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PRINCIPLES
SURGERY
                 BY JOHN PEARSON, F. R.  S.

SENIOR BURGEON OF THE LOCK HOSPITAL AND ASTLUM, BURGEON OF THE PUBLIC DIS-
     PENSARY, AND READER ON THE PRINCIPLES AND PRACTICE OF SURGERY.
----Rationalem quidem puto Chirurgiam esse debere,  instrui vero ab evidentibus causis
obscuris omnibus, non a. cogitatione artificis, sed ab ipsa arte rejectis.
                                             Aw. Corn. Celsus in Praefat.
          BOSTON:

STIMPSON  &  CLAPP.
J.  E. HINCKLEY AND  CO. 14 WATER-STREET.

                  1832. 
J
290
P3U?
I83X
\ 
PREFACE.
   SuRGERYhath commonly been defined the art of curing dis-
eases by external remedies,  or manual operation;  and hence
       teople have imagined, that  when  a  man has  learned
       of dressing sores, of  applying bandages, and  perform-
       srations with a  little dexterity,  he must necessarily
       ccomplished  surgeon.   If  a conclusion so gross and
       is had been confined to the vulgar  and  illiterate, the
       3 of scientific Surgery would have suffered little inter-
       ; but if young minds are directed to  these objects, as
       j important matters  upon which  their faculties are to
De exercised ;  if the gross informations of sense constitute the
sum of their knowledge, little more can be expected from such
a mode of study, than servile imitation, or daring empiricism.
   Indeed some people have  affected to oppose surgery  as an
art, to Medicine  as a science;  and if their pretensions were
justly founded, the former would  certainly be  degraded to a
mere mechanical occupation.  But it is not very easy to com-
prehend  the grounds of such a distinction.   The internal and
external parts of  the body are governed  by the same  general
laws during a state of health ;  and if  an internal  part  be at-
tacked with  inflammation,  the appearances and effects will
bear a great similarity to the same  disease situated externally;
nor are the indications of cure, in general, materially different.
If by science, therefore, be meant, " a knowledge of the laws
of nature," he who knows  what is  known of  the order and
method of nature in the  production, progress, and termination
of surgical diseases,  merits  as justly the  title of a scientifical
practitioner, as the well-educated  physician.  The practical
parts of Physick  and Surgery are very frequently disunited,
but their theory and principles are  indivisible, since they truly
constitute one and the  same science.  But although the sci- 
VI
PREFACE.
ence of Physic and Surgery cannot properly be separated, yet,
in the application of rules and  principles to the knowledge
and cure of chirurgical diseases,  an extensive acquaintance
with the theory of medicine will by no means be sufficient for
practical purposes : lax and general notions floating in the un-
derstanding can be of little advantage, until they are reduced
to something limited  and specific; and except knowledge be
in the  detail, the  application of it in particular instances will
be  attended with almost insurmountable  difficulties.  He
therefore, who  desires to practise Surgery  with probity and
success, must study it both as a science and as an art;  for a
man destitute of principles, is little better than a surgical au-
tomaton, while the man of mere erudition can  only be con-
sidered as a learned spectator.
   It is not a little extraordinary,  that in those  practical sci-
ences, where the principles of action chiefly consist of probable
truths, men should often fancy themselves qualified to judge
and to act without any  previous study : and yet, if a young
man performs but  a mere routine in lecture-rooms and hospi-
tals, he will probably make no doubt of his professional qualifi-
cations.  He knows, indeed,  that study and diligence would
be necessary to enable  him to exercise any of the liberal arts
with reputation and success ;  but it would seem  as if Surgery
were purely an intuitive business, the mere exercise of common
sense, and might be acquired  without the fatigue of observing
and thinking.   The progress of scientific Surgery, indeed, is
not to be compared with the improvements that have been
made in the operative part.  A successful  cultivation of anat-
omy hath drawn  aside the veil from nature in  so many in-
stances, that the performance of almost any  operation in Sur-
gery is become safe and easy, so as to give some  reason  to
fear, lest a fondness  for operating  degenerate  into excess.
This however is certain, that he who reduces the province of
a Surgeon to the performance of operations, and consequently
directs his attention in a transient and careless manner to the
less splendid parts  of his profession, may learn the art of mu-
tilating his fellow creatures with ease and dexterity, but will
never deserve to be treated as a good Surgeon.  The celebrity
which  an expert and successful operator readily acquires
among all ranks of people, has somewhat in it so brilliant and
seducing, that young minds are too apt  to fix their attention
upon this part of his character alone ;  and they overlook quali- 
PREFACE.
vii
fications more solid and  substantial:  hence  it is,  that  they
press with anxious solicitude to see a multiplicity of operations,
and perhaps remain ignorant  of the diseases  for  which  they
were performed, and the  subsequent mode of treating the
wound.   This is an error that hath  at different times  been
lamented and censured by  the most eminent  men in the pro-
fession, but it is to be feared that  the  evil will not be easily
eradicated.   " The study of chirurgical diseases which may,
and which ought to be cured  without  having recourse  to ope-
rations, should at all times be  considered as the principal sub-
ject of a  surgeon's attention.   Painful methods are  always
the last remedies in the hands of a man that is truly  able in
his profession ; and they are the first, or  rather they  are the
only resources of him whose  knowledge is confined to the art
of  operating.  If a surgeon wishes to obtain that knowledge
which is  capable of a happy application to practice, he  must
pass through a novitiate in hospitals,  and under able masters,
and learn from thence successfully to  unite theory with  prac-
tice.  Surgery is not to  be learnt by  desultory fits of atten-
tion ; it would demand the study of a whole  life; and is only
the fruit  of intelligent observation, profound  reflection,  and
learned experience.  When a man is  once properly instructed
in the principles of his profession, the time that is required to
learn the mode  of operating  is  exceedingly short: there is
something so obvious and gross in the route which the  hand
has to take, that we daily see the most ignorant and vulgar of
mankind perform very delicate operations upon brute animals,
without the trouble of purchasing dexterity by  a course of
study and experiments." *
   This  inattention to the scientific part of Surgery, of which
we now complain, does not always originate  from involuntary
mistake ;  it may often proceed from  indolence or dissipation,

