely came away. As the sloughing exposed
its vessels, which were large, they bled profusely,
insomuch that  the students endeavoured, but in
vain, to secure them by ligatures: for the substance
of the tumour was cut through, and  torn away in
the attempt. Pressure by the finger, continued for
some time, was the only effectual mode of restrain-
ing this hemorrhage.
   The loss of one gland relieved the distended skin,
which had  only ulcerated on  the most prominent
part of the tumour, and  had not become diseased.
It now lost its inflamed aspect; granulations formed,
and a cicatrix took place. In the opposite groin a
similar occurrence  happened.  One gland, exposed
 by the ulceration of the skin, sloughed out, being
 attended  by the circumstances just recited. How-
ever before the skin was cicatrized, ulceration had
 again taken place in the right groin, in consequence
 of the great distention of the skin from the growth of
 the tumour; and sloughing had  begun in the  tu-
 mour, when the patient, whose vital powers  had
 long been greatly exhausted, died.
   The testis was injected, and,  when divided, was
 found to be of a whitish colour, and moderately firm
 consistence, and was made  red  by the injection in
 various parts. The tumour formed by the inguinal
 glands on each side  was as large as a man's head,
 and the structure  was very similar to that  of  the
 testis, but more pulpy.  On opening the body  the 
202       A Classification of Tumours.

pelvis  was  almost filled  with  similarly diseased
glands, and  the vertebrae were hidden by others as
high up as the diaphragm. The disease  in the up-
per ones was not,  however, so  far advanced as in
the others: some of the former, which lay close to
the diaphragm, and were not larger than a walnut,
being  cut into, a thick fluid, resembling cream in
colour and consistence, escaped, and was expressed,
and the gland was  left a contexture of loose fibrous
substance.
   The state of  the  glands newly affected shows,
that the actions of this disease cause a secretion of
fluid like cream; that this fluid acquires consistence
during its residence in the part;; and that it is the
cause of the increase of size in the gland The pro-
fuse hemorrhage, which   took place during  the
sloughing, shows that there is  an increase of ves-
sels proportionate  to the augmentation  in  bulk of
the diseased part. The simple ulceration of the
skin from distention, and  the  subsequent healing
of the  ulcer, show that this morbid affection is un-
like carcinoma, which communicates its disease to
all contiguous parts: neither has it the hardness nor
the disposition to ulcerate, which characterize can-
cer. The  general disease of the absorbing glands
shows, that  the  diseased action  is readily propa-
gated  in  the course  of those  susceptible vessels;
and the glands of  the pelvis being affected equally
with  those  higher up,  renders it  probable that it
induces the  disease, as well by imparting irritation
to them, as by furnishing a matter capable of sti-
mulating  them  when  they have  imbibed it;  an
opinion that will be more strikingly verified by the
next case which I shall relate.*

  * The progress of  what is called the  scirrhous testis, is
similar to that of the  disease which I am describing, and of 
           A Classification of Tumours.       203

  This species of sarcoma, though it usually affects
the  testis, occasionally occurs in other parts.  I
shall authenticate this  fact by  the brief  relation
of another case, which will serve also to throw
additional light on the nature and progress of'this
disease.
                    CASE XI.
   A boy, about twelve years of age, was brought
 to the Hospital for advice, on account of a tumour
 in the front of his thigh: it had been growing three
 or  four months, and had then attained  the size of
 a large orange.  The base of  it was situated  close
 upon the bone. It increased, notwithstanding appli-
 cations that were employed to disperse  it, and the
 patient became confined to  his bed. After  some
 time the leg  became  cedematous to a very  great
 degree; the inguinal glands were enlarged, but not
 in a degree proportionate to  the oedema, none of
 them having  attained to more than the size of a
 small walnut.  The  parts in the ham  were also con-
 siderably swoln.  In a  short  time  the   cause  of
 the great degree of oedema was manifested; for the
 lower part of  the abdomen became distended*by a
 tumour, that seemed to rise out  of  the pelvis and
 compress the  iliac vessels. The boy's  health,  as
 may be  supposed,  gradually  declined; and, when
 the disease had attained to this state, he died.
  On examining the parts it was found, that the
 tumour,  though it lay close to the periosteum

 course very different from that of genuine carcinoma. It is
 not improbable,  that from  the similarity of the progress of
 these two diseases, and the equal fatality having been re-
marked, they first acquired the contrasted names of soft and
hard cancers of the  testis.
                       2D 
204        A Classification of Tumours.
of the thigh bone, had no connection with it; that
it was in structure like the disease last described;
and that the disease had extended, through the me-
dium, and in the course  of the absorbing vessels,
downwards to the ham, where the glands were en-
larged and formed a considerable tumour; and up-
wards into the pelvis, where the internal iliac glands
more than filled one side of that cavity, rising out
of it, as has been said, so as to distend the lower
part of the abdomen. The disease had also extended
so as slightly to affect  the lumbar glands.  The tu-
mours  in the ham and  pelvis were of the same
structure as the  original  tumour.  The  inguinal
glands, though affected apparently by the same dis-
ease, were not  considerably enlarged.
   This  case also shows the uncommon facility
with  which  this disease is  propagated along the
absorbing vessels; and its having extended down-
wards to the ham, as well as upwards into the pel-
vis, confirms the opinion, that it extends itself by
imparting irritation to the vessels, as well as, per-
haps, by furnishing a matter which, if imbibed,
may communicate the same irritation.
   I have mentioned, as a variety of this disease,
that  in  which  the  colour is different,  it being
between a brown and that of the blood;  but in
texture and  organization it does not appear dissi-
milar. It seems therefore as if the diseased action
caused the secretion  of a fluid, sometimes of a
milky,  sometimes of  a  more dusky  hue; which
gradually acquires solidity, and augments  the bulk
of the part. The diseased part acquires in general
a considerable solidity when it has  continued for
some time, so  as scarcely to deserve the names of
soft cancer, or medullary sarcoma. The hardness is
also, in some instances which I have seen, increas- 
A  Classification of Tumours.       205
ed, apparently by a thickening of the cellular sub-
stance which pervades the gland.
  It seems probable, however, that the same kind
of diseased  action may not be always  followed by
the like  alteration of structure, in the part which
it affects. Mr. Astley Cooper, in his Paper on Ob-
structions of the  Thoracic  Duct, mentions an  in-
stance in which matter imbibed from a testis affect-
ed with a disease like the present,  obstructed that
vessel. His description of the testis is, that it was
" a pulpy mass, composed of broken coagulable
lymph, and blood-coloured  serum."*
  I remember one instance of the inguinal and lum-
bar glands being affected with a disease similar to
those just described, from a diseased testis of a
different structure. The testis was removed in  the
Hospital, and was found  much enlarged, and vas-
cular throughout, except where some soft cheese-
like matter  was deposited.  Some  of the inguinal
glands enlarged, ulcerated,  and sloughed out, and
the wound seemed disposed to heal.  The lumbar
glands were affected, became extremely  painful,
and the patient being previously  much exhausted,
sunk under  this last complaint.
  He had been removed  to some distance from  the
Hospital, and I could not obtain permission to exa-
mine the body till four days  after his decease. I took
out the lumbar glands and put them in water; and,
the weather being extremely hot, when I examined
them the next day, I found that all the unorganized
deposited matter which had enlarged them, had  be-
come putrid,  and was washed away, leaving  the
capsule of the gland, and a congeries of flocculent
fibres occupying the interior part of it: these were
doubtless the vessels and connecting cellular sub-

      *Vide Medical Records and Researches, p. 96. 
206       A Classification of Tumours.

stance of the glands, not indurated (as I have seen
it in some other instances) by inflammation.
   In the advanced stage of this disease, sometimes
lymphatic glands out of the course of absorption,
and of the participation of irritation, become affect-
ed  with the same  disease; and a secretion of this
thick cream or bloody-coloured fluid takes place
on  the surface, or in portions, even in the liver or
lungs, or other viscera. I have heard this circum-
stance accounted for, by supposing that the absorp-
tion of the  matter deposited in the originally dis-
eased parts was so  abundant as to induce the ne-
cessity of depositing it in various places; but  it
seems to me more rational to attribute it to the pre-
valence of the  same diseased disposition through-
out the body. For we frequently find, that solid tu^
mours of similar structure exist in various parts
of  the same subject; and sometimes they rapidly
multiply as the  disease advances; as was mentioned
in  the case which is related of tuberculated  sar-
coma.

            Carcinomatous Sarcoma.

  The last species of sarcomatous tumour which
I have to describe, is the Carcinomatous.  It is not
here designed to give a full or distinct history of
Carcinoma, but only a general and comparative ac-
count of those circumstances in which it resembles
or  differs from other tumours.  This kind of tu-
mour, on account of its peculiar hardness, is em-
phatically termed Scirrhus, while it remains entire
and free from ulceration. But the word scirrhus is
frequently applied to  other indurations, and it seems
better, in order to  avoid ambiguity, to  use the
same term to denote  all  the stages of this disease,
naming it carcinoma, in the first place, and  ulce. 
          A Classification of Tumours.       207

rated carcinoma when that change has occurred.
This disease is not, in every instance, so peculiarly
hard as to entitle it to the name scirrhus; and how-
ever indurated it may be, it still must be accounted
a kind of fleshy tumour; therefore I may be allow-
ed to  call it carcinomatous sarcoma.
  I shall arrange the observations which I  have to
offer under three heads: 1st, The history of carcino-
ma. 2dly, Its anatomical structure; and, 3dly, I shall
compare this disease  with others which resemble
it. I shall suppose the carcinoma to arise in the fe-
male breast, as there it most frequently oceurs, and
can be best investigated.
  It sometimes condenses the surrounding sub-
stance so as to acquire a  capsule;  and then it ap-
pears, like  other sarcomatous tumours, to be a part
of new  formation: in other cases  the  mammary
gland seems to be the nidus for this diseased ac-
tion. The boundaries of the disease cannot be accu-
rately ascertained in the latter case, as the carcino-
matous  structure, having no distinguishable invest-
ment, is confused with the rest of the gland. In
either instance carcinoma  begins  in a small spot,
and extends in its progress from thence in all direc-
tions, like  rays from a centre. This observation
will serve to distinguish it from  many other  dis-
eases  which, at their first attack, involve a consi-
derable  portion, if not the  whole of the part, where
they occur. The progress of carcinoma is more or
less quick  in  different instances. When slow, it is
in general  unremitting; at least I  am inclined to
think  that  the disease, though it may be checked,
cannot be made to recede by that medical treatment
which lessens the bulk of other sarcomatous tu-
mours.  This circumstance affords,  in my opinion,
another  criterion, by  which it may in general be
distinguished. This obdurate and destructive dis- 
208       A Classification of Tumours.

ease excites the contiguous  parts, whatever their
nature may be, to the same  diseased  action. The
skin,  the "cellular substance of muscles, and  the
periosteum of bones, all become affected, if they are
in the  vicinity of cancer. This very striking cir-
cumstance in the history of carcinoma distinguishes
it from most of the diseases  already described. In
the pulpy  sarcoma the disease is propagated along
the absorbing system,  but the parts immediately in
contact with the enlarged glands do not assume the
same diseased actions. Neither in the tuberculated
species does the ulceration spread along the skin, but
destroys that part only where it covers  the diseased
glands.
   It was observed by Mr. Hunter that a disposi-
tion to cancer exists in the surrounding parts, prior
to the actual occurrence of the diseased action.
This remark, which is verified by daily experience,
led to the following rule in practice:  " That a sur-
geon ought  not to be contented  with  removing
merely the indurated or actually diseased part, but
that he should also take away some portion of the
surrounding substance, in which a diseased dispo-
sition may probably have been excited." In con<
sequence of this communication of disease  to the
contiguous parts, the  skin  soon  becomes indu-
rated,  and attached  to a carcinomatous tumour,
which  in like manner  becomes fixed to the mus-
cles, or other parts over which it was formed.
   As a carcinomatous tumour increases, it gene-
rally,, though not constantly, becomes unequal upon
its surface, so that this inequality has  been consi-
dered as characteristic of the disease;  and  it is a
circumstance which deserves much attention. A
lancinating pain in the part frequently accompanies
its growth; but in some cases this pain is wanting.
It  attends also on other tumours, the  structure of 
A Classification of Tumours.       209
which is unlike carcinoma; of which I have given
an instance in speaking of pancreatic sarcoma. This
cannot therefore be considered as an infallible cri-
terion of the nature of the disease.
  In that kind of cancer, from which this descrip-
tion is taken, the diseased skin covering a carcino-
matous tumour generally ulcerates, before the tu-
mour  has  attained any great magnitude;  a large
chasm is then produced in its substance by a partly  *
sloughing, and  partly ulcerating process.  Some-
times, when cells contained in the tumour are by
this means laid  open, their contents (which consist
of  a pulpy matter of different degrees of  consist-
ence, and various colours) fall out, and an excoria-
ting ichor distils from their sides. This discharge
takes place with a celerity, which would almost in-
duce a person ignorant of the facility with which
secretion is performed, to believe that it cannot be
produced by that process.
   When the diseased actions have, as it were, ex-
hausted themselves by their vehemence, an attempt
at  reparation appears to take place, similar to that
which occurs in healthy parts. New flesh is formed,
constituting  a fungus of peculiar hardness, as it
partakes of the  diseased actions by  which it was
produced.  This diseased fungus occasionally even
cicatrizes. But though the actions of the disease are
thus mitigated,  though they may be for some time
indolent and stationary, they never cease, nor does
the part ever become healthy.
   In the mean while, the disease extends  through
the medium of the absorbing vessels, and the glands
in the  axilla become affected.  The progress of car-
cinoma in  an  absorbent gland is the  same as that
which  has been already, described. The disease is
communicated  from  one gland to another, so that
after all the axillary  glands are  affected, those that 
210        A Classification of Tumours.
   lie under the collar-bone at the lower part of the
  ' neck, and upper part of the chest, become disorder-
   ed. Occasionally a gland or  two become  diseased
   higher up in the neck, and  apparently  out of the
   course which the absorbed fluids would take. The
   absorbent glands, in the course of the internal mam-
   mary vessels, become affected as the  disease con-
   tinues. In the advanced stage of carcinoma a num-
   ber of small tumours, of similar structure to the
   original disease, form at some distance,  so as to
   make a kind of irregular circle round it.
     Here it is no wonder that I conclude the account
   of the dreadful effects of this pernicious disease.
   For when  it  has  done so  much mischief, the
   strongest constitutions sink under the pain and irri-
   tation which the disease creates, aggravated by the
   obstruction  which it occasions to the  functions of
   absorption in those parts, the vessels of which lead
   to the diseased glands. Towards the conclusion of
   the disease  the patient is generally affected with
   difficulty of breathing and a cough.  In cases where
   the external disease has been removed, the same
   symptoms of disordered respiration  take place, and
   the patients  die of internal diseases.
      It has been a subject of debate and consideration,
   whether the disease of the absorbent glands, which
   takes place in carcinoma, be the effect  of the stimu-
   lus of matter imbibed by those vessels from the
   original disease, or of irritation propagated along
   them. The reason for supposing that  no poison is
'   imbibed is, that if it were conveyed  into the blood,
   it would  produce general disease in the constitu-
   tion;  but no more fever or general disorder is found
   to exist in carcinoma than  what would naturally
   be  produced by  the irritation  which the affected
   parts occasion.  It does  not  seem essential to my
   present design to discuss this subject at length: it is 
A Classification of Tumours.       211
however right to observe, that we  scarcely ever
see glands diseased out of the course which the ab-
sorbed matter would naturally take, though they are
affected in this  manner  in  diseases whih can be
propagated  by irritation. When the  glands of the
axilla are obstructed  by disease, the absorbed mat-
ter will pass by anastomosing channels, into the in-
ternal  mammary absorbents,  and if occasionally
one or two  glands in the neck are  found diseased,
they may become affected in the same manner, by
the fluids being obliged to take a circuitous route.*
   There is  another  circumstance in  the history of
cancer which deserves attention and  investigation;
that is, Whether a disease not  originally cancerous
can become so in its progress? We can only form
our opinions on  this  subject from analogy and ob-
servation. Analogy leads us to believe, that such an
alteration in the diseased actions may readily take
place.  Venereal  buboes often  change their nature
after the  administration of mercury, and become
troublesome sores, to which that medicine is rather
detrimental  than beneficial. Injuries induce inflam-
mation and  enlargement of parts, which afterwards
degenerate  into  scrofulous diseases.  But, though
analogy seems  so strongly to favour the opinion, I
cannot take  upon myself to say, that my observa-
tions have confirmed it. When tumours  have  been
removed, the history of which corresponded to that
of cancer, a cancerous structure was  observed in
them; and, on the contrary, in diseases of an appa*
rently different nature, a different organization has
been found.  I once, indeed, assisted at an operation

  * It may be proper to enquire, whether  those tumours,
which arise in the circumference of carcinoma, are not caused
by the absorbent matter being made to stop for a time in the
vessels, and thus to afford that irritation which induces dis-
ease in them and the contiguous parts? 
212       A Classification of Tumours.
where the tumour was of that kind which I  have
denominated pancreatic;  and I heard  afterwards,
that  the  patient died in  the  country of a  disease
which  was reputed cancerous. Again, in investi-
gating this subject, it deserves to be remarked, and
every surgeon  must, I  believe, be familiarly ac-
quainted with this fact, that many diseased tumours
remain in the breast for a great length of time, per-
haps during life, without undergoing any change in
their nature; or, in other words, without becoming
cancerous.
   It is difficult to convey correct ideas of the struc-
ture of carcinoma by words, or even by drawings.
In the  generality of instances the diseased part is
peculiarly hard, and  there  are intermixed  with it
firm whitish bands,  such as  Dr. Baillie  has des-
cribed and represented in his Book and  Plates of
Morbid Anatomy. There is indeed no other striking
circumstance, which  can be mentioned as constant-
ly claiming attention  in the structure of this disease.
These firm whitish bands sometimes extend  in all
directions from the  middle towards  the  circum-
ference of a carcinomatous tumour, like rays from
a centre, having little intervening matter. Some-
times they intersect it irregularly; having interposed
between them  a firm brownish substance, which
may be  scraped out with  the  finger. Sometimes
they form cells containing  a pulpy matter of vari-
ous colours and consistence;  and sometimes  these
bands assume an arborescent  arrangement, ramify-
ing through the diseased substance.
   Firm white bands, like thickened and  compact
cellular substance, are seen as the disease advances,
to extend themselves from  the  original  tumour
amidst the fat in which it is occasionally imbedded,
intercepting  portions of fat in the irregular areolae
which  they form. This circumstance deserves con- 
A Classification of Tumours.       213
sideration on account of its  practical application;
for if, after removing a carcinomatous tumour, the
surgeon  attends to the part which has been taken
away, he will see if any of these  bands have been
cut through, and,  consequently,  whether some of
this  diseased  substance,  which  ought to be re-
moved, has not been accidental!) left. This circum-
stance cannot be observed by looking at the bleed-
ing surface of the wound, but may be readily ascer-
tained by examining  the part  which has been re-
moved.
   These are the chief circumstances, which I think
sufficiently characterize carcinoma, and distinguish
it  from other sarcomatous tumours. The account
of them  is brief, and  much  has been omitted, be-
cause it  was not designed particularly to discuss
the subject of carcinoma, but merely to point out
its distinguishing  characters. I now  proceed  to
speak of diseases resembling  cancer; though, in
so doing, I shall digress a little from the principal
subject of this  paper, that is, to  describe the dis-
tinguishable kinds of sarcomatous tumours, and
give their history.
   According to the preceding account, carcinoma
begins in a smdll scirrhus, which gradually enlarges
and afterwards  ulcerates. It does so in the breast,
lip, tongue,  and cervix uteri;  yet it may be en-
quired if it does so in every  instance. Parts some-
times superficially ulcerate at first, and afterwards
acquire surrounding  hardness, and  strikingly re-
semble carcinoma, if they do not strictly deserve
that name. This is the way in which some of those
diseases proceed, which occur near the side of the
nose or eye, and which gradually destroy the parts
in which they are situated, and cannot be cured by
any mode of local or general treatment. The intelli-
gent reader will not  suspect me of  confounding 
214       A Classification of Tumours.

these more  malignant diseases with some herpetic
ulcerations of the nose, in  which the morbid ac-
tions gradually cease, and  the  first affected  parts
get well  whilst the surrounding parts become dis-
eased. I have known diseases beginning in ulcer-
ation and followed by induration, and the growth
of fungus, extend themselves  unremittingly, so as
to destroy the patient.  I have seen diseases of this
description  occur in the labia pudendi, some of
which have terminated  fatally, whilst others were
removed even at an advanced period of the disease
with success.
   Here  some additional discriminating  circum-
stances seem to be wanted, by which  we may dis-
tinguish  between these  ulcers and common carci-
noma. I have never  remarked, that  such ulcers
have  affected  the absorbent glands, though  1 do
not feel assured that  this occurrence never takes
place.  It  therefore remains to be determined by
future cases, how far this circumstance may enable
us to decide on the nature of these diseases. I shall
next  relate  the  principal circumstances of a re-
markable  case of this kind of disease, which will
serve to  elucidate the subject, and also to  exhibit
a specimen of the diseases  to which I allude.
                   CASE XII.