  * Histoire de V Acad.  Royale de Chirurgie. Tom. IV. p. 27.
  " A competent knowledge of Anatomy (says a sensible writer), a  steady
hand, and a calm temper, are qualifications which may  enable any man,
even of no great experience, to perform several of the more capital  opera-
tions with success, and accordingly, in almost every  hospital in Europe,
we continually meet with expert operators ; yet we do not find (which ia
much to be lamented) surgeons  possesed of such knowledge in prognosti-
cating the  events of surgical diseases as might be expected.  The reason of
this defect is evident: In the  present mode of education, the student be-
stows little attention on the subject, and suffers himself to be wholly occu-
pied in the various methods of operating, or in minute anatomical and phy-
siological investigations, which are more curious than useful."
                                  Monthly Review, Vol. LXXVII 
Vlll
PREFACE.
and not uncommonly it arises from some lofty conceit of supe-
rior talents.  As nothing is more flattering to youthful vanity,
so nothing is more dangerous and inimical to his progress in
knowledge,  than for a young  man to fancy  himself to be a
genius.   He will immediately  claim  emancipation from the
laws of patient observation and careful induction,  which are
imposed upon common-sized understandings,  and with a fas-
tidious impetuosity will attempt  to rend the veil from nature,
by the mere powers of his own intellect.  If  she cannot thus
be taken by storm, he will not  condescend to  interrogate her,
for, by the vastness of his mental powers, he finds it much ea-
sier to create a  world, than to give a natural history of that
which he inhabits.   The science of healing,  like every other
branch of natural knowledge, is not the production of a vigor-
ous imagination, nor a lively  invention, but it is the offspring
of long and diligent  experience;  and if  a man  attempts  to
learn  it in any other way than by going from his study to the
bed-side of his patient, and returning from thence to his study
again, he will find himself mistaken.   The human mind may
be dazzled by the boldness of her flights, or wounded by the
keenness of  her speculations ;  but the subtilty of nature can
only be penetrated by those who submit to become her patient
and vigilant servants.
  Sphynx (says the illustrious  Verulam)  was overcome by a
man that was lame in his feet;  for when men hasten with too
much violence and  rapidity to solve her  enigmas, instead  of
acquiring dominion over the works of nature, they wound and
distract their own minds by the  subtilty of their reasonings.*
  Some people,  indeed,   have treated theory and principles  in
medicine as  useless, or absurd, pretending that good-sense and
some  experience are sufficient for every practical purpose.   This
kind of language has something imposing in it, at first sight,
and is well calculated to entrap  the assent of  the vulgar  ; but
I would beg  leave to ask those gentlemen, what good-sense and
illiterate  experience  have been  doing for two thousand years,
that they have  suffered the art of healing to remain in so cir-
cumscribed and imperfect a state ? There is no opinion,  how-
ever  absurd, which may  not be defended  by some person's
experience;  and the  observations of our forefathers, like the
oracles of old, speak so equivocally, that a man may very com-
monly interpret them according to his own convenience.  Ex-
* De Sapientia Veterum. 
PREFACE.
IX
periments made  by those  who  are not duly  furnished  with
preliminary knowledge, may prove useful by accident, but can
never  be trusted till a mind properly  qualified  has verified
them.   A mere experimentalist is like a blind man who feels
his way by means of a staff; such an one indeed may stumble
upon a truth, which may afford  illumination to a man whose
senses  are perfect;  but it is an equal chance whether the dis-
coverer himself reaps any advantage.   These men despise
reasoning, because they can neither combine ideas, nor deduce
consequences :  they contemn  theories because they cannot
comprehend them.
   Let  us hear one  of these  gentlemen speak in the name of
his fraternity : " We are blind men, who have been long ac-
customed to travel in the same roads, and by dint of habit have
acquired so perfect a knowledge of every path,  that we are in
much  less danger of going  astray, than  your clear-sighted peo-
ple,  who have travelled the same roads  less  frequently than
ourselves."-----It is of little consequence,  indeed,  whether  a
man be actually blind,  or whether he never opens the eyes of
his  understanding,  but gropes his way  for twenty or  thirty
years in the same routine of experience, as he is pleased to call
it; for he is, perhaps, only so many years older in obstinacy
and prejudice.  Before we can derive advantage from what we
see,  it is necessary  to learn the art of observation ;  the  same
images may be painted upon the retina of a philosopher and a
peasant; but the mental process that follows the impression, is
dissimilar in a degree which none but a philosopher can com-
prehend.  But while I would advise the student to make him-
self acquainted with the  theory and principles of his  profession,
let me not be suspected of  recommending him to indulge in
simple speculation,  and philosophical abstractions ;  the  fancy
can  construct,  at will, seducing  schemes  of structure and de-
rangement, which no more represent the reality of nature, than
the wild illusions of a delirium resemble the orderly operations
of a sober  mind.   From a single history,  or a solitary fact,
men will sometimes rashly pretend to establish general princi-
ples ; which, being destitute of basis and support, are unable to
withstand the severe scrutiny of a just interpreter of nature.*