  A man was admitted into St. Bartholomew's
Hospital with a tumour beneath the jaw, having a
great degree of surrounding hardness, and contain-
ing three cells,  like those of  carcinomatous tu-
mours.  The  history which he gave of the disease
was very curious: he said that a redness took place
superficially in the skin, which gathered and burst,
and discharged good matter;  that the opening en- 
          A Classification of Tumours.       215

large d, and the surrounding parts indurated, and thus
produced an appearance like a cell in a carcinoma-
tous tumour; then, another portion of skin became
diseased in  the same manner, and  with the same
consequences, till, by degrees, the general tumour
had acquired its present  magnitude. To the truth
of this account we  had an opportunity of bearing
testimony; for this occurrence took place twice in
succession during his residence  in  the Hospital;
and thus two more cells were added to the general
mass. The inflammation of  the skin, and the sup-
puration,  which was healthy in appearance,  took
place beneath the tumour,  and made it reach al-
most as low as the sternum.  As the patient's health
had  considerably declined by the irritation of the
constitution which this disease kept up, and as no
amendment of the disease had taken place in con-
sequence  of the applications or medicines which
were employed, he left the Hospital, and went into
the country.
  Diseases  also,  which  strikingly  resemble car-
cinoma in appearance, form in the following man-
ner.  An enlarged lymphatic gland shall gradually
become soft, and contain a fluid. In this state it
ulcerates or is opened; but instead of subsiding, it
inflames; the surrounding parts become indurated;
the integuments acquire a dusky hue; the opening
and  cavity enlarge, and assume the appearance of
a cyst, from the sides of which fungus arises, and
turns over the everted edges of the opening.  I
have also seen, af^er the bursting of an encysted
tumour, the surrounding parts indurate, and throw
out  a  fungus, forming  a disease appearing like
cancer,  and  which could  not be cured.
  Are such diseases as  I have here described to
be accounted carcinomatous? If not, What are the
characters which  discriminate between  them and 
216        A Classification of Tumours.
carcinoma? As I  have no precise or  satisfactory
information  to communicate, I forbear to say any
thing on the subject.*
   Since the  first edition  of these  observations,
several publications have  appeared on  the subject
of cancer, and as there  are many  circumstances
relating to  its history, upon the determination of
which, by general observation and experience, our
practical rules of conduct must be founded,  I take
this opportunity of presenting to the public some
additional observations with respect to it, without
presuming to  comment on the opinions of others.
I shall also  in this account confine  myself to the
disease, as it appears in the female breast.
  The account  of carcinoma that  I have already
given,  is  taken from the most  strongly charac-
terized specimen of the disease occurring in that
part, which  is peculiarly  hard, and rarely attains
considerable  magnitude.  There  are,  however, va-
rieties; and one of the most remarkable is, that of
the disease attaining a very considerable size before
it  ulcerates.  In this case  sometimes the integu-
ments remain pale and pliant, and a surgeon who
first sees the breast in this state, may doubt whether

  * A patient was admitted into St. Bartholomew's Hospital,
with several indurated, foul, but small  sores, about the bend
of the elbow, and some which intervened between it and the
axilla.  The axillary  glands were much diseased, and the
arm  was  swollen and hard.  She said that the sores began
like common gatherings, and that they hardened after the
skin  had  given way.  That the disease began  in superficial
sores, and that the axillary glands were next affected.
  The patient died in the Hospital; and, on examining the
limb, a great number of tubercles were found in it, several
of which were imbedded in the nerves of the arm. The lungs
also  contained a great number of tubercles which appeared
to be the effect  of the same kind of disease affecting that
part. 
A Classification of Tumours.       217
the disease be actual cancer or common sarcoma.
The substance of the  tumour is also much  less
hard than in the specimen first described; yet  it is
mote compact and weighty than most other dis-
eases of the same bulk which are not carcinoma-
tous. If at first a 6urgeon  may hesitate to decide
upon the nature of this disease, his opinion will in
general be speedily determined  by  enquiry  and
examination.  If the history of the disease accords
with that of carcinoma; that is to say, if it began
in a small district, and regularly and unabatingly
attained its present magnitude; if the surface of the
tumour be unequal, having in various parts  pro-
duced  roundish projecting  nodules, the  disease
will almost invariably be found to be carcinoma.
The skin will soon adhere  to one or more of these
prominences;  it will ulcerate and expose the sub-
jacent parts, and the  future progress of the disease
will so exactly accord to  that of the harder and
smaller specimen which I  have described, as  not
to require a separate description.  In general, how-
ever, the absorbents are much  less liable to  be-
come affected  in the latter variety of this disease.
   Having thus represented the extreme varieties
of carcinomatous diseases, I need  scarcely observe,
that there will be intermediate degrees.  In carci-
noma, as in other  diseases, it appears to me,  that
the history and progress is more  declarative of its
nature than any circumstance which we may be
able to discover by the sight or touch.
   There is one circumstance in the history of  car-
cinoma which  may prove  very perplexing to  the
observer, and tend to induce him  to disbelieve  that
there is any regular progress belonging to this  dis-
ease. I allude  to the occurrence of cancer in parts
previously diseased  in another manner. Analogy,
as I have said, would induce us to  believe,  tha 
2J3       A Classification of Tumour*.

this might be a frequent occurrence;  vet I cannot
say that my observations  have led  me  to  think,
that  it very commonly takes place.  Cases  of  tu-
mours,  which have remained indolent for  twenty
or more years, becoming cancerous at an advanced
period of life, are not  unfrequently met with; and
when tumours form in or about the  breast at an
advanced period of life, though the progress at the
beginning may assure us that they are  not carcino-
matous, yet they may become so, after the lapse
of but  a few  years, or  even a shorter  period of
time. The  impression  which the consideration of
such  circumstances has left  on my mind (in con-
junction with the information which I  think I pos-
sess  relative to the general health of a patient liable
to cancer,  and which I will presently communi-
cate,) is, that the patients who are subject to such
an occurrence, might  have been  liable to the for-
mation  of a cancerous  disease at the same  period,
even  if no diseased structure had previously ex-
isted, and formed a nidus for  the cancerous actions.
That they are more likely to begin in parts pre-
viously diseased, I readiiy admit; and that  it may
be prudent and proper to remove such diseases as
I now allude to, under the circumstances which I
have mentioned, and shall still further describe, is an
opinion in which I readily concur; yet, if an idea,
that  most or many diseased  structures might be-
come cancerous was generally prevalent, it would
doubtless lead  to the performance of  many unne-
cessary operations.
  In the first volume of these Observations, I have
given an opinion, which I am inclined even more
fully and strongly to  repeat, that a great number
of tumours in and about the female mamma arise
from a disordered state of the health in general,
and  consequently that  the  most  judicious and 
           A Classification of Tumours.       £19

effectual mode of dispersing them, is by correcting
that general disorder. Such cases are very nume-
rous, and  very important,  as the reader  may see,
by referring to the few that I have printed; yet all,
or most of these, would be consigned to removal
by the knife, were the idea which I have mentioned
to  become prevalent. When, however, a tumour
that cannot be dispersed by the means to which I
now refer exists in or about the breast, and which
we feel assured  is not of a carcinomatous nature,
it may be well to remove it, because it is  often a
constant source of disturbance  and alarm to the
patient's mind; and, I am ready to admit, that it is
likely to  be a nidus  in which cancerous actions
may be engendered in a constitution predisposed
to that disease.  However I feel  myself fully war-
ranted in  asserting, from my own experience, that
many of them will  remain in the same state for a
great length of time, and even through life, with-
out becoming cancerous.
  That cancer, like most other local diseases, owes
its  origin  to a  disordered state  of  the health in
general, is an opinion which I do not expect to be
controverted. We express  it even by saying, that
there is a  preposition to  cancer. Mr. Hunter was
of opinion, that  cancer was so far local, that if all
the diseased part, or that which was so contiguous
to it, as to have  felt its influence, and to have ac-
quired a predisposition to disease, were removed,
the patient would be as exempt from cancer  in
that part as if it never had occurred.  This opinion,
deduced from his own experience, is very impor-
tant; it shows us how we ought to operate when
an operation  is  to be undertaken.  I am  ready to
admit the truth of this opinion to the extent affirmed
by Mr.  Hunter;  but though the patient may be as
exempt from the disease as if it never had occurred,
                    2 F 
220       A Classification of Tumours.
that state of constitution which induced  it origin-
ally, may after a certain lapse of time cause it to
form again,* or  may produce the same disease in
other parts of the body, or a patient may die of
other ills or diseases attendant on a cancerous con-
stitution.
   In our present state  of knowledge, we are not,
I believe, able to distinguish any peculiar circum-
stance as characteristic of a cancerous constitution.
We observe in it those circumstances which indi-
cate  a  disordered constitution, and  augment the
disorder by each reciprocally aggravating the other;
I mean irritation, weakness, or some  undefinable
disorder of the nervous functions;  and such  dis-
order in the functions of the digestive organs, as I
have described in the first volume of these Obser-
vations. I  see persons  having the  same  evident
affection of the health  in general,  subject to tu-
mours in and about the breast, which are not can-
cerous, and to those which are cancerous.  What
additional circumstances lead to the establishment
of cancerous actions in the local disease thus in-
duced,  we have yet to learn.
   Previously to the occurrence of  cancer the ner-
vous disorder, and that of the digestive organs,
have, in general, been greater in degree, and longer
in duration, than they are found to be antecedently
to other disorders.  Some  patients  having cancer
die of organic diseases  in the head or  abdomen. If

  * If after the removal of  cancer, when  the operation has
been  properly performed, the cicatrix  remains healthy for
five or six years, or even for a shorter period, and then be-
comes indurated and carcinomatous; it appears to me more
consistent with what we know of the action of this disease,
to suppose, that it has originated again in consequence of the
diseased propensities of the constitution, rather than that it
has lain dormant so long, and is but now awakened. 
A Classification of Tumours.        221
the  nervous and visceral disorders  are active  and
considerable, the progress of the local disease  will
be, in general, proportionately rapid and destructive;
and  if, on the contrary,  these disorders  are mild,
and  less in degree, the progress of the local disease
will be proportionally  slow and  gentle.  In confir-
mation of these observations, I  may mention,  that
I have seen several instances of  cancer proceeding
so mildly, that the patients have lived many years
with little suffering or inconvenience from the local
disease, and particularly where  attention  has been
paid to regulate the  functions of the digestive  or-
gans.*

  * There  can  be no subject which I think more likely to
interest the mind of a surgeon, than that of an endeavour to
amend and  alter the state of a cancerous constitution.  The
best  timed  and best conducted operation  brings with it no-
thing but disgrace, if the diseased propensities of the constitu-
tion are active and powerful.  It is after an operation that, in
my opinion, we are most particularly incited to regulate the
constitution, lest the  disease should be revived or renewed
by its disturbance. In addition to that attention to tranquillize
and invigorate  the nervous  system, and keep the digestive
organs in as healthy a state as possible, which I have recom-
mended in the first  volume, I believe general experience
sanctions the recommendation of a mere vegetable, because
less  stimulating diet,  with the addition of  so much milk,
broth, and eggs, as seem necessary to prevent any declension
of the patient's strength.
  Very recently, Dr. Lambe  has proposed a method of treat-
ing cancerous diseases, which is wholly dietetic. He recom-
mends the  adoption of a strict vegetable regimen, to avoid
the use of fermented liquors,  and to substitute water, purified
by distillation, in the place of common water used as  a be-
verage, and in all articles of diet in which  common water is
used, as tea, soups, Sec.  The  grounds  upon which he founds
his opinion  of the propriety of this advice, and the prospect
of benefit which it holds out, may be  seen in his " Reports
on Cancers," to which I  refer my readers.
  My own  experience on the  effects  of this regimen  is of
course very limited, nor  does it authorise me to speak  deci- 
 222        A Classification of Tumours.

   With a view to impress the contrary fact on the
 mind of the reader, I will briefly relate  two  cases
 in proof of it.


                      CASE XIII.

   A lady came from the country with a cancerous
 tumour  in the breast,  and  took  some  medicine,
 probably arsenic, by the desire of a female quack,
 which brought on the  most violent sickness and
 purging, with death-like faintings.  It was uncer-


 dedly on the subject. But I think it right to observe, that in one
 case of carcinomatous ulceration in which it was used, the
 symptoms of the disease were, in my opinion, rendered more
 mild, the erysipelatous inflammation, surrounding the ulcer,
 was removed, and the life of the patient was, in my judgment,
 considerably prolonged. The more minute details of the facts
 constitute the sixth case of Dr. Lambe's " Reports."
   It seems to me very proper and desirable, that the powers
 of the regimen recommended by Dr. Lambe, should be fairly
 tried, for the following reasons:
   1st. Because I know some persons who, whilst confined to
 such diet, have enjoyed very good health; and I have further
 known several persons who did try the effects of such a re-
 gimen, declare, that it was productive of considerable benefit.
 They were not indeed affected with cancer, but they were
 induced to adopt a change of diet to allay a state of nervous
 irritation, and correct disorders of the digestive organs, upon
 which medicine had but little influence.
   2dly.  Because it appears certain, that in general the body
 can be perfectly nourished by vegetables.
   3dly.  It seems sufficiently ascertained, that diseases have
in some persons been excited by water, and  therefore it is
 desirable,  that whatever is used should be made as pure as
 possible.
  4thly. Because all great changes of  constitution are more
 likely to be effected, by alterations of diet and modes of life,
 than by medicine.
  5thly. Because it holds out a source of hope and  consola-
tion to the patient, in a disease where  medicine  is known to
be unavailing, and surgery affords no more than a temporary
 relief 
          A Classification of Tumours.       223

tain for several days  whether she would survive
its effects.  Inflammation was induced in the local
disease to such a degree, that the cancer sloughed,
and came out, and violent erysipelatous inflamma-
tion extended itself from the skin of the breast to
a great extent.  The sides of the cavity, however,
threw forth a cancerous fungus, and  in this state
she returned into the country.
                  CASE XIV.
   A lady  about forty-six years of age, asked
my opinion  respecting a small lump in her breast.
She was  very nervous  and  agitated,  and  her
bowels extremely disordered. She said  she  had
sometimes twenty discharges from her bowels in
twenty-four hours; and that the secretion of bile
was as faulty  as  possible.  After about six weeks
she  called upon  me again,  having been in the
country:  the medicines which she  had tried had
been productive  of  little or no good.  Her con-
versation  was equally desultory and agitated.  Her
pulse very  frequent. The  lump was enlarged to
about the size of a  walnut, but had no signs by
which I should have known it to be cancer. Hear-
ing that her surgeon in the  country thought it can-
cerous, and believing that an operation in her pre-
sent state  was inadmissible, I recommended her to
take the  opinion of another surgeon. I did not
now see her for  some  time, I believe about two
months, when the tumour had become as large as
an  orange,  and had  thrown out a fungus, which
protruded in nodules. The tumour  had, she told
me, become soft,  and seemed as if it were gather-
ing; and these protrusions  took place afterwards.
Her general health was still  equally disordered, and
the  surgeon,  who had  seen  her, concurred with 
224       A Classification of Tumours.
me in opinion, that an operation under her present
circumstances was inadmissible. The lump rapidly
increased; and, in the course of a few months, be-
came as large as a child's head, having all the cha-
racters of carcinoma.  It  then  ulcerated,  and did
not afterwards materially enlarge. I  need not de-
scribe how it ulcerated, and how it, occasionally,
bled  profusely.  She gradually became emaciated
and feeble, and died exhausted, without the glands
in the axilla becoming diseased,  or any peculiar
symptoms occurring.
   In  order further to elucidate the opinions which
I entertain respecting  the constitutional nature of
cancerous disease, I select the following case.


                   CASE XV.
   A lady had had a tumour in, or near the  right
breast, for  more than  twenty years,  which,  when
she was between fifty and sixty years, may be said
to have become cancerous. The patient indeed in-
sisted, that the cancer did not begin in the original
lump, but  by the side of it. No  local treatment
arrested its progress; and, in a  short time, it be-
came cognizable from  its induration and  irregu-
larity of surface, as a decided case of cancer. The
tumour, and a considerable portion of the surround-
ing parts,  were therefore removed.  The wound
healed healthily in a short space of time, and the
patient left London. She had always  been, to use
her own expression, extremely bilious,  yet the
discharges  from the bowels  were  but rarely tinc-
tured with  good bile. She had passed gall stones.
Her bowels were very  irregular in their functions,
being frequently very costive, or the reverse. Whilst
I had attended her, she had taken five grains of the 
A Classification of Tumours.       225
compound calomel pill every second or third night,
and kept the bowels as regular  as possible. She
said, that  her health had  been greatly benefited
by these attentions, and I urged  her  still  to con-
tinue them. For a year or more, after she left Lon-
don, she was well, the cicatrix remaining perfectly
soft and smooth. Having occasion  to travel  after
that period during  the  winter, and  being  badly
accommodated  at the inns she met  with on the
road, she caught cold, and became very feverish
and unwell. The cold, she said, had fixed itself on
the lungs, for a cough, and a difficulty of breathing
continued, and increased, so that in a little  more
than a year from its commencement it destroyed
her. About six weeks before her death, she  came
to London, when she told me, that since the  time
of her catching her dreadful cold she had found a
lump begin to form in her other breast, and that
the cicatrix had afterwards become  diseased. The
tumour in the left breast was of a  globular  form,
of about an inch and a half in diameter; it was hard,
weighty, and  nodulated  upon its surface. It was
most  characteristically  cancerous,  but what  I
should  term a dwarf or  stunted specimen of that
disease, such as we see produced when the powers
of the constitution  are much lessened. This, and
the correspondent fact of cancer diminishing when
the powers of constitution decline, should be noted,
or else a surgeon might attribute such effects, the
consequences of natural causes,  to the medicine
which he employs. The upper part of the cicatrix,
on  the opposite side, had indurated  and ulcerated,
but not to a considerable degree. I was not per-
mitted to examine the body, which I much wished
to have done, because, I believe, the extreme diffi-
culty of breathing could not have been occasioned
by any thing less than organic disease of the lungs* 
226      A Classification of Tumours.

I have, however, examined the bodies of cancerous
patients  who died  with difficulty  of breathing,
without discovering disease in those organs.
  The symptoms subsequent to operations, being
the result of that excitement of constitution which
the thoughts and injury of the operation occasion,
often exhibit, in a very striking manner, the dis-
eased propensities of the constitution. I think it
may be useful briefly to relate those which occur-
red after the removal of a cancerous tumour in a
case which I lately attended.  The patient possessed
what might, in general, be called a good constitution,
and great fortitude, so that she bore  the operation
without the least complaint. Yet during the day pre-
ceding the operation, she had a slight lumbago, as
she called it, which I believed to be the effect of that
anxiety of mind which the thoughts of undergoing
the operation must occasion. In the evening after the
tumour had been  removed,  she complained of a
desire, and of an  inability to void  urine;  she had
also  sensations in the throat like hysterics.  Her
pulse was 80. She had no sleep during the  night,
but had voided half a pint of urine, which had no
striking peculiarity of appearance.  Saline draughts
had hitherto been given, and she was now desired
to take 5J of ol. ricini, mixed with mucilage and
cinnamon water, every fourth hour till a stool was
procured. She  took  seven draughts  without any
effect. The pain in the  back increased, and during
the second night  was so severe, that she groaned
very constantly from the pain.  On the third morning,
I found  her very  ill, yet her pulse  was not  more
than 90,  neither was her skin hot.  She had voided
no urine for the last thirty hours; pain continued
from the back down the thighs, but the absence
of fever convinced me, that  the pain in the  back
and suppression of urine could  not  be the effect   i
of nephritis. Thinking,  as  I had done from the 
A Classification of Tumours.       227
  beginning, that the kidneys were  sympathetically
  affected by the state of the bowels, and that  the
  I>ain of the back depended on the state of those
  organs, I now ordered her  a pill of extract of
  colocynth, and a draught  of  Epsom salts, every
  fourth hour, instead of the  castor oil.  In the even-
  ing discharges from the bowels took place;  she
  had five stools, and the pain in the  back had nearly
  ceased. Feeling  very languid, and  having had no
  sleep  during the two preceding nights, she took
  twenty drops of laudanum,  and  a  little nitrous
  aether, in  water. This  medicine  produced great
  heat and  uneasiness in  the stomach; and though
  she slept a little from the opium, her sleep seemed
  to be  attended with more disturbance than benefit.
  She voided some urine during the night,  which
•  was like extremely muddy water. As the discharges
  from  the  bowels had  ceased, and did  not seem
  likely  to  be  renewed,  she began  again  with  the
  castor oil  draughts, by  which an evacuation  of the
  bowels was procured in the  course  of the day.
  The  urinary secretion  continued, and  was aug-
  mented in quantity. As the stools were not pro-
  perly  tinctured with bile, three grains of the pilul.
  hydrarg.  were ordered  to  be  given every second
  night  for  the future.  Dyspeptic  symptoms  and
  flatulence now claimed our  chief attention.  She
  complained of great acidity,  of  distention,  and
  tenderness at the lower part of the  epigastric re-
  gion.  For this she  took  chalk mixture, with  aro-
  matic confection, and afterwards magnesia;  which
  latter  medicine  seemed afterwards  sufficient to
  keep  the bowels in a gently lax state. In about a
  fortnight  her bowels were in  a comfortable state,
  and in about three weeks the urine was clear, and
  secreted in the usual quantity.  On the eighth day,
  when  the  dyspeptic symptoms were severe, the
2G 
228       A Classification of Tumours.
patient had gout in her finger and toe, to which
she had been  previously subject. It is  right  to
mention, that  prior to the operation, the  urinary
secretion had never appeared to her to be irregu-
lar either  in  quantity or quality, and  that her
bowels  had been readily affected  by  rather slight
doses of medicine. The same circumstances were
observed after the subsidence of the disorder occa-
sioned by the operation. I have satisfaction in add-
ing, that though the wound  suffered during the
continuance of the constitutional  disturbance,  it
afterwards  healed rapidly  and smoothly,  so that
at the end of six weeks, it had the appearance  of
of a scar in perfectly healthy parts.
   If cancer be a constitutional disease; if patients
affected with it have occasionally other diseases  of
a fatal nature; if in some instances, when there is  '
no organic disease, the nervous system is so irrita-
ble, and the digestive  organs  so disordered, as to
render any operation perilous; these circumstances
must render every surgeon  who perceives them
reluctant to operate, and uncertain as  to the event
of the case. They show the necessity of solicitously
attending to the constitution of the patient after an
operation, with a view to prevent  the recurrence
of the disease, or its formation in other parts. They
explain how it happens, that the operation fre-
quently accelerates the death of the patient. I have
known a patient die soon after an operation for the
removal of a cancerous tumour of no  great magni-
tude, merely in consequence of the shock imparted
to the constitution by the operation. I have known
other eases, in which  the  diseased  state  of the
wounded  parts seemed  to have  been  the chief
cause of the speedy death  of the patient. I there-
fore concur in opinion with those surgeons, who
think, that  in many instances  an operation  for the 
A Classification of Tumours.       229
removal of cancer would be rash and unjustifiable.
Yet, however numerous and  momentous the de-
terring  reasons  may  be, I think they should not
prevent our operating in many cases. If the whole
of these diseased parts, and those which, from con-
tiguity with them, may have been so far influenced
as to acquire a disposition  to disease, can be  re^
moved, it surely ought  to be attempted, provided
the constitution is not so disordered, or diseased,
as to prohibit the  operation. We  ought to  bend
our minds attentively to make out  the characteris-
tic signs of cancer, that we may know it at an early
period, and  when the disease is in a small compass*
and the operation on that account less formidable.
To forbear  to operate is to  consign the patient to
hopeless misery.
   Fumigations with carbonic acid gas, weak acids,
and fresh vegetable juices, correct the fcetor, infu-
sions of  opium  lessen the pain, and  oxyds and
saline preparations of iron  seem to expedite  the
destruction  of  the  diseased parts, and cleanse  the
sore;  yet I have not seen  any such effects from
local  applications as leads me even to hope that
any  may be discovered that  will cure the local
disease.
   The  ulceration  and  self-destroying  process of
cancer  is so horrible a process,  that it  may  be
stated as an argument for the operation, that a pa-
tient gets rid of a quantity of disease upon easier
terms by having it removed by the knife,  than  by
suffering it  to proceed in its  natural course. When
the scar or  surface of a wound after an operation,
becomes indurated and cancerous,,the palient suf-
fers much less pain, and there is much less  fcetor
in the  disease  thus formed, so that the patient's
sufferings are,  on the whole, much diminished.
But if the  patient's constitution be  moderately 
230        A Classification of Tumours.
good, and if the operation be performed at a suf-
ficiently early period, I have known life prolonged
for five, six, or more  years; and when, after that
lapse of time, the cicatrix  has  become diseased,
the actions which ensued have  been indolent, and
the patients have gradually sunk and  died, rather
from some circumstances connected with  the state
of the general health, than from the degree of the
local disease.
   There are tumours, the structure of which may
not correspond with any of the descriptions that I
have given. I feel, however, unable, from  my own
observations, to depict any other species. It seems
to me, that  these diseases resemble colours  in this
respect, that a few of the primary ones  only can be
discriminated and expressed, whilst the interme-
diate shades, though distinguishable, by close at-
tention  and  comparative observation, do not admit
of description or denomination. There are single
tumours,  in the  composition of which several of
the above-described structures may be  found, and,
perhaps, some  part of which may not  correspond
to any description that has been given. If, however,
the history of these dissimilar  diseases which ap-
pear  in  the form  of  tumours, were  accurately
recorded, and their structure noted, we might per-
haps from the former be led to judge of the latter;
and thus attain a knowledge of the intrinsic nature
of the disease which would enable us to act rightly
in practice.


               Encysted Tumours.

  In the class of local diseases, and in the  order
of tumours, custom  seems to have  placed the
genus of Encysted  Tumours, next  to those of the 
A Classification of Tumdurs.       231
sarcomatous kind.  The arrangement  indeed  ap-
pears proper;  for they are so allied in  appearance
and in the sensation which they impart on exami-
nation, that they are not unfrequently mistaken for
each  other; and  yet, in general, the encysted tu-
mours have sufficient1}7 distinguishing characters
to enable a surgeon to determine their nature prior
to the performance  of an operation. The discrimi-
nating characters are, a regularity of surface and
shape, and a pulpy feel. Yel; most  surgeons  will, I
believe, acknowledge, that they have seen tumours
dispersed,  which they have  taken for wens; and
have  even, when they have removed  them  under
that belief, discovered the disease to have been a
soft regularly  shaped sarcoma, and not a cyst con
taining a pulpy substance.
  Respecting  the structure of encysted tumours
I have nothing to1 remark, but  what is, I  believe,
generally known. The cysts most frequently are
composed of many lamella?, which are sometimes so
compacted, as to be  scarcely distinguishable.  These
cysts  vary considerably in thickness; being  some-
times very thick and tough, and at others extremely
thin and tender. They sometimes most tenaciously
adhere to the  contiguous parts, so as  to  make  it
difficult to separate  them; and, at  others, they are
so loosely  connected, that, when  an  incision  is
made which lays bare the cyst, the whole tumour
starts out without any dissection.
  That the  interior  surface secretes the contents
formed in the  cyst,  is in  my opinion indisputable.
That  it is a  secreting surface I believe; because,
when a wen has spontaneously opened by ulcera-
tion, I have seen the cyst  produce granulations
from its surface. When also, the front of  the bag
has alone  been taken away,  and the  skin closed
over the back  of it, an union takes place between 
232       A Classification of Tumours.

the skin and cyst. When also a wen has burst, or
has been punctured, so that a  small aperture has
been  left  in it, which has occasionally given dis-
charge  to its contents; I  have  seen  the  cyst fill
repeatedly by a secretion of the same nature, but
more fluid than the  contents which were  at  first
found in it.
  Some notions have of late been entertained, that
these cysts may be of the nature of hydatids; it may
not, therefore, be improper, in  order to enable the
reader to form his own judgment on this  subject,
to mention the following case.
  A  gentleman had a wen in his cheek, which
spontaneously burst, and  on which Mr.  Hunter
tried various stimulating means to induce the cyst
to granulate or adhere, so  that no further  collec-
tion might ensue. His endeavours, however,  were
unavailing; for, after the opening closed, the cavity
of the cyst filled again, and the wen was as com-
plete  as before, and  had increased  in  magnitude.
It was situated  unfavourably for removal, and the
patient  was averse  to an  operation.  It  lay  so
deeply on the buccinator muscle, as to be  as per-
ceptible from the mouth  as on the  cheek;  and
there  was a great risk of dividing the  parotid
duct,  in an  operation undertaken for the  removal
of the  tumour.  The deformity which  the  wen
occasioned,  was,  however,  considerable, it being
as big as the largest kind of walnut; and the patient
was very desirous of having the tumour lessened,
though  very averse  to having it  extirpated. He
had for  this purpose used  salt and  water, which
made the skin inflame. Having consulted me, I
told him that  if stimulating applications  were to
do good, they could only  effect it by causing the
skin to ulcerate, and the contents of the wen to be
discharged,  as had formerly happened; all which 
A Classification of Tumours.        $33
might be accomplished in a more, direct, and less
teasing  manner, by just  pricking the bag with a
lancet, and squeezing out its contents.  I thought
it also probable, that the  small wound would heal,
and that the  operation might be occasionally re-
peated.  The patient was pleased with the proposal,
and it was put in execution. The  contents were of
the consistence which is  termed meliceritous, and
had a peculiar odour. No inflammation ensued, and
the wound healed; but, after a little time, it opened
again, and gave discharge to  a small  quantity of
watery liquor, of precisely the  same odour as the
original  contents, and  the little  puncture  again
closed up. From that time  to  the present, which
is  now  some years, the wound  has occasionally
opened, discharging  a small quantity of sometimes
a more fluid,  sometimes  a more meliceritous sub-
stance; and after this discharge, the aperture closes
up. This circumstance occurs but seldom; perhaps
every second or third month. The aperture is so
small as not to be discernible; no plaister is worn
upon it, and the patient has  got rid of a considera-
ble deformity, upon  what he thinks very easy and
satisfactory terms.
   I  have mentioned these circumstances to illus-
trate the functions of the cysts of these tumours;
and to show what may be done in some cases, as
a palliation of these diseases.  It  is not, however,
meant  to recommend such practice; for, on the
contrary, it will be shown hereafter, that it is dan-
gerous to tamper with encysted tumours;  and, in-
deed, I  should not have ventured on  this palliative
mode of treatment,  in the case related, had  I not
known  from  the  effects of the former conduct
which had been pursued, that the cyst and  con-
tiguous parts were of an indolent nature, and  not
disposed to re-act in consequence of  violence done
to them. 
234       A Classification of Tumours.

   The  contents  of encysted tumours have been
denominated from their consistence, steatomatous,
atheromatous, and meliceritous. To  this ancient
distinction must  be added another: the cyst some-
times secretes a substance like nail or  horn; which
is protruded when the skin ulcerates, hardens, and
is pushed forwards in  proportion  as  the cyst se-
cretes more of this substance, so as to appear like
horns; as has been shown by Mr. Home in the Phi-
losophical Transactions.
   There is  yet  another curious circumstance  to
be noticed with  relation  to  cysts; which  is, that
they have  sometimes hairs  growing  from their
interior  surface.  This  happens  in  those  cysts
which   are  not  unfrequently met with  in the
ovary.*
  But though the cysts of encysted tumours must
be  considered as possessing the organization  of
other parts, and  as secreting  and absorbing  sur-
faces; yet their vessels are probably very minute,
and  not endued with a  degree of strength ade-
quate to the  ordinary reparation of injury. If they
produce granulations they are flabby, and the sores
are not disposed to heal.
  It is  no uncommon circumstance to meet with
wens,  that  have burst  spontaneously, and have
thrown  out a fungus, which, like a foreign body,
prevents the  surrounding integuments from heal-
ing.
  Most parts that are weak, are irritable when ex-
cited, and  apt to assume diseased actions. This
frequently  happens in a striking  manner in  the
cysts of these tumours; and  as, perhaps, surgeons

  * Some of the tubercles which occur in the viscera seem
to be formed by the deposition of various kinds of substances
from the surface of a cyst, which appears to be the first
formed and most essential part of the disease. 
           A Classification of Tumours.       235

are not sufficiently apprized of the bad consequences
sometimes  occurring  from the  inflammation of
wens, and as it is proper to show the danger of ir-
ritating these diseases, I shall relate a few cases to
illustrate this fact.
   A woman, about forty years of age, was admitted
into  St. Bartholomew's Hospital, with a frightful
fungus  growing on the front  of the belly, below,
and to the right of the navel. She had been a healthy
lusty woman, but was  greatly deranged in health
by the pain and irritation which this had occasioned.
She  described it  as being a wen which had burst,
and her account was afterwards verified by dissec-
tion. The fungus bled,  and she could scarcely bear
the softest  dressings  to  be  applied  to the  part.
Nothing mitigated her sufferings so much as lint
dipt  in a solution of opium, and kept moist by very
frequently squeezing on it, from a sponge, a suffi-
cient quantity of the solution. Nothing allayed the
constitutional irritation but large doses of opium.
She died exhausted in  the course of a fortnight.
   I removed  the cyst from  off the aponeurosis
of the external oblique muscle,  where it covers
the rectus, leaving the  tendinous expansion quite
clean and unaffected.  The cyst had  ulcerated in
two small places, so that the fungus which it  con-
tained was visible from behind.
   A man between forty and fifty years of age, who
was  in St. Bartholomew's Hospital, had a wen on
his back, which ulcerated, discharged an atheroma-
tous substance,  and afterwards inflamed, and threw
out a fungus.  Extensive erysipelatous  inflamma-
tion  took place in the  surrounding integuments,
and his  constitution was greatly deranged by irri-
tation and fever.  When he was almost  exhausted
by these  circumstances,  and   before  any  local
amendment  had taken place, another wen of the
                    2H 
236       A Classification of Tumours.
same nature, which he had on  his right thigh, ul-
cerated,  and was followed  by the  same  conse-
quences; and, conjointly, they soon destroyed him.
   A gentleman, of a stout make, and about forty
years of age, had a tumour, supposed to  be sarco-
matous,  which  had  formed beneath the  integu-
ments on the lower edge of the pectoral muscle.
It-was attended with severe pain  occasionally, at
which time  it  rapidly increased in size, and pro-
duced a great deal of fever and irritation,* which
made him look  very sickly, and grow very thin,
and caused some persons to deem the disease can-
cerous.
   When the tumour had acquired a magnitude of
about four inches in length, and three in breadth
and depth, he submitted  to  its removal; the inte-
guments were  divided and  turned back, and the
tumour  dissected off the surface,  and,  in some
degree,  from  under the  edge of the  pectoral
muscle.
   When the tumour was examined, it was found
to be composed of a steatomatous  substance, con-
tained in a thin capsule. The substance resembled
that which  I have described as  being sometimes
found in cells in the  testis, or intermixed with the
diseased organization of that part. It was firm, and
resembled cheese in  its yellow  colour and unctuous
 appearance;  but it was not unctuous to the touch.