  * Monsieur Quesnay's observations upon this subject cannot be too high-
ly commended.  See Mem. de L'Acad. Royale  de Chirurgic.   Essai Phy-
sique sur V(Economic Animate, Discours Preliminaire.
B 
X
PREPACE.
By theory I mean, " an application of the  laws of  nature to
the solution of particular phenomena."—A  theory formed by
learned experience and legitimate induction,  must not only be
fruitful but luminous ; and it will serve as a  lamp to guide the
cautious  Student  through the dark and hidden labyrinth of
nature.  It is however to be  lamented, that the theory of med-
icine is still in a limited  and imperfect state.  Even studious
and thinking men, seem to bestow more  pains to become rich
in the  knowledge  of particular  instances, than to generalize
their facts, and reduce them to scientific  principles.   But, in-
deed,   until we have  " A true and active natural philosophy
upon which  the science  of medicine  can  be built," * there is
little solid ground to hope for a theory that would deserve to
outlive its inventer.
   We  are not to expect  to see these deficiencies supplied,  and
the fabric of  true chirurgical science erected,  by the particular
labours of separate individuals,  much less by the powers of a
single  arm ;  there must  be a combination of learned men, who
will act in concert under prescribed laws; and by the conjunc-
tion of their  labours, it is probable, that  such discoveries and
improvements might be effected, as we have  scarcely yet learnt
how to wish  for.f
   Before I close this Preface, it may  not be improper to give
some account of the book to  which it is prefixed.   The follow-
ing Work is primarily designed as a text-book, for the use  of
the gentlemen who honour  the author with their attendance
on his  Chirurgical Lectures.   In conformity with this  design,
it is drawn up in a concise and  aphoristical  form : the reader
is  therefore  requested to remember for whom it was written,
and not hastily to reject  the naked facts and  unsupported con-
clusions he  may  meet with, as many parts of  the work are
little more than a sketch of  what is delivered in the Lectures.
Nor is  the order in which  the different morbid affections are
treated, to be considered  as an attempt at a scientifical arrange-
ment.   I  am by no means satisfied with the manner in which

  * Restet unicum, quod pluris est, quam ilia omnia.  Desideratur nimirum
Philosophia naturalis vera et activa,  cut medicinm  scientia incedificelur.
Bacon, De Augmentis Scientiarum.----Lib. iv. Cap. ii.
  t ft is not a little extraordinary, that England, amidst all her learned
societies, cannot boast of a society  established for the exclusive purpose of
promoting chirurgical knowledge. 
PREFACE.
XI
surgery is divided at present, but it will scarcely become me to
criticise, until I have a better plan to propose.
  The doctrine of inflammation, and its modes of termination,
of Gangrene, Erysipelas, and Cancer, constitute a considerable
part of the outlines of scientifick Surgery.  In delivering the
history of these diseases, I have neither servilely imitated, nor
fastidiously rejected the labours of my  predecessors;  while I
have endeavoured  to avail myself of their assistance, I have
also assumed the liberty of thinking for myself.  Where it
hath appeared necessary to deviate from the opinions of others,
I have generally assigned some reasons for  my  conduct; if
they be good ones, the candid will approve, and if  they  be
sophistical, I shall have a pleasure in seeing them subverted.
I am very  sensible that it is an easy matter to adduce plausible
objections against almost any scheme of human invention ; it
it has  been my wish,  therefore, to avoid as much as  possible
that fondness for novelty, which delights in petty reformations;
to  encourage such a   taste  is the indubitable  character of a
minute  mind, which,  by endeavouring to  appear the  more
learned, only becomes the  more troublesome.  If there be any
particular  part of the work for  which an apology is more im-
mediately requisite, it is in those chapters where I speak upon
the effects of heat and cold, on living animals.   This is a
subject that hath not been  greatly cultivated, and luminous
facts are in so scanty a  number, that if little be performed, but
little was to be expected.   Perhaps it may appear paradoxical
to  some, when they see it  affirmed, that heat by its proper
effects stimulates and invigorates the body, while cold, on the
contrary, relaxes it.  This view of the subject is by no means
novel, and if it be admitted with proper limitations, there will
not be the least opposition between these assertions,  and  the
seemingly contrary effects which occur  to the mind on  a super-
ficial survey of the subject.   A  proper use of the cold-bath
certainly  braces and strengthens the system ; the  warm-bath
will generally produce relaxation and debility.  These  are use-
ful facts, but they are utterly insufficient to form the basis of a
theory of the effects of  heat and cold on living bodies.  The
proper qualities of natural  substances are fixed and immutable,
but their effects upon us are subjected to considerable variation ;
we are sure, however, that the same power cannot exert itself
in  opposite modes,  so  that  if contrary  phenomena  present 
xn
PREFACE.
themselves,  we are to seek for  the  cause in the state of the
object, and not in the properties  of the agent.
  If the  publication of  this first part of the Principles of
Surgery, shall excite a spirit of industry,  and assist the cbi
rurgical student in acquiring a knowledge  of his profession,
I shall think my time and labour well bestowed ;  and it will
probably encourage  me to prosecute the plan to  a greater
extent. 
ADVERTISEMENT.
  When I published the first edition of this little work, in the
year 1788, it was my intention  to  add one or  two volumes
more, so as to comprehend a large  proportion  of the  subjects
usually treated upon in a course of Chirurgical Lectures.   The
state of my health did not allow me to accomplish my  pur-
pose at that time; and increasing  engagements  in business,
afterwards, obliged me to defer, from one season to another,
the further prosecution  of my design.  Various reasons, of
little moment to the public, have at length determined me to
conclude the work, by relinquishing altogether the labour of
adding another volume to the Principles of Surgery.
   In revising the work, for the edition now presented to the
surgical student, I made some alterations, and interspersed sev-
eral additions, especially on the subject of Scirrhus  and  Can-
cer.   The chapter on the (Edema appears  now for  the first
time.
   Although many important additions have  been made, in
the course of a few years,  to the Principles of  Surgery,  and
several valuable improvements have been introduced into the
operative  part—yet a number of diseases still exists, for which
we have no adequate remedies,  and many operations continue
to disappoint the  hopes of the surgeon and the patient.
   If the prospect  of that which remains to be  done, after the
labours of so many ages, tends to abate hope and to discourage
endeavour—yet it should be remembered, that  no man can
determine the measure of success  which may be connected
with industrious research  and zealous exertion, and  that
whatever may be the degree of advancement of which surgery
is capable, he who endeavours to perfect it, has the satisfaction,
at least, of knowing, that he is  fulfilling his duty, when his
efforts are directed to alleviate the  sorrows and diminish the
sufferings of mankind.
Golden Square, August 20, 1808. 
 