   * Circumstances like these  should, I think, be  particularly
attended to in the history of  tumours; for they may serve,
perhaps, to characterize the  disease in  which  they occur.
Tumours of an innocent nature  commonly  increase in an
equal ratio, and do not excite irritation in  the contiguous
parts, or in the constitution. Yet this, as a general rule, has
exceptions.  Some of these have been stated under the head
of pancreatic  sarcoma, occurring in  or about the mammary
 gland. 
         A Classification of Tumours.        237

  The wound made in  the operation soon healed,
and  the patient's health was restored  to  as good,
or seemingly a better state than before the forma-
tion  of this  disease. He  also regained his usual
athletic form. But in less than three months after
his recovery, two new tumours formed, one above,
and the other below the cicatrix of the wound. The
patient did not particularly attend  to them till they
had attained a size equal to that of a large walnut.
To dissect out both  these tumours, and make so
free a removal of parts as to render it probable that
no new growth would ensue, seemed to be a very
formidable operation; and, as the nature of  the
former tumour was known, and it was supposed
that  these were of the same kind,  it was agreed to
puncture  the upper one, to express the  contents,
and await the event.  This was done by a  puncture
of half an inch in  length, made by an abscess
lancet. The contents were exactly like those of the
original tumour. Vehement erysipelatous or irrita-
tative  inflammation   took  place,  and sloughing
about the diseased part: the inflammation rapidly
extended  to  the  opposite side of  the thorax, and
then down the integuments of the abdomen to the
groin. The derangement of the constitution was as
violent as the local  disease, and in about a week
the patient died.
  These  cases are related to show the danger of
irritating wens, either of an irritable nature, or oc-
curring in irritable habits; and because I have not
met with  such cases described in books in a man-
ner adequate  to the importance of the subject.
   It deserves to be noticed in this brief account of
encysted  tumours, that the  disposition  to  form
wens prevails frequently in many parts of the body
at the same time. It is not very uncommon to  see
many, even twenty  or thirty wens, alike in their 
238        A Classification bf Tumours.
structure and contents, in various parts of the same
subject  Nay,  the disposition seems sometimes to
be hereditary, and transmitted from parents to their
children.
   The subject would  appear to me to be incom-
plete were I not to notice the formation  of cavities,
containing  different  substances, and  which  can
neither be  accounted  encysted  tumours,  nor ab-
scesses. The cysts are like the cysts of abscesses;
they are secreting  surfaces, not regular in shape,
but varying according to the  form of the  parts,
amongst which they are  produced. They adhere
also, like the sides of abscesses, to the circumjacent
parts, and are not easily separable from them like
the cysts of wens.  These cysts sometimes contain
a kind of serum and hydatids, like the cysts formed
in the liver, and other viscera.  Sometimes they
contain a number of granular substances of a white
colour, having a polished surface, and generally an
oval figure, which resemble  pearl barley,  but the
granules are generally smaller. I  have  seen the
cysts containing  hydatids, in  the back and  about
the hip, on the shoulder,  and in front of the  elbow
joint.*  I  never  met  with  any containing  these

  * The cysts from which such substances are discharged,
are, in general, very irritable. If they are kept open for some
time, an alteration seems to take place in  the actions of the
part, and they no longer  continue  to secrete that  matter
which forms  the granules I have described, nor the  fluid in
which hydatids are found.  As these diseases are  not so fre-
quent as to be familiarly known to surgeons, whose practice
is not  extensive, I will relate two cases to show the nature
and treatment of such diseases.—Case. A young  lady had a
considerable collection of fluid beneath the biceps  muscle of
the arm.  It protruded on either side of the  muscle, and
reached to about three inches above the elbow joint. I punc-
tured it with an abscess lancet, and discharged  about six
ounces of serous fluid, containing a few hydatids. The wound,
which  was an inch in length, was dressed with spermaceti 
A Classification of Tumours*        239
granular  bodies  but about  the  hip,  and  in  the
thecal of tendons;  I have  therefore  conjectured


salve, a bread and water poultice applied, and the arm  was
supported  by a sling. For a few days serous fluid oozed from
the aperture, when thy external wound  had closed so much
as to prevent its escape.  I introduced a probe into the cavity,
and afterwards a small tent, to prevent the aperture in the
cyst trom  closing.  This trivial  irritation caused great  dis-
turbance in the parts, to a considerable distance, which be-
came heated and swollen, and so painful, that  I dared not to
persevere. The wound was suffered to heal, which it soon did;
but the fluid collected again.  Instructed by  this experience,
I now opened the cyst with a lancet, introduced a probe-point-
ed bistoury, and enlarged the  aperture to the extent of an
inch and a  half. This wound was dressed superficially; it was
three weeks before it closed, and afterwards no collection of
fluid took place in the cyst, and the patient remained perfectly
well.—Case. A gentleman had for many years  suffered great
inconvenience from a collection of fluid beneath the fascia of
the ring finger, the palmar fascia, and that of the fore-arm.
The collection seemed to have begun in the palm of the hand,
but had extended itself half way up the  theca  of the ring
finger, and passing under the carpal  ligament, had made its
way by the ulnar side of the flexor muscles, and protruded
the fascia of the fore-arm in that part which intervenes be-
tween the flexors of the fingers and the  flexor carpi ulnaris.
At this part the fluid was nearest to  the surface, and it was
agreed, in  consultation, that it should here be  opened. I ac-
cordingly made a division of  the skin about  two inches in
length, to expose the  fascia of the fore-arm, which I divided
to the extent  of an inch and  a half.  I  then distracted  the
muscles a little, when  there gushed out a large  quantity of
fluid,  containing a number of the largest granules that ever
I had  seen  formed in the sheaths of tendons.  Several of them
were  as big as small  grapes. By pressing  the palm of the
hand more were forced out, yet I remained uncertain whether
the whole  were discharged. The wound was dressed super-
ficially with spermaceti salve, a bread and water poultice
applied, and the arm  kept supported in a sling.  Three days
after the operation, fearing lest some of the granules might
remain, I introduced the point  of a varnished catheter, and
impelled some warm water beneath  the fascia of the hand.
No granules returned with it; but this experiment caused
great  nervous irritation in the  part,  and in  the constitution 
240        A Classification of Tumours.

that  these cysts are enlargements  of the bursa:
mucosae.
  The greater number of these cases, which I have
seen, have ultimately,  but very slowly, done well.
However, some cysts,  upon becoming open, pro-
duce great and  even  fatal irritation  in  the  con-
tiguous  parts. Sometimes cysts, as Mr.  Hey has
lately remarked, produce  that  appearance, which
he  has called  fungus  h<ematodes.  Of  this  cir-
cumstance, as it appertains to the present subject,
I shall relate an instance; but to speak more largely
of that disease, would be deviating from the plan
of this paper, and would be unnecessary, as the nu-
merous and  accurate  cases, which Mr.  Hey has
related, show that this disease  may exist without
being connected with cysts.
  A girl  about sixteen years of age, who was in
St.  Bartholomew's Hospital, had  a collection of
fluid under the triceps  extensor cubiti, near to the
olecranon. When  I first saw it, it was not larger
than a pullet's egg, but it increased, notwithstand-
ing the means which were  employed to discuss it;
and, in about twelve months, it presented itself be-
neath the integuments on  the outside of the arm,
in the  space between  the  extensor and  flexor
muscles,  a little  above the elbow.  Upon corn-

in general. Nothing  therefore was further done that could
irritate the parts, and the wound healed in about six weeks,
in the following manner:  The skin on  either  side  of the
wound became  tumid, and threw forth exuberant granula-
tions to such a height, that a swelling as  big as half an egg
cut lengthwise,  projected above the level  of the skin; as the
granulations from either side touched, they coalesced, and
thus the divided fascia was covered, The  granulations being
afterwards  absorbed,  the cicatrix appeared like  one from a
common cut, and the integuments were flat, and  in a natural
state.  I saw  the patient two years after this operation, and
there had been no new collection of fluid. 
A Classification of Tumours.       241
pressing the projecting integuments, a fluctuation
of fluid was felt beneath the triceps muscle  in the
inside of the arm, and the collection seemed to ex-
tend high up  on the back part of the os brachii.
As the parts containing the fluid seemed more dis-
posed to increase in dimensions, than to give way
and  discharge their contents,  the  collection was
opened where it pointed, and a quantity of serum
was discharged. On introducing the  finger, some
strata  of  coagulated blood  came  away, and this
was succeeded by so great an hemorrhage, that it
became necessary to enlarge the wound, in  order
to search for the  bleeding vessels. In proportion
as this was done, and more coagulated  blood was
detached from the sides of the cyst, which had con-
tained  both it and  the serum, the hemorrhage in-
creased, and the blood flowed so profusely from so
many and such large arteries, that it was impossi-
ble to control its effusion. Amputation seemed una-
voidable,  and was  performed  as high up as pos-
sible, but not clearly above the cyst, some part of
which remained amongst the muscles of the stump.
   On examining the amputated limb, a thick and
firm stratum  of coagulated  blood was found ad-
hering to the sides of a cyst, which extended from
a little above the olecranon, where it was large, to
nearly  the upper part  of the os brachii, where it
gradually tapered to a small size. The upper part of
the cyst was cut off from the  rest by the ampu-
tating  knife,  and  of course  remained  upon  the
stump. At first, the stump appeared to do well, but
shortly after the sides of the wound separated, con-
siderable inflammation came on, and a fungus was
thrust forth. Great fever and irritation accompanied
this local disorder, and the girl  died.*
  * An  unrestrainable hemorrhagic tendency seems to be
'.he essential character of that disease, which Mr. Hey has 
242       A Classification of lumours.
   The treatment of encysted  tumours resembles
that of the sarcomatous kind. By abstracting blood
and heat from the part it is probable the growth of
them will be stopped, and the disease made for a
time  stationary. They  are  not  likely to  be dis-
persed; and, as the magnitude is increased by delay,
and the spontaneous opening of the cyst generally
leaves a vexatious and intractable sore, and some-
times  is  attended  with more  dangerous conse-
quences,  the  early  removal of  the  disease is  the
best practical conduct that can be pursued.
    Another  genus  of  tumours  is  the  osseous.
Those which hang pendulous into joints are some-
times  bony. Osseous tumours  also form, though
not frequently,  in other parts: of this circumstance
I shall relate the following instance. A woman was
admitted  into St. Bartholomew's Hospital, with a
hard tumour in the ham. It was  about four inches in
length and three in breadth. She had also a tumour
on  the front  of  the  thigh a little above the patella,
of less size and hardness. The tumour in the ham,

denominated Hxmatodcs. That it takes place from diseased
structures is manifest;  yet I  have known it happen without
any morbid growth having preceded it. 1 shall briefly relate a
case of this description, because the  term fungus hsematodes
seems to be a name commonly now applied to every bleeding
fungus, whilst that hxmatodal disposition, which Mr. Hey
has described, is  a very  rare occurrence.—Case. A young
man, who was out of health, complained of stiffness and pain
in the bottom of his belly, and took to his bed, declaring his
inability to move about. Suddenly a  swelling formed above
the Poupart's ligament, which rapidly increased, and the skin
ulcerated. A frightful  fungus seemed to present itself, and
an uncontrolable hemorrhage ensued. When the case was
examined after death, all that bulged out could  be removed
by the finger or sponge, and appeared to be coagulated blood,
rather than fungus, and at the bottom nothing was seen  but
the abdominal muscles, which had that bruised and brownish
appearance which  Mr.  Hey has described. 
           A Classification of Tumours.      243

 by its pressure on  the nerves and vessels, had
 greatly benumbed the sensibility, and obstructed
 the circulation of the leg, so that it was very oede-
 matous.  As it appeared impossible to remove this
 tumour, and, as its  origin and connections were
 unknown,  amputation was resolved on. On exa-
 mining the amputated limb,  the tumour in the
 ham could only be divided by a saw; several slices
 were taken out of it by this means, and appeared to
 consist of  coagulable  and vascular substance, in
 the interstices of which a great deal of bony matter
 was deposited. The remainder of the tumour was
 macerated  and dried, and it appears to be formed
 of an irregular and compact deposition of the earth
 of bone.  The tumour on the front of the thigh was
 ©f the  same nature with that in the ham; but con-
 taining so little lime, that it  could be cut with a
 knife.  The thigh  bone  was  not at  all diseased;
 which  is mentioned, because, when bony matter is
 deposited in a limb, it generally arises from a dis-
 ease of the bone. This case,  however, shows that
 the vessels of a tumour  may secrete phosphate of
 lime, and convert it  into an  osseous  substance,
 without any manifest cause existing to excite such
 ossific  inflammation.
  Vascular tumours  also may  doubtless become
 converted into a  substance  resembling cartilage,
 like those found in joints; and their hardness might
 then exclude  them from the genus sarcoma. I have
 not however met with such instances.
  The diseases which I have been describing may
 be considered as edifices which are built up by dis-
eased actions, and  in which those diseased actions
continue to reside. The actions themselves do not
admit of examination, though the  structures do
which they erect. Therefore, as Dr. Baillie has ob-
served, it is by an  examination of diseased  struc- 
244       A Classification of Tumours.
ture that we must be slowly led to a knowledge of
diseased actions. It does not follow as a certain con-
sequence, that similar diseased actions will, in eve-
ry instance, produce  precisely  the same  diseased
structure; though it is  highly  probable that they
will do so in general. This observation would  di-
minish our  surprize if, in some rare instances, we
found  cancer existing where a cancerous structure
was not strikingly manifest;  or if, in others, a struc-
ture like that of cancer was observed where no
cancerous actions were apparent. The scirrhous tu-
mours, which form beneath the peritoneal covering
or lining of the uterus, have something of the struc-
ture of cancer, and yet they are not cancerous. In
all cases where tumours are formed  we must sup-
pose an increase, and, in some degree, a disordered
action  of the vessels which form them; but, in many
these actions possess but little diseased peculiarity.
As in every case of growth,  in the re-production of
destroyed parts,  the  gelatinous substance of  the
blood  is first deposited, and afterwards  rendered
vascular, therefore  I have  considered a tumour
formed in this manner as one  of  the most simple
kind, and possessing the least of diseased peculiari-
ty; but I am aware that I may have included under
this general  character tumours of essentially differ-
ent natures.  In the adipose sarcoma there must be
some peculiarity in the arrangement and actions of
vessels which form this tumour; but it must be ac-
counted a natural rather than a morbid peculiarity.
The pancreatic sarcoma, I  should suppose, differ-
ed but little from the first species. It may be con-
sidered as a  new growth  characterized merely  by
the peculiarity of its  appearance,  in consequence
of its  being separated  into many distinct parts,
which  sometimes cohere by a looser  kind of tex-
ture, and sometimes are separated by a firmer sub- 
           A Classification of Tumours.        245

stance.. The connecting medium appears like the
thickened cellular substance of the part in which the
newly organized matter is formed. Indeed I  have
sometimes pressed  out the  separated portions of
this substance from the connecting medium which
environed them. In  the mammary sarcoma I sus-
pect some diseased peculiarity to exist, as has been
mentioned in  speaking of that subject. In the tu-
berculated sarcoma the predisposition to that dis-
ease seems general on the  part of the constitution.
In the medullary sarcoma the disease seems local,
in the first instance, and  propagated by means of
the absorbing vessels to their  glands, and frequent-
ly in a course retrograde to that which the absorbed
fluids would naturally take;  but in  the  advanced
state of the disease the morbid disposition appears
to be  general.  In  carcinomatous sarcoma the dis-
ease appears to begin in a point or small district,
and to extend in every direction, as rays do  from
a centre, affecting every surrounding part, whatever
may be its nature. The diseased actions also, though
they may be at times more Violent or more  tran-
quil,  never cease. This disease is also  extended
through the medium of the absorbing vessels in the,
direction which the  absorbed matter would natu-
rally take. 
SURGICAL OBSERVATIONS.
    ON CHRONIC AND LUMBAR ABSCESSES.

lyHRONIC abscesses differ from those produced
by phlegmonoid inflammation in many particulars.
In diseases of an active and violent nature, the con-'
tiguous parts become affected, whilst in those of an
indolent disposition they remain free from disease,
and unaltered in structure. An absorbent gland, for
instance, may be enlarged to a considerable  size;
yet, if the disease be of an indolent nature, the sur-
rounding cellular substance is loose and pliant. On
the contrary, if one or two of these glands undergo
active inflammation, the surrounding parts partici-
pate  in the affection, and all traces of the  glands
primarily affected, are lost in the more general in-
flammation and abscess. In phlegmonous abscesses,
the inflammation which was most violent  in the
centre, and had there terminated  in suppuration,
had, at the  same time, induced adhesion of the sur-
rounding cellular substance; and thus, the sides of
the abscess are, as it were, walled in and support-
ed, and the extension of the disease in the circum-
ference is to a certain degree prevented. It also ap-
pears, that  it is  very much owing to the parts co-
vering the front  of the abscess participating in the 
            .  On Lumbar Abscesses.          24,7

irritation, that the matter so readily makes its way
to the surface, and is discharged.
   On the contrary, in chronic abscesses it general-
ly happens, that very little adhesion of the surround-
ing substance takes  place, and the matter is more
at liberty to extend  itself in all directions; at the
same time, the parts covering it do not participate
in the disease, they  therefore do  not  inflame and
ulcerate till their distention induces them to do so,
and such  a degree of distention may not take place
till the abscess has acquired  an enormous magni-
tude.
   Now, if it could be proved, and I think it prac-
ticable,  that chronic abscesses are not from  their
nature deleterious diseases, but are disturbing and
destructive to the constitution in proportion to their
magnitude, we should then clearly see, that the ob-
jects of surgery in their treatment ought to be those
of preventing their increase, or reducing their di-
mensions.
   As inflammation varies in its degree, so there are
many abscesses neither strictly speaking phlegmo-
nous nor chronic, but  of an intermediate nature. I
think, therefore, it may be useful  to insert a case
of purely chronic abscess, as an illustration of the
preceding remarks.


                    CASE I.
   An abscess containing twelve  ounces of well-
formed pus took place beneath the integuments co-
vering the  upper part of the pectoral muscle;  it
elevated the skin, and  had formed a globular kind
of tumour. This suppuration had been attended
with scarcely any pain, and  the  integuments, al-
though distended, were indolent, and appeared per-
fectly  healthy  and  natural.  I punctured  the ab- 
248          On Lumbar Abscesses.
scess with  a  lancet conveyed obliquely  between
the integuments and  the  cyst, evacuated the con-
tained pus,  and  closed the aperture with sticking
plaster: but on the re-accumulation of matter it was
no longer confined in a cyst, but became diffused
through the  cellular substance leading to the axilla,
in which a slight inflammation was produced. I was,
therefore, obliged to make a new orifice, and leave
it open,  that  the secreted matter might  have an
outlet, and not extend disease, by thus pervading
the cellular substance.
  The surface of the cysts of all abscesses has the
power of secreting and absorbing their contents.
Even phlegmonous abscesses occasionally disperse,
and many cases are on record of large abscesses,
which I conclude were of a  chronic nature, being
dispersed in consequence of the occurrence of a
diarrhoea. It appears to me, that  the cysts of ab-
scesses perform the same function with respect to
their contents  that the membranous surfaces of ca-
vities do in cases of dropsy. In either  instance, if
secretion exceeds absorption, the  disease enlarges;
if it be equal, the disease is stationary;  and if it be
less, the  disease diminishes.
  With this view of the subject,  and knowing the
danger arising from the  opening of  chronic ab-
scesses, I have endeavoured to disperse them, and
I have sometimes been successful in my attempts.
As an instance of what may be accomplished, I re-
late the following case:

                   CASE II.