CONTENTS.
                                                         Page
                          CHAP. I.
  Of Inflammation in General •     .    .     .        •        17
Sect. I.   Of the Phenomena of Inflammation     .        .    17
Sect. II.  Of the Remote  Cause of Inflammation  ...    22
Sect. III.  Of the Proximate Cause of Inflammation   .    .    23
Sect. IV.  Of  the Distinctions between  Inflammation and
      Erethismus.........25
Sect. V.  Of the Progress  and Terminations of Inflammation .    26
Sect. VI.  Of the Treatment of Inflammation    ...    33

                          CHAP. II.
Sect. I.  Of the Furunculus, or itile.....39
Sect. II.  The  Mode of Treatment    .                     41

                         CHAP. III.
Sect. I.  Of the Abscess  of the  Breast     ....    42
Sect. II.  Of the Treatment of the Mammary  Abscess   .    .    44

                         CHAP. IV.
Sect. I.  Of the Paronychia, or Whitlow    ....    45
Sect. II.  The Mode  of Treatment.....47

                          CHAP. V.
Sect. I.  Of the Empyema Psoadicum.....49
Sect. II.  The  Mode of Treatment.....52

                          CHAP. VI.
Sect. I.  Of the Gangrene and Sphacelus                     53
Sect. II.  The Symptoms  of Gangrene, &c.....55
Sect. III.  The Treatment  of Gangrene     ....    61
Sect. IV.  The Local Treatment......61
Sect. V.  The  Treatment of Sphacelus     ....    62
Sect. VI.  The Local Treatment of Sphacelus     ...    62

                         CHAP. VII.
Sect. I.-  Of the Anthrax,  or Carbuncle.....64
Sect. II.  The Treatment of Anthrax.....65

                         CHAP. VIII.
Sect. I.  Of the Pernio, or Chilblain.....66
Sect. II.  The  Treatment of Chilblains  .....    70 
XVI                     CONTENTS.

                                                         Pnge
                        CHAP. IX.
Sect. I.  Of Burns and Scalds......71
Sect. II.  The Treatment of Burns and Scalds     ...    75

                         CHAP. X.
Sect. I.  Of the Erysipelas.......^
        Of the Zona........°3
Sect. II.  The Mode of treating Acute  Erysipelas    .     .    84
Sect. III.  The Treatment of Edematous Erysipelas   .     .    85
Sect. IV.  The Local Applications to be used in Erysipelas  .    86
Sect. V.  The Treatment of Zona......87

                         CHAP. XI.
Sect. I.  Of Scirrhus and Cancer......88
Sect. II.  Of the Cancer.......91
Sect. III.  Of the Locality of a Cancer.....97
Sect. IV.  Desiderata........100
Sect. V.  The Treatment of Scirrhus and Cancer  .    .        100

                         CHAP. XII.
Sect. I.  Of the Ozaena     .......   105
Sect. II.  Of the Treatment of the Ozaena   ....   107

                        CHAP. XIII.
Sect. I.  Of the Canker of the Mouth.....108
Sect. II.  The Mode of Treatment.....109
                         CHAP. XIV.
Sect. I.  OftheGEdema      ......
Sect. II.  Of the GEdema Simplex Flaccidum
Sect. HI.  Of the Treatment of the CEdema Simplex Flaccidum
Sect. IV.  Of the CEdema Simplex Durius
Sect. V.  Of the Treatment of the CEdema Simplex Durius
Sect. VI.  Of the CEdema Symptomaticum
Sect. VII.   Of the CEdema Deuteropathicum seu Puerperarum
Sect. VIII.   Of the Treatment of the CEdema Puerperarum
Sect. IX.  Of the CEdema cum Erythemate
Sect. X.  Of the Mode of Treatment    ....
Sect. XI.  Of the CEdema Purulentum   ....
Sect. XII.   The Mode of Treatment    ....
110
112
113
114
115
115
117
118
119
120
121
122
Abernetht's Surgical  Observations on  the  Constitutional
      Origin and Treatment of Local Diseases     .    .     .   123

Abernethy on Aneurisms.......235 
PRINCIPLES   OF   SURGERY.
           CHAPTER   I.

OF  INFLAMMATION  IN  GENERAL.
                     SECTION I.

          OF THE PHENOMENA OF  INFLAMMATION.

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

  * To a particular series of appearances, uniformly  connected, is given
the name of inflammation; but we are unacquainted with  that specific
morbid alteration in which the several phenomena necessarily exist, in a
combined state.
              3 
18
OF INFLAMMATION.
   III. In every true inflammation, there subsists either an ab-
 solute,  or relative plethora : a plethoric state  of  the general
 system will have a considerable  effect in increasing the vio-
 lence and extent, and influencing the termination  of this dis-
 ease ;  but the effects of a  partial  plethora will be very much
 regulated by the state of arterial contractility.
   IV. As an inflamed part  seems to contain more blood, ce-
 teris paribus, than during its healthy state,  and as the vessels
 which contain this fluid, propel their contents with an increased
 momentum and  velocity,  more  or  less of obstruction to  its
 transmission must be the consequence.  But this obstruction
 does not necessarily  arise  from any  alteration in  the qualities
 of the  blood ; it may be explained, by reasons founded upon
 the change produced by disease in this  part  of the  arterial
 system,  and the effects of lateral  pressure.   The increased
 quantity of interstitial fluid, a necessary consequence  of arte-
 rial irritation, must also contribute to augment the  obstruction,
 and to give bulk to the diseased part.
   V.  Blood taken away during the prevalence of inflammation,
 is longer in coagulating than healthy  blood, and frequently ex-
 hibits a buffy, or sizy, coat  upon its surface ;  but these circum-
 stances do not indicate any material  change in the qualities of
the blood, although there is commonly some alteration  in the
relative proportion which the several constituent parts  bear to
 each other.*
   VI.  It is very probable,  that a true  inflammation is princi-
 pally seated in  those  blood-vessels which  are  possessed of a
systole  and diastole,   and which are  consequently not beyond
 the sphere of the heart's immediate influence.
   VII.  When the immediate seat, of inflammation is assigned to
the living solids,  the  humoral pathology is not  thereby  meant
to  be rejected.    Every considerable  change in  the  properties
 and relative quantity of the fluids, produces an  alteration in
the motions, tension,  and sensibility of the moving vital solids;
 and every great derangement of vascular action, has a propor-
tionate  influence  upon the  condition  of  the  fluids.   But to
 make such a practical application of  these facts, as to be able,
 in  every particular instance of the disease, rightly  to separate

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

  * It may be doubted whether such a state as this  be at all  compatible
with life. 
20
OF INFLAMMATION.
distinct  or  opposite modes of action in the morbid parts ; for
an attention to the previous state of the system, and to the seat
of the disease, will  generally enable  us  to  account for this
want of uniformity.
  XIII. In applying the preceding  doctrine of inflammation
to those diseases, that  are more immediately  the objects of
chirurgical  treatment, we shall not make  use of the common
divisions ; many of them being founded upon the mode in which
an inflammation terminates, rather than upon specific and  es-
sential peculiarities in the form and  character of the existing
disease.  It is,  therefore,  proposed,  to  consider  inflamma-
tion as  an  homogeneous disease, possessing  one  determinate
character;  and to avoid all such  distinctions, as  tend to con-
found it with affections of  a very different kind.  When it is
also further considered, that the  indications of cure, in  every
true  inflammation, are  nearly similar, the propriety of mul-
tiplying  species will be  rendered  extremely doubtful.
  XIV. It has been already hinted (No. 10,  11) that there
is some  variety in the phenomena exhibited  by the  inflamma-
tion  of  different  parts ;  exempli gratia,  when the substance
of the brain, or of the lungs,  is  inflamed, the  pulse is  much
softer, than when the investing membranes of these  viscera la-
bour  under the  same  disease.   A remarkable depression of
strength very  frequently attends  an inflammation of the intes-
tines, accompanied with a  small, hard pulse ;  whereas, when
that  disease is situated  on the  surface of the body, there is
often  a temporary augmentation of tone, with a  full, strong and
hard pulse. The peculiar symptoms which originate from the
different organization and  functions of the parts affected, re-
quire a  close attention in studying the  history of particular in-
flammations.
  XV.  Inflammation ought to be carefully distinguished from
Fever,  Erysipelas, Erethismus,  or symptoms of  Irritation,
Scrofula,  and from the specific action  of  certain poisons.
  XVI. As it would be esteemed absurd  in physics to  affirm,
that an  atom could move in contrary directions at the same in-
stant of time, so  it would be equally unreasonable to suppose,
that the human body, or any part of it, could exist in opposite
conditions at the  same period.  To  assert, therefore, the sub-
sistence  of an  inflammation in  any particular part, while the
same part labours under an  affection which implies a state the
reverse of  inflammation, would be inaccurate and unphilosoph-
ical. 
OF INFLAMMATION.
21
   XVII. Although the general  truth of  the foregoing proposi-
tion seems tolerably obvious, yet such is the involution of dis-
eases, that appearances seemingly inconsistent with  its validity,
very often present themselves.   It may not be possible to give
a  perfectly satisfactory solution  to  every difficulty  which can
be proposed ; but without attempting so  extensive  a task, the
following considerations are offered, by way of elucidating the
general  principle, and  rendering its practical application less
difficult.  There are many stimulating matters that  possess the
power of increasing the action of the system, without increas-
ing its strength;  as  for  example, a certain  quantity of wine
will produce a temporary state of tone and  vigorous action  of
the blood-vessels, in a  very feeble body; but this high state of
excitement  is  known  to be artificial, and dependent upon the
continued action of its cause.  If therefore in Fever, Erethis-
mus, Scrofula,  he. symptoms  resembling  true  inflammation
shall appear, in consequence of pain, irregular  determination
of the nervous energy, &c. it may not be improper to consid-
er those diseases as acting upon die general principle of stim-
uli.   We ought also to  remember,  that  the  actual strength of
the system is not augmented  by  topical congestion taking  place
in  fever;  and that such  phenomena do  not  unequivocally
prove the conversion of one  disease into another.
   XVIII.  The presence  of scrofula generally implies the
presence  of a state of the system very remote from a  tonic
state; and the supervention of an  inflammatory disease will
commonly produce a temporary suspension of its progress and
appearance.   If  any  appearances  resembling  inflammation,
shall therefore take place in a scrofulous patient, it will be very
improper to  give them the  name of scrofulous  inflamma-
tion, since scrofula is merely  the remote cause of  these phe-
nomena.
   XIX.  In Lues Venera,  the acrimony of the  poison some-
times excites very severe inflammation in the contaminated parts;
but  such an affection ought not to be denominated  venereal
inflammation :  it is of importance carefully to  discriminate be-
tween an accidental occurrence, and the proper and peculiar
effects of the venereal  poison. 
22
OF INFLAMMATION.
                    SECTION  II.

         OF THE REMOTE CAUSE OF INFLAMMATION.