  A gentleman about twenty-six years of age, con-
sulted me on account of a very large abscess which
had formed amidst the muscles of his thigh. It pro-
truded the fascia on the front of the vastus internus 
             On Lumbar Abscesses.         249

muscle, from the patella to above the middle of the
thigh: the posterior muscles of the thigh also bulged
outwards, so as to give a considerable convexity to
the back part of the limb. The patient looked un-
healthy;  he  was  languid and  irritable; he had  a
furred tongue: the actions of his bowels were irre-
gular,  and the secretion of bile was deficient  or
faulty. I desired him to drink  a pint of the decoc-
tion of sarsaparilla daily; to take five grains of the
pil. hydrarg.  every  second night, and to pay strict
attention to keep  his bowels regular. I also recom-
mended a bandage to give support to the sides of
the abscess. However, it continued to increase, and
in about six weeks the integuments at the lower
part became  more prominent  than  elsewhere, and
felt heated and uneasy.  Fearful of their  becoming
inflamed, and frustrating the plan of treatment which
I designed to pursue, I opened the abscess with an
abscess lancet, making a wound about three-fourths
of an inch in length. About thirty ounces of serous
pus flowed through this orifice, but the current was
very frequently  obstructed by large clots of that
flaky  substance  which  is  so commonly found in
such abscesses. Towards the end of the discharge
clots of blood obstructed the orifice, and they were
so numerous and large, and came out of the aper-
ture with so much difficulty, that I  thought it bet-
ter to close the wound, even before the abscess was
completely emptied, than run the risk of irritating
the sides of the wound  by  too much poking, or of
admitting air into the cavity of the abscess. I there-
fore cleaned and closed  the sides of the wound by
sticking plaster, and applied a roller round the limb.
The wound healed, and the patient's health was in
some degree improved.  At first the cavity of the
abscess filled rapidly, so that the fascia protruded
again. The protrusion,  however, did not increase, 
250
On Lumbar Abscesses.
 and the disease seemed stationary. After about three
 weeks the patient was permitted to take exercise
 on account of his health, and he generally slept in
 the country. By these  means, and with  the con-
 tinuance of his medicines, his appetite became good,
 and his bowels regular. He then left off the  sarsa-
 parilla, and  took the pil. hydrarg. only,  when he
 observed that the faeces were not  of a proper co-
 lour. As the patient's health amended, the abscess
 decreased, so  that in about  six months there re-
 mained no evidence of such a disease having exist-
 ed. After some time, the patient went into the ar-
 my, where fatigue and irregularity of diet made him
 ill again, and  he perceived some  fluid in the ab-
 scess. He, therefore, relinquished this mode of life.
 On the restoration of his health, to which the use
 of the same medical means seemed to be contribu-
 tory,  no  vestiges of the abscess  remained; and
 though many years have now elapsed, no return of
 the local disease has taken place.
   As chronic abscesses  in general  form in conse-
 quence  of a disordered state of the constitution;
 and as it is subject  to great disturbance when they
 become open, so it  is requisite to endeavour to im-
 prove the general state of health prior to that event.
 By such  means I have  seen several chronic ab-
 scesses dispersed; and even if our endeavours have
 only the  effect of rendering the abscess stationary,
 whilst the patient's health is improving, it is pro-
 ductive of great good, since it enables the constitu-
tion to encounter that disorder attendant on the ab-
scess becoming open. Such topical applications as
will afterwards be mentioned, may  be employed at
the same time, with a view to render the abscess
stationary, or to diminish it, by lessening the secre-
tion into  the cavity, and by  promoting absorption
from it.  I may also add, that J have seen several ab- 
              On Lumbar Abscesses.         251

scesses, which continued to enlarge under such
management in  the first instance, dispersed by it,
after they had been once punctured.
   The foregoing remarks and cases are  designed
to illustrate the nature of chronic abscesses in gene-
ral, and I now proceed to consider the  most im-
portant species of such a disease that we meet with
in practice, I mean the lumbar abscess. Some lum-
bar abscesses  can indeed scarcely be denominated
chronic; they are formed with  so much  pain, the
pus which they contain being good, and so unlike
what is generally found in the cysts of indolent ab-
scesses, that we  must  suppose the  disease which
produced  it was  of a different nature. I have seen
also inflammatory fever induced when such an ab-
scess has become open, which was an additional proof
of its  being of a  phlegmonoid nature. Such occur-
rences are indeed very rare: but it very commonly
happens that the formation of lumbar abscesses is
attended with  more pain, and other inflammatory
symptoms, than are incident to chronic abscess in
general.
   Whatever the nature of a lumbar abscess may
be, the surgical  treatment of it must be similar to
that of a chronic abscess; for as the matter presents
in a part of the body which is so remote from that
where  it  was originally formed, as not to sym-
pathise with the disease; so the progress of the ab-
scess, before breaking, will resemble that of a chro-
nic abscess. To use the language of  Mr. Hunter, a
lumbar abscess, where it presents, is to be consi-
dered as an abscess in the part, and  not as an ab-
scess of the part.
   As  lumbar  abscesses in general  descend along
the psoas  muscle, under Poupart's ligament, and
present beneath the fascia of the thigh, the resist-
ance of the fascia affords an additional obstacle to
                       2K 
252          On Lumbar Abscesses.
 the progress of the  matter to  the surface, so that
 such abscesses, if left to themselves, often acquire
 an enormous magnitude before they spontaneously
 open.
   Lumbar abscesses  also, in general are not sim-
 ple diseases; they arise from and communicate with
 carious vertebrae; which circumstance is, I believe,
 the cause of their frequent fatality. The first eight
 cases that I attended, after I  had  adopted a new
 mode of opening them, were simple abscesses, and
 not arising from disease of the  bone; which led me
 to believe, that they were more frequently uncon-
 nected with diseased  bone than later  experience
 has taught me. The  general opinion of surgeons, in
 which I entirely concur, is, that lumbar abscesses
 most frequently arise in consequence of diseases of
 the vertebrae, and they should certainly all be treat-
 ed as if such was their origin.
   Before I proceed to  describe  the particular treat-
 ment which I  would  recommend in chronic and
 lumbar abscesses, it  will be useful to enquire into
 the cause of that constitutional disorder, which is
 so generally consequent to  their becoming open. It
 has been ascribed to the admission of air into the
 cavity of the abscess,  or to the absorption of pus
 from  it. That it is not  owing to the former, we in-
 fer, because air does not appear to be stimulating
 to those surfaces of the animal body, to  which it is
 not naturally applied.  The air which escapes from
 a wounded lung, and renders the cellular substance
 emphysematous, produces no  inflammation of it.
 Air has also been blown into  different cavities of
the body, to ascertain its effects; and it has been ab-
 sorbed from them without having excited any in-
flammation. Neither  does air appear to  be stimu-
lating to the exposed surfaces of ulcers  which are
in a state of disease. Yet, though air seems  to have 
             On Lumbar Abscesses.          253

no stimulating property to such surfaces, and there-
fore cannot be assigned as the cause of that irrita-
tion and inflammation consequent to the opening of
an abscess, yet it is of the highest importance  in
pursuing the treatment which I have recommended
in these abscesses, that no bubble of air should  be
admitted into the cavity,  because  it would proba-
bly cause the putrefaction of the fluid contained in
the abscess, the absorption of which would be very
deleterious.  To show the consequences that might
arise from such an occurrence, and to urge the ne-
cessity of all that caution which I  shall recommend
in opening lumbar abscesses, I relate the following
case:
                   CASE III.
  A surgeon discharged a large quantity of pus,
containing flakes, from a lumbar abscess, which
presented itself  beneath the fascia of the thigh.
The matter was discharged through a wound made
by an abscess lancet, and in holding open the ori-
fice  with probes,  in  order to give discharge  to
some coagula, a bubble or two of air was  admit-
ted into  the  cavity of the abscess.  His assistant
perceived this occurrence, and mentioned it to me
prior to the coming on of those symptoms which
afterwards  took place.  When the abscess was
emptied, the wound was closed with sticking plas-
ter, and  bound  down by  many straps of plaster
placed over it.  On the third  day the patient was
attacked by so violent a putrid fever, that it could
be compared to no other, unless to such as is oc-
casioned by  the plague. The fascia of the thigh
was elevated as much  as it had been before the
operation; the skin was very hot, and of a dusky
colour.   On removing the straps and  coverings 
254          On Lumbar Abscesses.
from off the wounded  part, a  large blast of foetid
ajr  burst from the aperture, which  was followed
by  the  discharge  of a considerable  quantity of a
very offensive and bloody fluid.  The patient lived
but twenty  hours; and, on examining  his body
afterwards, a considerable quantity of bloody fluid
was found effused into all the large cavities.
  If the notions which  have  been delivered  res-
pecting abscesses  be correct, I mean, that  there is
continual secretion, and continual absorption from
the cyst, as from  a membranous surface, or from
that of  an ulcer, then it would follow, that the ab-
sorption of pus cannot be productive  of fever.
Though absorption of pus is continually taking
place, yet no fever occurs before the opening of
an  abscess, neither does it come  on where  ab-
scesses are dispersed, and  where such absorption
must indisputably have happened.  It is true, in
these cases, the pus is generally inoffensive in its
qualities; it might be  contended, that though it be
admitted into the circulation with  impunity, yet
some of the foetid matter usually discharged from
the surfaces of open abscesses, being absorbed from
them, might prove the cause of the  fever.  We do
not however find  such fever produced  by the ab-
sorption of foetid matter from the surfaces  of large
ulcers.  We frequently apply the term putrid to sub-
stances merely foetid, as well as to  those in a state
of chemical putrefaction; and from this  inaccuracy
of language, I suspect the equal inaccuracy of opi-
nion has arisen, which has led to the belief of delete-
rious consequences succeeding to the absorption of
matter. I need not discuss  these subjects  further,
because the enquiry into the true cause of the fever
will furnish arguments to refute false notions.
   An attentive  examination of  the  subject will, I 
On Lumbar Abscesses.          255
believe, convince us, that the fever depends  upon
the state of irritation and inflammation which  takes
place in the cyst of the abscess. First, because its
violence corresponds with the degree of local inflam-
mation. Thus, in the  old method of opening  chro-
nic abscesses by an incision of considerable length,
the fever was much  more  violent than when the
abscesses were suffered to break of themselves, or
when they  are merely punctured.  Secondly, be-
cause the kind and degree of fever accords with
the state of inflammation and irritation existing in
the cyst of the abscess. Thirdly, when a lumbar
abscess opens spontaneously, in a manner produc-
tive of  the least possible irritation to the cyst, the
patient  sometimes remains  for many days without
heat or pain in the part, and without fever.  After-
wards,  when the  cyst has become irritated and
inflamed, and the constitution disturbed by a  pecu-
liar kind of fever,  the symptoms may, and  gene-
rally do subside, and the patient merely feels lan-
guid, and slightly hectical.  If local  irritation  is
again excited, again the concomitant fever  takes
place.  The cases  which I shall afterwards  relate
will, I think, prove these assertions, and they have
induced me to believe, that the disturbance of the
constitution at large  depends upon, and accords
with the local disease. Such opinions lead to this
practical conclusion, that if we wish to prevent or
mitigate  the fever, which  exhausts the  patient's
powers, we should do every thing to  prevent and
allay the local  disorder, which is likely to arise in
the abscess.
   There seems  nothing mysterious or difficult to
account for, in the  effects resulting from an abscess
becoming open.  If  any of the natural cavities of
the body were  in the  same state,  inflammation
would  ensue, and  would produce a fever corres- 
256          On Lumbar Abscesses.
ponding  to it in its nature and degree.  From the
weak and peculiar state of constitution, subject to
chronic abscess,  both the local inflammation and
the concomitant fever are in general of a peculiar
kind: the  local  inflammation  partakes  of  what
would, in general, be denominated an erysipelatous
nature, and the fever of a violent and rapid hectic.
I have however known  the opening of a lumbar
abscess productive of inflammation of a phlegmo-
noid character  in the cyst, and then the constitu-
tional affection  was likewise what we term inflam-
matory fever.
  Having thus endeavoured to investigate the cause
of the evils resulting from a chronic abscess be-
coming open, I  may further add, that if the opinions
which I have formed of them be correct, the danger
must greatly depend  upon the dimensions of the
abscess.  A chronic abscess, beneath the  fascia of
the thigh, may be  opened, when it contains four
ounces of pus; and if the surface becomes irritated
and  inflamed, it may  induce a degree of constitu-
tional disturbance and fever; yet such  an abscess
neglected, may increase  till it holds four quarts;*
and  then, if  it becomes open, and has  the  same
degree of local disease, and it were granted that it
should only act upon the constitution in the  same
proportion, it must produce more than thirty times
the degree of fever. If also we are to ascribe the
weakness consequent  to the opening of chronic ab-
scesses in any degree to the drain of fluids which
takes place from them, it will  be in the same pro-
portion greater  in the latter than in the former case.
It seems  however  probable, that  it is the violent

  * I have discharged four ale-house quarts full of matter
from beneath the fascia of the thigh. 
On Lumbar Abscesses.          257
actions which exhaust the patient's strength, and
not the loss of fluids;  for in  dropsies of the ovary
a much greater loss of more nutritive fluids is not
attended with weakness in any material degree.
   After this discussion of the nature and cause of
the ill consequences resulting  from the opening of
chronic  abscesses, we may proceed  to  establish
rules for their treatment. The  first object, I think,
is to disperse, if possible, lumbar abscesses,  be-
cause it is most probable that the matter is in con-
tact with diseased bones; and that the inflammation
consequent to the abscess becoming open, will be
communicated to those parts.
   With this view, an  issue should be made in the
loins, which  is likely to be beneficial by its counter
irritation, even when the abscess  is not connected
with  diseased bone; but when it is, then an issue
will be still more serviceable and necessary. The
patient also should be kept  in bed till all  inflam-
matory tendency, which  will  be  indicated by the
increase of the abscess, has ceased. Then exercise
in the open  air  may be permitted, on account of
its beneficial operation on the constitution of the
patient.*  It  should indeed be  our unremitting ob-
ject throughout to invigorate and tranquillize  the
constitution; and  the means which I should employ
for this purpose,  are those which tend to preserve
the digestive organs in, or restore them to a state
of health. If the  abscess becomes open  notwith-
standing all our endeavours to the contrary, these
measures will enable  the  constitution to bear up
against the  disease; and as such  local diseases are
the consequence  of a weakened and disordered

  * Probably it would be best to exercise with crutches, as
the lumbar muscles on the affected side would then be ex-
empt from action. 
258          On Lumbar Abscesses.
state of body, they may, by relieving the cause,
remove at the same time the effects, as has been
shown in the second case.
   That  lumbar abscesses may be  dispersed by
these measures, will be proved by the cases which
I shall afterwards relate:  that we shall often fail in
our endeavours to disperse them, is indeed highly
probable in  reason, and equally proved  by occur-
rences in practice.'
   Let us  then  suppose, that  a lumbar  abscess
treated in this manner continues to  increase, that
it protrudes the integuments; that  they, from dis-
tention, become irritated; that their temperature is
slightly augmented; what are we then to do? Are
we to wait till evident signs of inflammation appear?
I think not. I  would then relieve them  from dis-
tention, by emptying the  abscess through a wound
made by an abscess lancet.  I would open the ab-
scess  for a  reason which appears  paradoxical on
its first proposal,  which is, that it  may be  kept
closed. We can empty a cavity, and by  healing
the wound, keep it afterwards shut, and no inflam-
mation ensues. If nature opens the cavity by ul-
ceration, the opening is permanent, and the inflam-
mation consequent must  be endured. When I first
treated abscesses  in this manner, I punctured them
with a trochar. I now use an abscess lancet, which
is introduced with very little obliquity, so far that
the wound  of the cyst  of the abscess should be
half an inch in length, and that of the integuments
of course a little  longer. A wound of that size is
generally sufficient to give discharge to the solid
flakes which will occasionally block up the opening,
without much poking. It is necessary that the flow
of matter should  be uninterrupted, so that no air
should gain admittance;  it  is therefore right  to
make pressure on the  abscess in proportion as it 
              On Lumbar Abscesses.          259

 is emptied. The abscess where it presents itself is
 emptied before that part of it in the loins is com-
 pletely so. The surgeon should then press the sides
 of the wound together with his finger and thumb,
 so as to prevent the ingress of air, and desire the
 patient to cough repeatedly, which will  impel the
 matter  from the internal  part of the abscess into
 that which is punctured. When  the  abscess is
 emptied as much as  possible, the wound should
 be attentively wiped, and the edges placed in exact
 contact, and retained in that state by strips of plas-
 ter.  I interpose some lint between the plaster and
 the surface of the wound, closing it exactly as that
 made in venesection.  I think  it useful  to put a
 small compress over the part where the orifice is,
 and  give it a  slight degree of pressure  by longer
 strips of plaster. It is of great consequence that the
 patient  lie perfectly  still, and  that the  plasters are
 not moved.  I  think it better not to put on a band-
 age,  because then the patient may perceive whether
 the plasters  are right or wrong. I dress the wound
 every second day. It generally unites by adhesion,
 though  sometimes otherwise,  for it may discharge
 a little,  and yet unite firmly.  An abscess, thus
 treated, is as free from inflammation as it was be-
 fore  it was punctured.  The abscess will, however,
 fill again, and  that sometimes even rapidly. In the
 first  cases which I attended, I punctured it pretty
 regularly after  the expiration of a fortnight, and I
 found in general, that the  abscess contained about
 one-third less of fluid.  I have,  indeed, been obliged
 to puncture the abscess at first before the end of
 the fortnight,  because it  had become distended,
and I was fearful that  the distention  might cause
 the newly healed wound to inflame, or unclose it-
 self.  After having discharged  the contents of the
abscess three  or four  times, I found that it  was
                       2 L 
260          On Lumbar Abscesses.
not necessary, nor indeed  easily practicable  to
puncture it at the end of the fortnight,  because it
was so little filled and prominent. Since my atten-
tion has been  more directed to the  dispersion of
abscesses,  I have generally been able, by  such
means as tend to lessen the actions, and consequent
secretion of th'e cyst  of the abscess, and also to
promote  absorption,  to protract considerably the
intervals  of time at which it has seemed necessary
to puncture the abscess, lest it should become dis-
tended. Nay,  I have been  able to disperse many
lumbar abscesses after  having punctured them
twice or thrice, though I  was incapable of pre-
venting their increase prior to these measures.
   The  dispersion of lumbar abscesses  is the
grand object which a surgeon should have in view
throughout the treatment of them. He should en-
deavour  to disperse them,  but by means which
are, at the same  time, calculated to  increase the
patient's  strength.  If, however, the abscess in-
creases, and he is obliged  to open  it, in order to
prevent its becoming open spontaneously, he should
still pursue the same  measures; for the necessity
of his puncturing it again  is thereby diminished,
and he gains time, which he employs in endeavour-
ing to invigorate the constitution,  and  diminish
the disease of the bone,  upon  which perhaps the
abscess depends. Suppose, however,  he is unable
to effect  his chief design,  that of dispersing the
abscess; suppose  after having punctured it five or
six times,  at long intervals, one of the  punctures
inflames and ulcerates; it must, I think, be evident,
that great good has been effected by the measures
that have been pursued. After a lumbar abscess
has been  punctured,  the fluids secreted into it,
will flow into that part where there is the least re- 
               On Lumbar Abscesses.         261

 sistance, which is the part that has been punctured.
 The  pressure  of respiration will urge  them from
 the original cavity into the now vacant space, where
 the abscess had presented itself. The original cavity
 being a long time thus kept empty, will contract
 into a small fistulous tube.
   Those  who are advocates for  letting lumbar
 abscesses  open themselves  by ulceration, because
 it imparts less irritation to  the cyst than a  wound
 occasions, have in this case their wishes gratified;
 a much reduced lumbar abscess does, when  treated
 in this manner, open by ulceration. If there  be any
 truth in the reasonings which I have employed,
 showing that the constitutional disorder will be in
 proportion to the extent of the surface affected with
 disease, that surface is now comparatively small.
   It  must however be granted,  that under these
 favourable circumstances, when  the abscess leads
 to carious bones, the disease is  generally, though
 not constantly, fatal. Instances have been  known
 of pieces of mouldered vertebrae making their way
 through  the fistulous remains of the abscess, and
 obtaining an  external outlet; and yet the  patient
 has recovered. As we  cannot know whether the
 bone  be diseased or not, and as these abscesses so
 generally arise from that  cause,  we should  always
 act with a caution suggested by the opinion that
 they  do  so. When the abscess has become open
 by the ulceration of one of the punctures,  which
 the surgeon has made in order to  reduce its dimen-
 sions, or  so to alter its  state as to increase his
 chance of dispersing it, the patient must encounter
 the risk attendant on the disease; but the surgeon
 has still much to  do. The ulcerated part should be
dressed with  mild salve; evaporating washes, or
poultices, should be applied  over  it; in short, every
means should be employed to prevent the cyst in- 
262          On Lumbar Abscesses.
flaming, in consequence of irritation imparted to it
from  the ulcerated puncture.  Perfect  quietude
seems  to be essential  at  this period of the case,
for motion of the loins will induce or aggravate  in-
flammation in the originally  diseased parts. Some-
times a considerable time elapses before the cyst
inflames, and when it does, opium should be given
to quiet it. Sometimes the irritation and inflamma-
tion of the cyst subsides, and the abscess becoming
indolent  the constitution  is no  longer  disturbed,
and the  patient may be permitted to exercise  for
the benefit of his general health.
   Before I proceed to the  relation  of  the  cases,
from which the preceding views of the nature and
treatment of lumbar abscesses were taken, I think it
right to relate the case which first suggested tome
that mode of opening these  abscesses which I  re-
commend; because, it shows that an abscess of this
kind, attended  with even  very favourable circum-
stances, may prove  a fatal disease if mismanaged.