   XX. A Remote Cause is an agent, or a power, extrinsic to
the subject acted upon, which being applied, an alteration suc-
ceeds, which is termed the  effect.  These two facts, the an-
tecedent and the consequent, it is of importance to know, but
no one has yet explained, satisfactorily, the nature of the con-
nexion between them.   It is however useful to inquire into the
nature of the alteration produced, and the several changes that
take place in succession, until the complete effect  be  formed.
  XXI.. In assigning to any known action the prerogative of a
cause, nothing more is intended to be  implied than  this,  that
the application of certain substances, &;c. is generally followed
by, and connected with, determinate, and similar phenomena.
  XXII. Whatever  hath a power of greatly accelerating the
motion of the heart,  and increasing the force of contraction in
the arteries,  may, in  certain assignable circumstances, prove a
remote cause of  inflammation.
  XX III. Among other remote causes, the following may be
properly enumerated :
  1.  The application of chemical stimuli, as
  a.  High degrees of actual heat.
  b.  Caustick substances.
  c.  Alcohol.
  d.  The partial application .of cold.
  e.  Certain poisons, introduced artificially, or generated with-
in the body.
  f. Acrid vapours.
  2.  The application of mechanical stimuli.
  a.  External  violence,  as dividing, bruising,  or  suddenly
distending any part of the body.
  b.  Extraneous  matters lodged in any part of the  body,
whether introduced from without, or generated by disease •  as
calculous matters, bones, bullets, splinters, &c.
  XXIV. In  the  preceding enumeration of remote causes
the same effect has been ascribed to powerful agents,  whose
mode of action  must be apparently very  diverse from each
other, as  heat, cold, poisons,  he.—But it may  be observed, 
OF INFLAMMATION.
23
that when we call certain  effects specific, the epithet  is per-
haps more applicable to the limited state of our knowledge
than to the nature  of the subject; for  many phenomena that
have been occasionally thought to be peculiar, have afterwards
been resolved into a  common principle.
   XXV.  The application  of any of  these remote  causes,
(particular poisons excepted) is not in all cases necessarily fol-
lowed by a true inflammation : the power and certainty of their
action  will be influenced by several circumstances,  amongst
which it may be proper to enumerate the following:
   1. The temperament of  the patient.
   2. The previous state of the system.
   3. The age of the patient.
   4. The climate.
   5. The season of the year.
   6. The general manner of life.
   XXVI. The powerful effects of habit, in enabling a  part to
resist the morbid action of  the remote  causes of disease, are
very remarkable ;  and, on the contrary, the mildest substances
will on certain occasions be attended with all the  consequences
of acrid stimuli; for  we know by experience, that the simple
admission  of  atmospheric air into cavities which are not na-
turally exposed to its influence, will be  very often followed by
severe inflammation.
   XXVII. There  is  considerable variety  in the susceptibility
of different persons, to be  affected by the application of nox-
ious powers, and of the same person at different periods ;  so
that the same  agent  may in one instance  produce phlegmon,
in another erysipelas,  and  in another  erethismus, he.   The
laws by which  these effects are regulated have  not yet  been
ascertained.
                   SECTION  III.

       OF THE PROXIMATE  CAUSE OF INFLAMMATION.

   XXVIII. In attempting to assign the  Proximate Cause of
any morbid alteration in the human body, we ought carefully
to distinguish between a true physical  cause,  and those which
may be termed metaphysical.   A knowledge of  the former 
24
OF INFLAMMATION.
constitutes real science,  and conducts to useful  practice : to
rest satisfied  with  the  latter, is  to be contented with empty
figments and barren  speculation.   If from a defective  natural
history  of man, in the states of  health and  disease, we are
unable  to  assign an adequate physical  cause to explain the
phenomena,—instead  of  terminating  inquiry by feigned or
nominal solutions, it becomes us  to prosecute the subject still
further, with  patience and  sagacity.
   XXIX.  After the foregoing observations, it will scarcely be
expected that we should examine  the merits of those causes,
which are proposed to us under the  different terms of Archa?us,
Anima, Vis Medicatrix Naturae, Constitution, Living Principle,
Sympathy, he.   The existence of morbifick  and  curing
faculties, must be first demonstrated, before any interpretations
founded upon their agency  can be admitted.
   XXX.  By Proximate Cause, is to  be  understood a real
physical cause, so inseparably connected with the disease, that
the presence  of one implies the agency of the other :  upon the
existence  and duration of  the proximate  cause,  depends the
existence  and duration  of the disease,  and  if the  former be
changed, there is a correspondent  change in the latter.
   XXXI. The opinions of learned and  ingenious  men  upon
this subject, have been  extremely  diverse ; but without enter-
ing into a particular enumeration of them, the principal causes
that have  been assigned may be reduced under  the following
heads,  viz. that the proximate cause  of  inflammation  is to
be sought for, either,
   1. In a morbid change of  quantity or  quality in  the fluids,
or,
   2. In a spasmodic affection of the living solids.
   XXXII. The sentiments that are included  within these di-
visions, have  been severally supported by appeals to facts, ex-
periments, and learned authorities ; and  they  have been suc-
cessively opposed by the same  sort of pretensions.  Without
presuming to decide with whom truth and science will be found,
it  is not improbable, that the different systematic  writers  have
been too hasty  in  forming their several conclusions.  Their
inferences cannot yet be supported by the premises we possess,
since each seems to have assigned  to  a  striking  phenomenon
the dignity of a law of nature.
   XXXIII.  As the several  phenomena that constitute an in-
flammation, are  only learnt" by the  diligent study  of nature, 
OF INFLAMMATION.
25
there can be very little room for debate upon such appearances
as are the objects of sense ;  and when the symptoms that char-
acterize a  disease are  once duly ascertained and verified, we
ought next to  endeavour to detect the laws by which  they
are regulated.   But, to exalt any single  phenomenon to the
rank  of  a proximate cause, while it  impedes further  inquiry,
must  prove a fertile  source of fruitless contention.  Let it be
granted  that bile, acidity,  lentor, plethora,  or  spasm, is the
proximate cause of inflammation,  and then inquire how much
true science will gain  by  it.   What is that general  law of
the system by which the connexion between the remote and
proximate  cause is  regulated ?   Any of the  causes above
enumerated may exist  in the body, without  being necessarily
accompanied by the presence of phlegmon ;  which is a strong
presumption that they  are simple  phenomena, and  by  no
means characteristic  of the  form or essence of  the  disease.
To expose, however, the fallacies  by which  different systema-
tic writers have been misguided, is no part of my present busi-
ness ; but I shall endeavour  to avoid  the  censure of temerity,
by declaring that I am  unable  to  assign  in a satisfactory man-
ner the proximate cause of inflammation.
                    SECTION  IV.