                   CASE IV.'
   A young man, about twenty-seven years of age,
of a muscular form, and healthy constitution, came
from the  country to the hospital,  to  obtain relief
from a collection of matter  which presented itself
in the upper and fore-part of the  thigh, beneath  the
fascia,  and immediately below Poupart's ligament.
The pain which he had previously suffered in  his
loins, and the impulse of matter into the tumour
upon his coughing, left little doubt of the original
seat  of the disease. The  fascia  of the  thigh  had
yielded considerably  to the  collected pus, so that
it did not descend  so  low as is  common, but  ap-
peared very prominent. Although he had endured 
              On Lumbar Abscesses.         26j

considerable pain, he had not suffered much from
fever on the first formation of the abscess.
  A caustic was applied on the tumour to give dis-
charge to the matter, and three days afterwards the
eschar was divided. Eight ouncesof very perfect-
ly formed, moderately  consistent, and  inodorous
pus  issued  from the incision.—The sides of the
eschar now closed up  the wound and  prevented
any further evacuation of matter. This the surgeon
did not attempt to produce,  thinking  the  delay
would be useful.
  For three days no more fluid  was evacuated,
during which time the young man remained per-
fectly well, and his thigh free from inflammation.
On the fourth day the eschar  became  so  much
loosened  in its circumference that part  of it gave
way, and eight ounces more of similar and perfectly
inodorous pus were discharged. In twelve  hours
after  this detachment  of the eschar, he suffered
much from fever and pain in the part, and the dis-
charge became putrid. In two days the fever,  which
was of the hectic kind, seemed to be established,
and from the sore there flowed a copious and in-
creasing quantity of foetid pus. His skin was now
hot, his face flushed, he sweated profusely in the
night, his appetite failed  him, his pulse beat  120
in a minute, his tongue was but little altered from
its  natural appearance, he had no sleep, and was
distressingly restless. These symptoms continued
about a week without cessation; they then appear-
ed slightly to remit, and proceeded for three weeks
in the same manner, with  some little diminution in
their severity; his strength was now greatly  ex-
hausted, the discharge from the abscess very pro-
fuse, and in this state it was thought right to have
him conveyed into the country, where I am inform-
ed  he gradually declined, and in about six weeks
more he died. 
264          On Lumbar Abscesses,
 Cases of Lumbar Abscesses dispersed without being
                     opened.

                    CASE V.
   I was desired to visit a young lady in the coun-
try, in order to open a lumbar abscess, which pre-
sented  beneath the fascia of the thigh. It was not,
however, sufficiently prominent to admit of the in-
troduction of a  lancet with safety, but there was a
very forcible impulse of matter into it when  the
patient  coughed. The patient was  about fourteen
years of age; her lumbar vertebrae were bent into
more than a semicircle, and it is certain that a great
number of the bodies of the vertebrae were destroy-
ed by disease. The countenance was flushed, the
pulse 120; the body emaciated, and the appetite
lost. In short, it appeared to me, and the other me-
dical  attendants, that she was not likely to live. I
explained to  her father, that the opening of the ab-
scess would be almost certain to destroy her;  that
if a necessity arose  from its increase, it might be
punctured at a future period, only in order to pre-
vent its being  permanently open. I endeavoured
to explain to him the necessity of attempting to re-
lieve the disease on which the abscess depended.
With this view I recommended rest, and a horizon-
tal position, except when exercise in a carriage was
permitted for the benefit of her general health. A
moderate-sized blister was also directed to be kept
open, by means of the savine cerate, on each side
of the spine. Great  attention was also paid to im-
prove her health, by obviating errors in the func-
tions of the digestive organs. The patient lived at
a. considerable  distance  from London, and I  re- 
             On Lumbar Abscesses.          265

ceived during about fifteen months, frequent letters
from  her father, containing little else than expres-
sions  of exultation and thanks. His daughter's ap-
petite was improved, and her strength increased;
the hectic fever had  left her; the abscess could no
longer be perceived; she had become quite fat and
robust, and had grown two inches in stature within
the twelve months. After this time, the tone of his
letters varied. He thought the  discharge  from the
blisters might produce weakness;  and, I believe,
they were not continued for any considerable time,
though I urged it as strongly as I could. The young
lady,  however, recovered, and had  no return of the
abscess.

                    CASE VI.
   A  man between  thirty and forty years  of age,
came from the country to St. Bartholomew's  Hos-
pital, on account of  a  lumbar abscess, which had
made its way outwards, and protruded the  integu-
ments of the back, on the left side of the  lumbar
vertebrae. The  skin was very prominent, and the
circumference of the abscess considerable. I  think
I do not exaggerate, when I say, that twelve ounces
of pus were  collected in  the external abscess. The
patient was  feeble,  and  of a sickly aspect, and I
thought that the bone was diseased. I desired him
to remain in bed, and to keep  open  a moderate-
sized blister on the left side of the loins; endeavour-
ing, at the same time, to produce, by means of me-
dicines, an  amendment  in his general health. In
about two months there  was no  appearance of any
external abscess.  The patient was now  desired to
 get up daily, and walk in the open  air, but to  lie on
 The bed when he returned. He remained in the Hos-
 pital   pursuing  these  measures for  two  months 
266          On Lumbar Abscesses.
longer; and though there was not the least apj>ear-
ance of the abscess during this period, I could not
perceive much amendment in his general health or
appearance. Indeed, as no good seemed to be done
by  his residence in the hospital, I advised him to
return into the country, requesting him, at the same
time, to inform me of the progress of his complaint
or recovery; but I never afterwards heard of him.
  I was induced to put down this brief account of
the preceding case at the time, from the surprize
which it excited in my  mind, as I had expected it
to proceed in a very different manner. Later  ex-
perience would prevent me from feeling surprize at
such occurrences, for I  have seen several lumbar
abscesses  dispersed by  similar measures; I mean,
counter irritation, and  endeavours to improve  the
patient's health. Though I could relate the circum-
stances  from memory, and even refer to some of
the subjects of them, yet the narrative would be
little more than a repetition of the fact, and it might
tend to induce students  to expect such occurrences
to be frequent; whilst, on the contrary, I am ready
to admit, that they probably will be rarely met with
in general  practice.
Cases of Lumbar Abscesses that have been dispersed
     after their Contents have been discharged.

                   CASE VII.
  ----Harris, thirty-five years of age, had a con-
siderable collection of matter beneath the integu-
ments of the abdomen, forming a moderately pro- 
On Lumbar Abscesses.          267
minent tumour, about three inches in diameter, and
situated just above Poupart's ligament. The patient
had suffered a great deal from pain in his loins; and
the motion of the thigh had been much impeded,
but was now tolerably free. Indeed there was no doubt
that the  matter had been originally formed in the
loins; from whence it was violently impelled, so as
to elevate the prominent integuments of the abdo-
men,  whenever  he coughed.—By  permission  of
Mr. Long, under whose care he was admitted into
the hospital, I punctured the tumour, and  dis-
charged  about twenty-four  ounces of pus, mixed
with some flakes of a curd-like  substance. The
wound healed readily, and no considerable altera-
tion of his health  ensued, though he found himself
weaker for some days after the operation.—At the
end of a fortnight, I made a second puncture, and
let out between six and seven  ounces of a turbid
fluid. He now thought himself so much better than
after the first evacuation, that he went out of the
hospital;  but returned again at the expiration of a
fortnight, when, by a third puncture, six ounces of
purulent matter were discharged; and, after another
week, four ounces  more were  let  out. A caustic
was now applied to his loins, and four or five peas
used to keep the ulcer open; from which time  no
matter could be  discovered in the abscess during
the six weeks that he remained in the hospital.
   About eighteen  months  after this, he was ad-
mitted into the hospital on account of a fever and
sore throat; and  it appeared he had never experi-
enced any farther complaint in his loins.
   This case, I think, is very interesting, inasmuch
as it contributes  to prove that the cavity of a lum-
bar abscess may  be entirely obliterated without the
cyst undergoing any of those changes which gene-
rally take place when it is laid open.
                      2M 
268          On Lumbar Abscesses.


                   CASE VIII.
  Elizabeth Smyth, aged twenty-seven, had a lum-
bar abscess, which presented beneath the fascia of
the thigh. The previous symptoms rendered the
nature of the complaint indisputable; and as she not
only showed evident marks of a scrofulous habit,
but also felt  considerable inability  in  moving the
spine, there was great reason to suspect that the ab-
scess originated  from a disease in the bone. She
was likewise troubled with cough, and drew in very
little air when she inspired. Her appetite, too, was
often deficient, and her bowels frequently disorder-
ed. It may also be  added, that her brother, who
greatly  resembled her, was at this time a patient in
the hospital, under Mr. Long, on account of a scro-
fulous disease of the spine, which had occasioned
an affection  of the medulla  spinalis.  When all
these circumstances were taken into account, she
certainly appeared a subject by no means capable of
sustaining the irritation and  disorder which  the
bursting of a lumbar abscess might be expected to
produce. I therefore punctured the abscess imme-
diately, and discharged from  it twenty  ounces of
flaky matter: and having healed the wound, I gave
her emetics of vitriolated zinc and copper, and after-
wards of ipecacuanha, twice or three times a week,
for six weeks. At the  end of this time, there was
so little matter in the abscess, that I thought it too
small to be punctured with safety; and as  her health
was too infirm to admit  of the emetics being con-
tinued, I tried to produce absorption of the remain-
ing matter, by passing the electric fluid through the
abscess. Very small electric shocks* were accord-

  * These small shocks, which, for the sake of distinction, I
shall call electric vibrations (a term, I believe, generally ap- 
              On Lumbar Abscesses.          269

ingly sent from different  parts by the  side of the
lumbar vertebras, down to the groin, and upper part
of the affected thigh; and, under this treatment, the
contents of the  abscess soon disappeared; nor did
any further collection of matter take place during
the time of her  remaining in the house, which was
nearly two months. The electricity also brought on
the menstrual discharge, which  for a long time had
been  very  irregular;  and her  general  health was
greatly improved before she  left the hospital.*
                    CASE IX.
   Elizabeth Hart, about thirty years of age, had
suffered greatly from  pain in  her  loins, for ten
months. During that time, matter had been formed,
and made its  way  down beneath Poupart's liga-
ment, in such quantity as considerably to distend
the fascia of the thigh. She was much reduced in
strength, and in the appearance of health, by  this
complaint; but as her constitution  was good, and
she could move the spine with facility, there was
no reason to suspect any disease of the bone.
   I punctured  the  abscess, and  discharged  two
quarts of very healthy pus: and occasionally, after
the orifice had closed, I ordered her  emetics.  She
could not continue them regularly,  hovyever; as,
during  their use, her bowels  became disordered,

plied to them,) were made by discharging a small jar, the
coated surface of which did not exceed fourteen square inches:
and by placing the ball of the electrometer at a small distance
from the conductor, generally about a quarter of an inch. One
of the discharging rods was then moved about on the upper
part of the thigh, and the other on the loins, so that the elec-
tric fluid might pass through  the abscess.
  * I have lately heard, that the abscess has not appeared
again, though a year has since elapsed;  but the pain m her
loins, has (as might have been expected) recurred. 
270          On Lumbar Abscesses.
and she lost her appetite and strength. The accu-
mulation of matter was, notwithstanding, evidently
delayed by them; for when, at the end of three
weeks,  I next  punctured the  abscess, only  one
quart of serous fluid was evacuated. After the space
of a month had elapsed,  another quart was dis-
charged. During this time she had  taken  emetics
occasionally; but her health was far from good, and
the pain in her  loins was still considerable.—I had
now witnessed the beneficial effects of electricity in
the case of the  last patient, and resolved upon try-
ing it here. It was accordingly employed three times
a week, for three weeks. At  first, a small collection
of fluid in the abscess was perceptible; but this was
gradually absorbed; and by the end of the  third
week, there was no longer any pain in her loins,
her health was greatly improved, and she was able
to walk about, without the least appearance of her
former  complaint.  She was therefore  discharged
from the house; but  came once a week, for some
time, to be electrified.*
   The two last cases point out to notice a remedy
that is  likely to be of much advantage in the future
treatment of lumbar abscesses. My experience of
it, however, has not yet enabled me to determine
how far it may  be generally  beneficial.  In  one in-
stance  where I  employed it  after the abscess had
been once punctured, it kept the matter from col-
lecting  for a long time;  but the patient growing
tired of the confinement, and apprehensive lest the
lancet should be again employed, left the  hospital
without  my knowledge.—Of another,  and some-
what analogous disease,  in which  it  was tried,
though not with complete  success, I shall  here re-

  * This patient  remains at present in perfect health; nor is
there any reason to expect a relapse. 
              On Lumbar Abscesses.          271

late the particulars; first remarking, that all the ob-
servations which I have made on electricity applied
to diseased parts,  led me to conclude, that it acts
as a stimulus, which has the peculiar effect of ac-
celerating that process which happens to be going
on at the time.—Thus, in some states of inflamma-
tion, it hastens suppuration, whilst in others it pro-
motes dispersion.  We should therefore  always en-
deavour, previous to the use  of  this remedy,  to
bring the tumour  or abscess into that state in which
its progress is stopped, and in which, perhaps, it is
rather inclined  to  recede; and by this  rule I have
been guided  in the application of this remedy to
lumbar abscesses.
   I have also been attentive to  proportion the num-
ber  and strength  of the vibrations to the  effect
which they appeared to produce on the abscess: their
operation seemed to be most beneficial when they
occasioned a kind of irritation  or slight uneasiness
in the part for a short time  after  their application.
But if this sensation amounted to pain, or if it was
of too  long continuance, I then suppose  that the
stimulus had  been employed in too great a degree.
                    CASE X.
  Israel Brooks, aged twenty-five, about two years
ago, was first seized with violent pain in his loins,
which prevented him from either riding  or walking
for  some time. About three months afterwards, he
had the rheumatism in the joint of one of  his fingerst
which  shifted to his wrist, where it produced a
thickening and disease of that part; and  at present,
all the carpal bones are evidently diseased, and dis-
placed. This disease also attacked his left knee,
where  it occasioned an  enlargement of the joint, 
272          On Lumbar Abscesses.
 which still continues. Two  months after  this, he
 discovered a swelling beneath the glutaeus muscle,
 which has gradually increased; and since that time
 the pain in his loins has become much less severe,
 but a  sensation of great weakness remains. This
 abscess was shown to me at the hospital, as an in-
 stance of a remarkably large one; and there was no
 doubt but that it contained between two and three
 quarts of matter. There was also a prominence of
 the fascia on the front of the thigh below Poupart's
 ligament, accompanied with  evident  fluctuation.
 The several gentlemen, who examined this latter
 tumour, thought they could perceive  an impulse
 given to it from within, whenever the patient cough-
 ed; whence it was supposed to have its rise from a
 lumbar abscess: but whether the abscess under the
 glutseus muscle communicated  with the loins or
 not, we were unable to determine, as no such im-
 pulse could be felt in it.
   I gave the patient emetics of vitriolated zinc and
•copper; and kept up an eruption of pimples on the
 «kin covering the abscess, by  rubbing it  with  a
 strong solution of tartarised antimony. Gentle elec-
 tric vibrations were also daily passed from the loins
 through  the front of the thigh,  and also through
 the glutaeal abscess. By this treatment, continued
 for two months, the tumour was very much reduced
 in size; that is, as far as could be judged of by the
 eye; for its situation prevented any accurate mea-
 surement of it. In spite of our endeavours, however,
 the patient's health had declined since  his admis-
 sion into the hospital; and in proportion as he lost
 strength, his other local complaints  became worse.
 As it  was now summer-time, and  he had  an  op-
 portunity of going to the sea, which had formerly
 been of service to him, I punctured the glutaeal
 abscess without loss of time, let out three pints of 
              On Lumbar Abscesses.         273

healthy pus, and then healed the opening. His weak-
ness increased  considerably after this discharge,
and all his other complaints were much aggravated.
The electricity was still  persevered in; and at the
end of three weeks, the quantity of matter in the
abscess was very small; I cannot  suppose it was
more than eight ounces.—I very much wished  to
have had an opportunity  of making fresh punctures
in this case; but the state of the patient's health
obliged me, however reluctantly, to discharge him
from the hospital.
   I have always found  that abscesses, evacuated
in this manner, filled again  to one  half or two
thirds of their original quantity in the space of a
fortnight: so that here also, the beneficial effects
of electricity are, in my opinion, sufficiently ma-
nifest.
   Of late years I have  not,  however, employed
the measures pursued in the cases above recorded,
but trusted  altogether to  such as seemed calculated
to improve the health, by tranquillizing and invi-
gorating the digestive organs. The result of such
management has been, that, in general, the abscess
has  disappeared for a considerable  time,  after it
has been two or three times punctured. After the
lapse of some time, however, one of the punctures
made for the discharge of the matter has unclosed,
either with  or  without  some trivial collection  of
fluid previously being formed in the cavity; and, I
regret to add,  that of late, in general, the disease
thus circumstanced, has  terminated fatally. Yet, I
think, it will be admitted, that abscesses which
open in this manner,  open in a manner producing
the least possible irritation to the constitution; and
that the previous treatment, which they have un-
dergone, has materially tended to diminish the risk
commonly attendant  on  such diseases. I conclude 
274          On Lumbar Abscesses.
then by relating one case of lumbar abscess, treated
in the manner which seems to me best, which ter-
minated fatally, as an example of what, I fear, will
be the frequent termination of such cases. I will
add, however, several cases, to show,  that lumbar
abscesses, whon open, are not necessarily  destruc-
tive diseases, and to  suggest the treatment which
ought to  be pursued under such  adverse  circum-
stances.
 Of Lumbar Abscesses becoming permanently open.