OF  THE DISTINCTIONS BETWEEN INFLAMMATION,  AND  ERE-
                         THISMUS.

  XXXIV.  1. Inflammation  is  attended with an increased
force in  the action  of the  arterial system :  Erethismus  is
characterized by a remarkable depression  of strength.
  2.  The presence of  Erethismus depends upon  the  contin-
ued application of  the  remote cause : Inflammation will con-
tinue  and  be progressive, after the  remote cause has ceas-
ed to act.
  3.  In Inflammation the pulse is often full, but always  hard
and frequent: Erethismus is  marked by a small, quick, and
often  an unequal pulse.
  4.  Inflammation may be an idiopathic  disease: it is never
stationary, but always tends to increase, to  resolution,  or to a
                  4 
2G
OF INFLAMMATION.
termination in some other disease, as effusion, abscess,&x,
Erethismus is a symptomatic  affection, where  the  action of
the system  does not appear to be directed to any determinate
end : it regards no periods, it does not admit of cure by any re-
gular natural  process, nor by the conversion of this into some
other disease.
  XXXV. It is  probable that the  symptomatic fever which
often attends  the infliction of large wounds, &c. is not  a fever,
in the proper sense of the term, but would have a  more  pro-
per arrangement  under the head  of  symptomatic inflamma-
tion or  erethismus.
                    SECTION V.

 OF  THE  PROGRESS AND  TERMINATION OF  INFLAMMATION.

  XXXVI.  When a particular part of the body is in a state
of high inflammation, and the general  condition of the system
is favourable to the disease, there is reason to apprehend the
supervention of a great  degree of  symptomatic inflammation.
  XXXVII.   A local inflammation may be properly divided
into three distinct periods; the commencement, the acme, and
the  termination.  The circumstances that tend to accelerate or
retard its progress through these successive stages, and to de-
termine its mode of termination, may  be  referred  to the pre-
vious state of the system; to the action of the remote cause;
and to the organization, functions, &c.  of the  part affected.
  XXXVIII.   The progress of a phlegmon is marked by an
increase, more  or less rapid  and severe, of  all the symptoms
enumerated at No. 2.
  XXXIX.  An inflammation  is never stationary; but when
it is once  properly formed, is either in progression towards a
natural cure ; or to the destruction of the part;  or it proceeds
to a termination in  some other disease.
  XL.   Inflammation may terminate by
       Resolution:
       Effusion :
       Suppuration—Abscess:
       Retrocession : 
OF INFLAMMATION.
27
       Induration :
       Gangrene and Sphacelus.


  OF  RESOLUTION AS  A TERMINATION  OF INFLAMMATION.

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

   OF  SUPPURATION, AS A TERMINATION OF INFLAMMATION.