                   CASE XI.
  James White, aged twenty-five years, came from
Essex to be admitted into St. Bartholomew's Hosr
pital,  on account of a lumbar abscess. He had suf-
fered much from pain of his loins for twelve months;.
and for  some time past had experienced a difficulty
in lifting up his right  thigh. There was a curva-
ture in the dorsal  vertebrae; but that, he informed
me, was an old complaint. Yet, from the general
appearance of the man, from the difficulty he had
in moving the upper part of the trunk upon the
lumbar  vertebrae,  and from the caution with which
he attempted this motion, I could not but suspect
a disease of the spine. Issues were therefore made
in the loins; and on the 25th of June, I let out two
quarts of purulent fluid from beneath the fascia of
the thigh. He had less pain  in  his  back after the
operation: and though he  was teased with a cough,
his  strength did not suffer  any diminution.—On
July 7th, I discharged from the abscess fourteen
ounces more, of a turbid  brownish fluid.  On the
 
On Lumbar Abscesses.          275
17th, though the tumour in the thigh was inconsi-
derable, yet the part  first punctured was elevated
and  inflamed. It seemed that the puncture in the
integuments had healed, while that in the fascia had
not united  firmly, but had suffered the matter to
pass through it, so as  to elevate the skin. To reme-
dy this, which threatened to lay open the cavity of
the abscess, I was obliged to puncture it in another
place; and  eight ounces  of fluid were discharged.
The patient was now in  much better health than
he had been  for more than a year, and was able to
lift up his  thigh without pain. I therefore set him
to exercise the muscles in  the neighbourhood of
the disease, thinking that if the  exertion did not
produce irritation, it might answer a good purpose.
With this  view, he stood upon the  leg of the sound
side, and alternately lifted up and let fall the other,
until he was  somewhat fatigued. By frequent repe-
tition of this exercise, the muscles of the diseased
side acquired considerable strength; and in a little
time he felt himself (to use his own  expression)
" able to go  to plough."
   The fascia  of the thigh  was  punctured  every
fortnight for some time, and afterwards every three
weeks. When  he had been nearly three months in
the  hospital, he became tired of  the  confinement,
and, feeling  himself strong, was very solicitous  to
have the abscess opened, and suffered to discharge
itself  The disease of the spine made me unwilling
to comply with his desire; and I sent him into the
country for  three weeks, that  he might ascertain,
by  the iourney, whether he was  as strong  as  he
supposed; thinking  that if  he bore it without fa-
tiaue, it might be of service to him. At the same
time  I save  him strict injunctions not to exert
himself if his loins or thigh became painful; and,
 in that case, to return again  by the first convey-
                      2N 
276          On Lumbar Abscesses.
ance. It was five weeks, however, before he came
back; when I found that the abscess had inflamed,
and burst, about twenty days after he left town; in
consequence  of which he became  so ill, that he
could not bear removal. He was now in  a most
wretched condition, being scarcely able to  turn in
bed, from the weak and painful state of his loins;
his pulse was rapid, and his skin hot, and  he had
occasionally fits of chilliness succeeded by sweat-
ing.  He became considerably better, however, and
continued so for some time, in  consequence of the
attention paid to him in the hospital; but his health
again declined;  and after  several  relapses,  with
intervals of temporary amendment, he at last sunk,
and died at the end of three months from his re-
admission.
  On opening the body after death, I found  that
the abscess extended upwards to  some diseased
vertebrae. The diseased bone, however, did not im-
mediately some into view ©n lifting up the perito-
naeum; for the tendinous expansion, which covers
the bodies of the vertebrae, was still entire,  and
formed a kind of cyst distended with matter. When
this was opened, it was found  to contain pus, to-
gether with the fragments of three of the  bodies
of the lumbar vertebrae; there being ten or twelve
detached pieces of bone  lying  upon the medulla
spinalis,  and surrounded with  matter. This  was
evidently a  peculiar disease of the spine, which
neither caustics nor any other remedy could alter.
It greatly  resembled  that  diseased  state which
sometimes  occurs in the carpus and tarsus, in
which the small bones composing these parts are
broken down, and lie  confined in  a ligamentous
capsule, surrounded with matter. If the dead por-
tions of the vertebrae had not been thus confined,
they might have had some chance of removal; but
under the circumstances already noticed, it is most 
              On Lumbar Abscesses.          277

probable that they would remain, and act as extra-
neous bodies, exciting irritation, and increasing the
disease.
                   CASE XII.
  July 1790. John Tucker was admitted into St.
Bartholomew's Hospital on  account  of a Psoas
Abscess.  His health had been declining for more
than three years.  He  had for a considerable time
been an out-patient under the care of  Dr. Austin,
who had unavailingly endeavoured to prevent the
formation of this abscess  by issues made in his
back, and by the administration of various medi-
cines. He had suffered greatly from pain in his loins
and fever: the abscess was very large  and had de-
scended very low on the inside of the thigh; the
integuments covering it were natural;  the impulse
of matter into the tumour upon coughing very con-
siderable.
   His pulse was feeble  and beat eighty-six in a
minute; previous illness  had exhausted his consti-
tution; he had a constant cough,  and  undoubtedly
much diseased lungs.  He had little appetite, and
was of a costive habit—he was of fair  complexion,
light hair, and blue eyes, and his countenance fre-
quently flushed:—He was on all these accounts as
unfit a  subject, as can well be supposed, to  en-
counter  the derangement of constitution,  which
must  succeed to the ordinary evacuation  of the
abscess.
   On Wednesday the 28th  of July,  I  tapped the
abscess  with a small hydrocele trochar, and dis-
charged three pints of pus of good quality, although
in a small degree more fluid than common. I dressed
the part with considerable  caution.  I  moistened 
278          On Lumbar Abscesses.
 the lint which I applied to the orifice with tinctura
 benzoescomposita, over this I applied some stick-
 ing plaster, which was retained by cross slips, and
 afterwards varnished over with gum; some com-
 presses of linen were applied over the abscess, and
 gently bound on by a flannel roller.
   On Thursday,  there  was no  very perceptible
 difference in his health;—he had  slept and eat as
 usual, his tongue was moist and natural, his pulse a
 few strokes quicker.
   On Friday, he said, that he found his loins re-
 lieved by the evacuation, that he could perceive no
 difference in his health, and his pulse was the same
 as before the operation.  For many days his health
 remained unchanged, he  became he thought a little
 weaker,  and the frequency of his pulse  had en-
 creased  about  four  strokes in a minute.  For this
 little alteration we could  readily account, knowing
 that some fluids were drained from the circulation
 into the cavity  of  the abscess, and that some little
 exertion of the system  would necessarily ensue.
 The abscess  remained without pain or inflamma-
 tion,  and his constitution free from fever;  his skin
 continued  in  its  natural state, his appetite  was
 good, his sleep sound, and  his countenance unal-
 tered.  Three days after  the  operation  I removed
the dressings from the punctured part; it appeared
healed; I however  carefully renewed the dressings
 every third day.
  Friday, the 13th of August, sixteen days after
the first  discharge,  the  tumour having  become
prominent, I again punctured it, and evacuated its
contents. I knew the discharge would encrease his
 weakness; yet, if the collection were suffered tore-
main it would shortly distend the cyst to its former
dimensions, and my original plan  of treatment
would be frustrated. 
              On Lumbar Abscesses.          279

   The quantity of the discharged fluid was nine
 ounces;  in  appearance and  chemical  properties it
 much resembled blood.  This bloody effusion was
 probably the consequence of laxity of the exhaling
 vessels,  as there had  not been the least expression
 of inflammation in the abscess. Before I discharged
 the matter the second time he complained of some
 pain  in his  loins; but the following day he said he
 was much relieved, and  found himself remarkably
 well. This  second puncture was dressed  like the
 former,  and quickly healed.
   During the time which had elapsed between the
' first and second discharge, he had  not  been con-
 fined  even  to the ward, but often went from the
 hospital  to see his friends. This, his cough, the
 weak state  of his health, his disinclination  to live
 in the  hospital, and  the  obvious  impunity with
 which  it was done, induced me to permit. After
 the second evacuation he altogether lived with his
 friends, promising to  come every week to let  me
 see the state of his complaint; however, the' second
 week when the matter ought the third time to have
 been evacuated,  he failed  in his promise. I was
 now obliged to leave London for some  time, so
 that  I did not see the patient again until September
 the 8th, which was four weeks and five days from
 the former evacuation; he had refused to have the
 matter let out during my absence. I now discharged
 in like manner ten ounces of lymphatic exhalation,
 rather dark coloured and turbid, as if mixed with
 true pus.  The man, during the last week, had
 complained of pain in  his loins and in his knee,
 both of which were relieved as usual by the opera-
 tion.
    Before the abscess  was first opened the impulse
 of matter  from the  loins,  on coughing, was  ex-
 tremely forcible, but was now not at all perceptible, 
280           On Lumbar Abscesses.
 It appears to me that a very considerable advantage
 is derived from this mode of treating these com-
 plaints. Whatever  secretion is made in the abscess
 of the loins, will^  by its gravity, descend into the
 space left by the seceded fascia of the thigh. The
 abscess of the loins being left perfectly free from
 distention will most probably contract to very little
 dimensions, if it be not perfectly abolished.  Hence
 in the subsequent treatment of these complaints
 you have only to  attend to  the disunited  fascia;
 whilst the cavity in the loins scarcely deserves no-
 tice.
  September 22d, a  fortnight after the former eva-
 cuation, I discharged four ounces of similar serous
 fluid mixed with pus. During  its evacuation,  which
 was very speedy, Ihad applied my fingers beneath
 Poupart's ligament,  as  if to obstruct the descent
 of any matter from the loins.  I then desired the
 man to cough, but no matter descended, and the
 collection appeared to  me entirely confined to the
 thigh.
  I found some difficulty in introducing a trochar,
 when the abscess contained  so little  fluid.  This
 was remedied by first introducing a lancet through
the fascia, and then conveying the trochar through
 the aperture made  by the lancet.
  Thus after discharging the matter four times,
 the complaint was reduced from a lumbar abscess,
 containing three pints, to a small collection of mat-
 ter beneath  the  fascia,  containing four  ounces.—
 What communication this had with the loins, and
 what was the state of parts there, cannot be  deter-
 mined. To appearance there was no collection. If I
 had now immediately opened  the abscess, the con-
 taining cyst  being small, the inflammation probably
 would not have been considerable. But the state of 
On Lumbar Abscesses.         281
the man's health induced me for a short time to
defer this final attempt, this radical cure, as I may
express it,  and to be  contented with only evacu-
ating the matter when  collected, without suffering
the collection  to  increase the size of the cyst. It
might  be expected, by repeating the evacuation,
that the cavity would diminish to its total abolition.
This would probably happen were the abscess in
the cellular substance;  but the inelastic fascia can-
not contract, and the subjacent muscles cannot
be  elevated,  so that  the  effused matter, though
very small in quantity, would still keep them dis-
united.
  I had let out  four ounces of matter once in Octo-
ber, and on the fifth of November I  opened the
abscess by an incision  about an inch and a half in
length  at the lower part.  I introduced my  finger
beneath the fascia as high  as Poupart's ligament, I
desired the patient to cough,  but  no matter de-
scended from the loins,  neither could I ascertain
any communication. The extent of the detached
fascia was about four inches and a  half in length,
and nearly four in breadth. The cyst inflamed after
opening. The  hardness  and quantity of the dis-
charge encreased for four  days, and then gradually
subsided. His thigh was stiff and sore, so that he
could not easily move  it,  but he had no particular
pain in his loins—his pulse did  not vary—his
tongue was not furred—his sleep  was not inter-
rupted—nor could any derangement of his  health
be perceived.
  Granulations grew from the edge of the incision,
and the opening nearly closed and afforded scarcely
any discharge. Yet, on  introducing a probe through
the orifice, I found that the  fascia remained dis-
united. With a view to produce an  union, by ex- 
282           On Lumbar Abscesses.
citing inflammation, I introduced a seton from this
lower orifice to the upper part  of  the  cyst. The
fascia again inflamed, indurated,  and united, only
the track of the seton was unclosed; and  this by the
injection of some spirit and water, was also soon
induced to fill up. In discoursing with the patient,
after opening the abscess, respecting his health, he
said,  he was ten times better than  before  it was
opened;  that until  this time he had always been
subject to fits of pain,  and to  a state  of  weak-
ness and faintness which he could not describe.
   After the perfect closure of the abscess, he could
extend and bend his thigh with freedom and ease;
he could also readily put his foot upon a chair set
before him. This it would  have been impossible
for him to have done during the  formation or con-
tinuance of the abscess. This freedom of action in
the psoas muscle indicated considerable soundness
of it, and of the  contiguous parts.  He  still, how-
ever,  complained of much rheumatic pain  in his
hips,  and sometimes in  his loins; and  as  I sup-
posed his constitution might  be affected  by the
suppression of  a  long-continued  purulent  dis-
charge,  and  might attempt  for  its  relief  the
formation of a new  abscess, I inserted two  setons
in the integuments of the loins, with  a view of
preventing inflammation of the internal parts.
  They  did not, however, relieve  his pains; he
complained  much of their  inconvenience,  and as
he  designed to go  into the country,  they were
discontinued. I saw him about a  year afterwards—-
no alteration had taken place in the  thigh,  nor no
fixed  pain had attacked the  loins, but he was  still
much teased with unsettled rheumatic pains.
  The preceding case was very unfavourable both
from the patient's constitution and from  the degree
of the disease. Yet, by four times discharging the 
               On Lumbar Abscesses.         283

matter, which was not attended with much more
pain than bleeding, it was reduced from a lumbar
abscess, containing three pints, to a small collection
beneath the  fascia of the  thigh, containing four
ounces, and  without any evident  communication
with the loins. Each time, instead of suffering in-
convenience, he  experienced relief; he  had no
fever,  neither was he restrained from his  usual
occupations.
  The final opening might have been sooner made,
but as this was the first case in which I had pur-
sued this practice, I  was uncertain  of the event,
and irresolutely protracted it for two months, in
expectation of amendment of his health. When it
was opened no perceptible fever followed, and it
shortly  got well  by the treatment which  I have
related.

                  CASE XIII.

  Isaac Dean, thirty-seven years of age, had  come
from Hampshire to London, to obtain advice for a
Psoas Abscess. He was admitted into the hospital
under the care of the late Mr. Pitts.  The account
which  he gave of himself was,  that his business
had obliged him to be much  on horseback; that
he had formerly,  when  riding,  bruised his  left
testis, which accident had occasioned an incurable
disease  of that gland; he therefore had suffered its
removal about two  years  since in  some  county
hospital. Since that time he had frequently suffered
much pain in his loins; about eight months before
his admission into the hospital he had caught cold:
the pain in his loins then became more violent and
constant, and  much  impeded  the  motions of his
left thigh. About three months after this attack of
severe pain, he perceived  a tumour  in the upper
                  20 
284          On Lumbar Abscesses.
part  of his thigh, which had gradually increased
until the time of  his admission into  the  hospital.
Since the  appearance of the  tumour, the pain in
the loins  had  much abated.  The  matter  now
descended  about four inches  beneath Poupart's
ligament; and it received a forcible impulse when
the man coughed. The fascia of the thigh at this
part was very prominent, and the  skin  covering it
was more red than the rest of the integuments.
  The patient's health was not unfavourable; his
pulse was rather  strong, beating  seventy-six in  a
minute, his tongue rather  pale, his hair and  eyes
dark.
  Monday, 3d of October,  1790, by Mr. Pitt's
desire  I introduced a trochar into the lower part
of the tumour, and gave discharge to twenty-four
ounces of pus, moderately tenacious, and contain-
ing some flakes  of firmer  matter:  I cautiously
closed the orifice, as in the former case, applied  a
compress, and bound it moderately tight with  a
roller.
  I could not  in  this case  perceive  any alteration
in the  man's  health deserving to  be recorded,
except that  the pulse was a little quickened: he
eat and slept as usual.
  I carefully took  off the sticking-plaster at the
end of three days, and renewed a  similar dressing.
On Thursday, 13th of  October,  the abscess was
now again prominent, and the puncture  made by
the irochar  seemed slightly  inflamed. As I  con-
cluded the distention of the fascia caused this in-
flammation, and  supposing that if the  pressure of
the matter from beneath was  suffered to continue,
it might occasion it to  ulcerate,  I determined to
prevent this effect by again evacuating the matter.
This I accomplished by passing a trochar into the
lower part of the abscess, at some distance  from 
On Lumbar Abscesses.         285
the former opening; and by this means discharged
between eight and nine ounces of pus, thinner and
rather darker  coloured than  the  former, but not
tinged with blood as in the preceding case.  I now
carefully dressed both orifices, and again applied a
bandage.
  I cautiously removed  the dressings,  at the end
of three days;  the second puncture had  healed, and
the first had lost its disposition to inflame. After
having dressed the punctured parts, and applied
the bandage, I desired him to moisten it witfi aq.
saturn., which I thought by keeping the skin cool,
would prevent its disposition  to inflame. The man
suffered no alteration in his health from this second
evacuation. On the 25th, at the end of  a fortnight,
the tumour being again prominent, I introduced a
lancet into the fascia, and, through the  orifice thus
made, the trochar, which discharged six ounces of
turbid serous fluid, and I pursued the same  subse-
quent mode of treatment.
  After another fortnight had elapsed, the tumour
was  much less prominent than before, and there
appeared a degree of irritation in the skin. The
punctures showed a disposition to inflame.  I now
desired the man to cough, but could discover no
impulse of matter from the loins. This I had not
before  done,  lest  the exertion should affect the
punctures, which were not so firmly healed as in
the former case.  As the patient  had not suffered
much from  discharge, as his health seemed fully
capable of sustaining the effects arising frdm open-
ing  the abscess, as  it was  not  probable that its
dimensions  could suffer further diminution  by
delay,  on Friday the 23d of November,  I opened
the  cavity by an incision  of about  an inch in
length, at the  lower part, and immediately passed 
286          On Lumbar Abscesses.
a seton through to the upper part, with a view to
insure the union of the fascia.
  An usual degree of inflammation of the  fascia
and stiffness of the affected limb followed, but  he
complained of no particular pain  in his loins
further  than general stiffness.  The slight  fever
which accompanied seemed rather  inflammatory
than  hectical, his pulse became a  little  quicker
and harder, and his tongue  slightly furred. These
symptoms gradually abated, and at the expiration
of three weeks the fascia appeared to have adhered
firmly to the  subjacent parts: I therefore withdrew
the seton.
  As he now found his health tolerably good, and
being, as he thought, recovered from what he con-
sidered as  a  dangerous complaint, and imagining
that he was made weaker by staying in the  hospital,
he went  into the country, promising  to inform me
if any change happened; but I have not since heard
of him.

                   CASE XIV.
  February, 1791. James Leaver is in the 21st year
of his age, has light brown hair, blue eyes, dilated
pupils, pale countenance, frequently flushed, and is
apparently of an irritable constitution.  About nine
months ago he was affected with a pain in his loins
when he  moved, which soon  became very severe,
even when he was at rest.  This  pain was accom-
panied with fever. Four months  afterwards he per-
ceived a small swelling in the upper part of his right
thigh, which has since gradually  increased, and has
now descended nearly to the middle of the thigh: he
remarked, that he  never had the least pain in the
part where the tumour was  formed.  After the ap-
pearance of this swelling, he no longer experienced 
On Lumbar Abscesses.          287
the same degree of  uneasiness in his loins; and
shortly after, he acquired the power of lifting up his
right thigh, which he  had for some time lost.
  For four months previously to his admission into
the hospital, he had regularly profuse  night sweats,
which began about twelve o'clock, but did not pre-
vent his sleeping;  when  he awoke he found his
clothes  very wet, and himself very chilly; he had,
however, an appetite for his breakfast.
  On the 5th of February, Sir  James  Earle  intro-
duced a trochar into the most prominent part  of the
tumour:  between two and  three  pints of healthy
matter was evacuated, the wound was  immediately
closed, and lint and adhesive plaster were applied.
The night succeeding the operation he slept little,
but was free from perspiration. On each succeeding
night he slept as usual, but had not in the least de-
gree those sweats which had been constant until the
discharge of the matter.
  On the 8th  of February, he said he found himself
no worse for the operation, he was  free from night
sweats and slept soundly. His appetite was perfectly
good, his bowels  unaffected, and his tongue  moist
and florid.  His  pulse, before  the operation, was
ninety, and for fifteen days afterwards it varied be-
tween that and a  hundred. February 15th, ten days
after  the evacuation, his night sweats returned,
although in a less degree than formerly.
  February 26th, three weeks after the first dis-
charge, the tumour had now become nearly of its
original size;  the integuments were much distended;
the part punctured by the trochar had for three days
appeared inflamed;  and on the tumour being now
compressed,  the  cicatrix  gave  way,  and the con-
tained matter  oozed from  the orifice.  The trochar
was again  introduced through the former orifice,
and eight ounces of brownish matter discharged. 
288           On Lumbar Abscesses.

The wound was carefully dressed, in hopes that as
the distention  was taken off, it might close. After
the second evacuation, the night sweats a^ain ceased;
he said, he was rather weaker, but no other alteration
in his health was perceived.
  On the 2d of March, while in the act of coughing,
the imperfectly healed  wound made by the trochar
gave way. Very little pus was discharged, but as it
was impossible to  heal this ulcerated opening, and
as the continuity of the  cyst was now destroyed,
the rnode of treatment hitherto pursued  was  frus-
trated. Much inflammation of the cyst immediately
took  place, and the constitution became  greatly
affected.  The next day, if the finger slightly com-
pressed the abscess, it  gave him great  pain;  but
before the cavity of the  abscess  became  exposed,
the part was perfectly indolent. When pressure was
employed,  a foetid,  frothy matter issued  from the
ulcerated orifice. The cyst, however, was emptied,
and, except when pressed, there  was no discharge.
Such were the appearances of the part. The general
disturbance of the constitution was also very great;
his  countenance exhibited strong expressions of
alarm; if any one  approached him he started, and
when any one  touched him he trembled.  His pulse
beat from 130 to 140 in a minute—for two days his
bowels were disordered—however, the inflammation
of the cyst gradually abated, and in like manner
the  constitutional derangement subsided. At the end
of about eight days, he was much amended, and in
about six weeks the aba ess appeared  nearly well,
and his constitution  r !:eved frpm febrile  indispo-
sition.
  In this case it is clear, that the second  discharge
of matter was too long delayed, and to me it appears
equally evident that the patient derived  much ad-
vantage from the mode of treatment which had been 
On Lumbar Abscesses.           28'9
pursued; for by it the complaint was reduced from a
large  abscess, containing nearly three pints, to  one
which held less than eight ounces. Yet, even in  this
diminished state, great derangement of the constitu-
tion followed the exposure of the cavity of the ab-
scess: indeed. I have little doubt, if the abscess  had
been  opened whilst it retained its original dimen-
sions, but that  the  patient would have fallen a  vic-
tim to the more extensive inflammation, and more
violent fever which would then have taken place.
                   CASE XV.
  Elizabeth Ridley, aged fifty-five, had, for one year
and a half before  her admission into the hospital,
suffered much from bad  health; she then had a se-
vere cough, accompanied with much fever.  About
ten months before she was admitted into the hospi-
tal, she had  a  very acute pain in her loins, which
abated, in some degree, ten weeks after its first at-
tack;  at  that time she observed a tumour  in her
groin, which had gradually increased in  size.  The
pain had been continual, though at intervals it suf-
fered considerable abatement: the veins on the fore
part  of the  thigh had become varicous and the leg
cedematous. The  tumour was  of  a circular form,
about four  inches in diameter. It had much  pro-
truded the fascia, and matter was violently impelled
into it on coughing. She  now complained of occa-
sional pain of her stomach, of failure of appetite, and
a costive state of her bowels;  her pulse was  slow
and feeble, her tongue pale, and her health consider-
ably beneath the natural standard.
   On the 8th of November, I punctured the lower
part of the tumour with  a lancet, carrying it ob-
liquely about half an inch between the skin and the
fascia, and discharged eleven ounces of good  pus. 
290          On Lumbar Abscesses.
 but did not empty the abscess. The orifice of the
 skin and cyst did not then correspond, and on cough-
 ing there was still perceived a considerable  impulse
 of matter from the cavity in the loins. I was unwil-
ling to irritate the cyst  by the introduction of any
 instrument to separate the lips of the wound, there-
 fore I closed the orifice with sticking plaster, and
 every thing remained quiet till the  third day, when,
 by  a fit of coughing, the orifice was burst open and
 matter oozed from beneath the plaster.  If I  suffered
 it to  remain open, my original plan of treatment
 would be frustrated. I therefore resolved to let out
the collected matter, lest distention of the fascia and
integuments should  prevent  the wound from heal-
ing. I again introduced the lancet through the same
orifice, and wounded it  so  as to make  it bleed and
give a discharge to five ounces of pus;  the abscess,
however, did not even now appear to be completely
emptied.
  The woman suffered  no evident alteration in her
health, but  became much easier with respect to her
loins. The varicose veins and the oedema of the leg
now no longer appeared. These symptoms, doubt-
less, originated from the pressure in (he loins, occa-
sioned by matter, of which it was very evident there
was a large collection.
  On the  18th, the tumour was again punctured
and eight ounces of fluid evacuated. The matter be-
fore had been incompletely discharged; now 1 believe
the  tumour was entirely emptied.  This last  dis-
charged  matter  was perfectly inodorous and the
thigh uninflamed.  I made this aperture at the side of
the  tumour with  the edges of the lancet held up-
wards and downwards,  and not transversely as the
former openings had been made. This I did that the
efforts employed in coughing might have less effect 
On Lumbar Abscesses.          291
in impelling the matter through the orifice, which
soon healed.
  In  the following week  she complained that she
was restless and  could not sleep, neither had she
her usual degree of appetite; her pulse, however,
was not quickened, nor did any other signs of con-
stitutional indisposition appear. No matter was now
collected beneath the fascia, and after waiting ano-
ther  week  without  any  apparent  collection  being
made, on the 25th of November I introduced a lan-
cet through the fascia of the thigh, with a design to
leave the cavity of the abscess permanently open.  I
did not perceive any matter issue from the opening.
As the integuments covering the fascia were thick-
ened and showed some disposition  to inflame, I di-
rected the aqua plumbi acetati to be applied to them.
On the  following day some matter flowed through
the  orifice.  The patient supposed,  if collected, it
might be a table spoonful; nearly the same quantity
continued to discharge for about  a  fortnight, and
afterwards  it gradually diminished, and the wound
healed. She was not affected by fever in consequence
of this last  opening, and seemed to suffer very little
inconvenience with respect to her health. She, how-
ever, complained  much of pains resembling those
of the rheumatism,  which affected  principally hqr
hips, though sometimes they attacked her loins; for
these  pains she was placed under the care of the
physician,  and as her constitution was languid, she
was recommended  to continue the medicines pre-
scribed  for her as an out-patient.
  In this case one circumstance appeared to me cu-
rious; after I had twice discharged the contents of
the abscess, no farther collection of matter  took
place. Yet  not because the cavity of the abscess was
abolished, but because from some little indisposi-
tion of the  constitution the secretion into that cavity
                      2P 
292          On Lumbar Abscesses.
 was for a time suspended. This, however, was rather
 an advantageous circumstance, for as the cyst was
 empty, the contraction of the sides was unopposed.


                   CASE XVII.
   Charles White, thirty-six years of age, and not
 unhealthy, had a lumbar abscess, which presented
 beneath the fascia of the thigh, and which there was
 no reason to suppose connected with any disease of
 the spine. From this abscess I discharged, by punc-
 ture, twenty-four ounces of healthy pus, and healed
 the orifice. The patient suffered some weakness and
 derangement of health;  but they were not consider-
 able. The operation was repeated every fortnight;
 and, by the fifth time of performing it, the quantity
 had decreased to four ounces. At the end of another
 fortnight, I made the opening to discharge the mat-
 ter, larger than common, and  did not  attempt to
 unite it, but directed a poultice to be applied to the
 thigh, and the  patient to be kept in bed. No percep-
 tible derangement in his health took place in conse-
 quence of this.  The lips of the wound granulated,
 which,  I think, is  always a good sign;  the fascia
 seemed to adhere to the parts  beneath;  and in the
 course of a month  he was  thought well enough to
 leave the hospital, although there was still some mat-
 ter discharged from the wound.   In a few  weeks
 more, the part was entirely healed; nor had he after-
 wards any return of the  complaint.


                  CASE XVIII.

  William Hankes, when about twenty-eight years
of age, had a collection of matter formed in his loins,
which descended beneath Poupart's  ligament, and 
On Lumbar Abscesses..         293
elevated the fascia  of the thigh.  The formation of
this matter had not been attended with pain; neither
were the motions of the thigh impeded during its
collection. The  elevated portion  of the fascia was
about three  inches  in length, and two in breadth;
and the impulse  communicated to it from the loins,
on coughing, was distinct, though not very forcible.
I punctured  the abscess,  and discharged  twelve
ounces of pus, in which there were some flakes of
coagulum. The wound healed speedily, and the pa-
tient not only suffered no inconvenience, but even
found himself better  than  before the operation.—
After three weeks' time, the matter which was col-
lected gave so little prominence to the fascia, that,
when I punctured it, I was apprehensive of injuring
the subjacent parts;  and not more than between five
and six ounces  of  pus flowed from the orifice on
this occasion. As the quantity of matter contained
in the abscess at first was small  when  compared
with that in many other cases which terminated well,
as the patient also was young, and apparently capa-
ble of sustaining the degree of irritation likely to
ensue, I thought there was no great risk in leaving
the orifice unclosed.  Accordingly, a poultice was
applied over the part; and I hoped that, by thus en-
deavouring as much as possible to lessen inflamma-
tion about the wound, I might prevent any consi-
derable degree of it from taking place in the cyst.
For some time the  fascia felt sore, and was  painful
when the integuments were pressed; but this ten-
derness abated'in about ten days; the discharge also
lessened,  and there appeared ground to hope  that
the  patient  would  soon get well. He was now at-
tacked with pain in his loins, accompanied by fever:
the discharge also increased, and had a foetid smell.
These  symptoms,  however, gradually abated, but
left the patient greatly reduced in strength.  After  a 
294           On Lumbar Abscesses.
short interval, he again experienced a similar relapse
and recovery, by which his weakness was still farther
increased.  He  had been occasionally troubled with
cough, which now became very constant, but with-
out any expectoration;  and I observed that  he drew
in very little air when he inspired.—As the abscess
discharged largely, and the strength of his constitu-
tion was rather declining, I made  a large  issue in
the integuments of his  loins, with a view to lessen
the internal disease. This seemed to be of great ser-
vice; for the pain of his loins went off, and the dis-
charge from  the abscess  abated gradually, and at
last became inconsiderable.  Still, however, he  did
not recover his health; and the country air was now
recommended by Dr. Latham,, who had prescribed
for him, during his illness, those medicines which
his disorder seemed to  require. He accordingly left
the hospital, and, at the end of ten months, returned
to town;  when the  wound in  his thigh still continued
to discharge a small quantity of matter.  Afterwards,
a thickening of the integuments on the front of the
thigh took place;  and  two or three small ulcers
formed there, which did not readily  heal, but were
sometimes in a better and  sometimes  in  a worse
state.—I saw him  occasionally, for two  years, dur-
ing which time he had tried the effect of sea-bathing.
His health, however, was not good, though it did
not appear to me to suffer from the remains of the
abscess, which neither occasioned pain, nor hindered
his walking. At last, his strength declining, he was
again admitted into the hospital, under Dr. Latham's
care. He was  now much troubled with cough, and
hectic fever; and, under the fascia of the other thigh,
opposite to the dorsum of the ilium, a fresh abscess
appeared, which, however, had no communication
with the abdomen. The powers of his  constitution
were now evidently broken, and he gradually sunk,
and died. 
              On Lumbar Abscesses.         295

   Being greatly hurried during the only opportunity
I had of inspecting the body, my examination of it
was very cursory.  I can,  therefore,  only  say that
both lungs were irregularly and generally indurated;
that the cavity of the original abscess still remained
opened,  but was contracted into a narrow  fistula
leading from the thigh to  the  middle of the psoas
muscle. There was another large abscess on the op-
posite  psoas muscle, which had not yet descended
to the thigh, where, as has  been already mentioned,
there was also an abscess of considerable magnitude,
but unconnected with this  in the loins. The lumbar
vertebrae were perfectly sound.
   That the death of this man was not owing to the
original abscess in the loins, is to me very evident.
That abscess did, indeed,  for a considerable time,
greatly disturb his constitution; but it afterwards be-
came indolent, and acquired a state incapable of ex-
citing  irritation.


                    CASE  XIX.

   Having  unfortunately lost the minutes  which I
took of the next case that occurred in the hospital,
I can only give  such a general  account of it as my
memory supplies. The subject of it, Doods  King,
who was under the care  of Mr. Blicke,  was about
thirty years of age,  and of  a very sickly aspect. The
abscess  presented  beneath Poupart's ligament;  it
contained at first about twenty ounces of curdly
matter, and was punctured four times, with the
usual progressive reduction in the quantity of matter
discharged: but before the  fifth time of opening, one
of  the punctured places ulcerated.  There was in-
deed, from  the beginning,  in this case, a great dis-
position in  the  skin to inflame  and ulcerate, and it 
206          On Lumbar Abscesses.

was with difficulty I could heal the orifices made to
let the matter out. As soon as the cavity had thus
become open, a poultice was applied to the part, and
confinement to bed strictly enjoined. The patient
became somewhat weaker, but no fever ensued.  I
did not suffer him to go about, however, for a long
time,  lest the motion of the parts should induce in-
flammation.  The abscess  at last  became perfectly
indolent  itself, and un-irritating to the constitution;
but it did not show much disposition to heal.—He
was discharged in this state, and promised to apply
again  if his  complaint  became troublesome. I saw
him about a month after his dismission, when he
mentioned a design of going into the country;  since
which I have not heard of him.
                   CASE XX.
  Catharine Vallance, nineteen years old, of a healthy
appearance, but having a considerable inclination of
her body forwards, from  a former disease  of the
dorsal  vertebrae, had, for twelve months  before I
first saw her, laboured under severe pain of  her
loins, accompanied with fever.  There  was at that
time a large  lumbar  abscess, the matter of which
had descended to the upper part of the thigh, where it
distended the integuments, so as to render them pro-
minent and thin. A surgeon pricked this tumour with
a lancet, and let out more than a pint of very healthy
pus; by which the bulk of the swelling was scarcely
diminished: but as  no  more matter 'would flow, a
piece of sticking-plaster was applied over the orifice.
Four days  afterwards,  another surgeon, observing
that the integuments were  inflamed, and the punc-
tured part much disposed to ulcerate, made another
aperture, at some distance from the former, and dis-
charged three pints of good pus;  which completely 
              On Lumbar Abscesses.          297

emptied the cavity. The last puncture being atten-
tively closed,  healed readily, and the first lost  its
disposition to ulcerate. The young woman continued
perfectly in health for  ten days, when some little
distention  of  the abscess again occurring, the first
puncture  ulcerated; in  consequence of  which the
collected matter made its way out, and left a perma-
nent opening into the cavity. Considerable fever now
came on, the  patient's  pulse was rapid, her tongue
white, and her skin hot and dry; but these symp-
toms abated after a short time, and she again reco-
vered  her  former state of health; the abscess not
falling into any secondary state of disease  after the
inflammation went off; nor did any hectic fever take
place after the first derangement of the constitution
had subsided.
 ^  Another abscess now presented itself, in the same
situation,  on the opposite side. As soon as this had
acquired sufficient prominence  to give security to
the parts beneath, it was punctured;  twelve ounces
of  healthy pus were  let out, and the  orifice was
closed. When the matter collected again, the wound,
made to discharge it, was suffered to remain open.
The inflammation which took place  in the cyst in
consequence of this, was very slight, and hardly af-
fected the  constitution: the parts soon became  indo-
lent, discharging but little matter, and  both the ab-
scesses healed gradually.
  It is how three years since that case occurred;
and I have lately seen  the patient, who  has  expe-
rienced no inconvenience from the complaint  since
that period.


                   CASE XXI.
  A young woman had a lumbar abscess presenting
in the upper part of the  thigh, from which a surgeon 
298           On Lumbar Abscesses.
discharged,  by puncture,  nearly a quart of matter,
and healed the opening. At the expiration of a fort-
night,  a second  puncture was  made, and  twelve
ounces of matter let out. The last orifice was closed
like the first, but after a few days  it ulcerated, and
the cavity of the abscess became exposed. The pa-
tient now growing very ill, was admitted into St.
Bartholomew's Hospital.  Her pulse was weak, but
not deficient in strength;  her tongue white, and her
skin hot and dry: the discharge from the abscess
was not great, but the pain of her loins was very se-
vere. A large poultice was applied  to the thigh; and
the common saline mixture, with small doses of an-
timonials, was given.  In  the course of a week, a
considerable change took place; her pulse, though
still quick, was rather feeble; her tongue moist, and
not furred; and she had frequent perspirations with-
out any evident cause:  the pain in her loins abated
considerably, and the discharge from the abscess be-
came copious, thin and foetid.  She  now  began to
take the Peruvian bark, and in the space of a month
gradually recovered from this state of debility. Hav-
ing acquired strength enough to sit up, and to  walk
a little about the ward, she  one day imprudently
went into the air, and walked until she was much
fatigued. The consequences of this were, a return of
the pain in her loins, with quickness and  hardness
of her  pulse, white tongue,  and hot and  dry skin.
As the pain  and fever went off, they were succeeded
by an increased discharge  from  the abscess, and ir-
regular  perspirations, which gradually abating, the
abscess at length became indolent, and no longer
affected the constitution. Warned by her former ex-
perience, she now took exercise very cautiously; and
when she  found she could bear motion without ex-
citing irritation in the abscess, she went into the 
On Lumbar Abscesses.          299
cbuntry, where she regained her health; the abscess
healed, and she has since continued perfectly well.
  When a permanent opening is made in a lumbar
abscess, the part generally falfs into a morbid state,
and this is accompanied by a sympathetic affection
of the constitution, corresponding in its nature with
the local complaint. In the first of the two cases just
now related, both the local and constitutional disease
were of a more purely  inflammatory kind, than in any
other that I had ever seen; nor was it succeeded by
that ill-conditioned state of the sore, accompanied with
a thin foetid discharge, and hectic symptoms, which
so frequently occur in this disorder.  In the second
case, as  the  patient's general  health was  tolerably
good, the disease  in the beginning approached to the
nature of common inflammation,  then gradually ac-
quired the usual  state of these  abscesses,  but after-
wards became indolent; the  sympathetic affection of
the constitution exactly corresponded to the state of
the abscess. At first the fever was inflammatory, then
hectical; and when the  local complaint became in-
dolent,  the general state of the patient's  health was
no longer affected. These circumstances  still more
strongly appeared after the accidental re-excitement
of the inflammatory symptoms.
  In order further to confirm the foregoing opinions,
I may  add, that I have known a  considerable space
of time elapse, between the first bursting of a lum-
bar abscess and its assuming that morbid state which
is so peculiar to  those diseases, and which produces
a corresponding affection of the system in general.
2Q 
 
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