   XLVIII. When an inflammation has subsisted in a very vas-
 cular and sensible part, during a few days, it may be expected
 to  terminate by  Suppuration.  The  period assigned  for the
 commencement  of this  process  has  been  the fourth, or the
 sixth  day; but absolute precision upon this point is  neither at-
 tainable nor important; for  the formation of purulent  matter
 will always be  influenced by the general state of the patient's
 health, the violence of the disease, and the structure  of the
 part, &c.
   XLIX. Suppuration  is immediately preceded by  an ex-
 acerbation of the  inflammatory symptoms ;—it is generally (not
 constantly) attended with rigors, shooting pains, and a sense of
 throbbing in the part.  As  it proceeds, there is a gradual remis-
 sion of pain  and tension, the  redness upon the  surface is less
 vivid,  there is a gentle subsidence  of  the tumefaction, and,  at
 length, it is known to be completed, by the evident fluctuation
 of a fluid, and the conical figure of the part  affected.   To the
 assemblage of these phenomena we give the  name of abscess.
   L.  An  Abscess is a circumscribed cavity, formed by disease,
 and containing  pus ; its internal surface may be considered, as
being  somewhat similar to that of an ulcerated part.
   LI. The cellular membrane  is most commonly the  seat of
 suppuration  and principally forms the parietes of  an abscess;
in the natural and healthy state, pus, or any other fluid would
be readily diffused through its cells ; but the previous inflamma-
tion produces an union of its lamina sufficient to render it im-
permeable.
   LII. Purulent matter is generally first formed about the cen-
 tre of the phlegmon;  and in proportion as the  quantity in-
 creases, the cavity of the abscess is enlarged, and  becomes
 most prominent on that side  where there is the weakest resist-
 ance.    Hence, an abscess  sometimes  bursts into  a natural
cavity; or when the matter is confined by an  aponeurosis or
 is seated very deeply among parts that  resist its pressure  one
 or more  sinusses  may be  formed of considerable extent  the 
OF INFLAMMATION.
29
aperture of which may be at a considerable  distance from the
original seat of the disease;  and if the matter exist in a very
large quantity, the gravitating force of the fluid will  give it a
tendency to a depending part.  Hence, it may be  understood,
why  an abscess  most commonly bursts  upon the surface of
the body.—Med. Observ. Vol. 2.
   LIU. The nature of Pus, and the mode of its formation,
hath given occasion  to  great diversity of sentiment: it is not
our intention to examine all the opinions  that have been pro-
posed upon this subject, but only to hint at some of the princi-
pal ones.
   LIV. It hath been imagined,
   1.  That pus consists of the serum of the blood, deprived of
its more watery part, and converted  into a new substance by
fermentation.—Gaber.  Sir J. Pringle.
   2.  That blood, or  the coagulating lymph,  or a  mixture of
blood and  solid  parts in a state  of dissolution, chiefly contri-
bute to  the formation of this fluid.—Boerhaave. Heister. Plai-
ner. De Haen. Sauvages. Grashuis. Eschenbach. Portal.
   3.  That the solid  parts are often actually melted down into
pus.  Faudacq, fyc.
   4.  That  pus  is  a  secretion  from an ulcerated  surface.
Simpson. Morgan. Hewson. Hunter. Brugmans. Home, fyc.
   LV.  It is very certain that pus is not  the  produce of  the
putrefactive fermentation ; its sensible qualities being very  re-
mote  from those that are exhibited by a putrid fluid.
   LVI. Nor is the blood, nor the inflammatory crust, nor any
of the solid parts ever converted into true pus. When blood is
once extravasated, the system has  no  power to  produce a
change  in its properties ; it  either coagulates, or  degenerates
into an  offensive sanious matter.
   LV1I. As in the formation of an abscess, there is necessari-
ly some dilaceration  of vessels  and  rupture  of the  cellular
membrane, it is probable that the matter  is not always entirely
free from these substances; but the quantity of solid parts that
is injured, or wasted,  bears  no proportion  to  the quantity of
pus that is evacuated from  an  ulcerated  surface.
   LVIII. Dead animal matter certainly  does not  furnish  the
pus album lave et cequale ; for in cases of sphacelus  purulent
matter is not evacuated, until a separation  between  the dead
and the living parts has begun to  take place.
   LIX. Purulent matter does not exist formally in the blood ; 
30
OF INFLAMMATION.
it is furnished by living vessels, in consequence of previous in-
flammation, and probably undergoes some change  after it is
poured upon an  ulcerated surface, or is evacuated into  the
cavity of an Abscess.*—Vide Fizes fy M.  Quesnay,  Sur  la
Suppuration.
  LX.  There  is a kind of matter very much resembling pus,
that is discharged  from the surfaces of inflamed membranes,
and which may with some propriety be considered as a secre-
ted fluid.   No  experiments that  have been  yet made public
have proved sufficient to establish  certain criteria  for distin-
guishing purulent  matter, at all times,  from  what  has been
called  inflammatory  exudation.-f—Med. Observ.   Vol.  11.
Pott's Works,  Vol. I.
  LXI. The fluid that is excreted from a suppurating surface
does not always possess the properties of good healthy pus :  the
varieties that are met with will depend either  upon the previ-
ous state of the fluids from which the purulent matter is furnish-
ed ;  upon the action of the vessels by which it  is  formed ;  or it
will be influenced by the condition of the fluid and solid parts
taken conjointly.   This subject may be illustrated by applying
the preceding observations to contagious matter;—to  the  dis-
charge from scrofulous ulcers;—and to  the matter of critical
abscesses, he.
  LXII.  The  fluids that are evacuated from different ulcera-
ted surfaces may be arranged under the following heads, viz.
       Pus.
       Ichor.
       Sanies.
       Sordes.
       Malignant Matter.   Quesnay.
       Contagious Matter.
  LXIII.  Pus is a smooth, white, uniform fluid, inodorous,
void of acrimony, lightly tenacious, and nearly of the  consist-
ence  of cream.   When viewed in a microscope, in  its  pure
state, it is found to contain globules.J  This fluid  is discharg-
ed by a healthy granulating surface.

  * The change which pus undergoes after its exit from the vessels which
form it, has been  described by Mr. Home, in his Dissertation on Pus.
  1 That a breach in the substance of a part was not necessary, in  order
to the discharge of a matter resembling pus in all its sensible properties,
was known to Boerhaave, Sharp, Morgagni, and others.
  t The globules in pus  were first observed by Dr. Morgan  and Mr.
Hewson, and have been since noticed by Mr. Home. 
OF INFLAMMATION.
31
  LXIV. Ichor,  is a thin, watery,  acrimonious  discharge: it
is frequently  attendant on cutaneous diseases,  superficial ul-
cerations, and painful,  ill-conditioned sores.
  It ought  to be distinguished from  serous effusions under the
cuticle ;  from acrid fluids poured out by mucous membranes;
from lymphatic discharges, he.
  There is a species of ichor which  was called Melicera  by
the Greeks, that is discharged from sores which  are seated  on
ligaments,  or about the articulations.   This ought to be dis-
tinguished from Synovia, and from the fluid that is contained in
Bur see Mucosa.
   LXV. Sanies  is a  fetid ichor mingled with some of the
red  globules  of the blood.  It is often discharged  by varicose
ulcers; by extremely irritable sores ; and such as are disposed
to form repeated sloughs, or to become  gangrenous.  It must
be distinguished from that discharge which follows a few hours
after the infliction of large wounds, he.
   LXVI.  Sordes, is a matter  of denser consistence than sa-
nies :  it  is  grey, or of  a  leaden colour,  and  sometimes resem-
bles an imperfectly coagulated mass : when a subjacent bone
is affected, it emits a  very offensive  odour of a peculiar kind.
A silver probe imbued with this fluid, becomes of  a dark col-
our.
   LXV1I. Malignant  matter  is a fluid  that is often discharg-
ed from those imposthumes, which form in pestilential diseases :
the  vapour ascending from this matter has a sudden and pow-
erfully injurious effect upon the nervous  system, but does not
communicate any specific disease.
   LXV1II.  Contagious  matter being received  into the  body,
is multiplied, and produces a disease according to its own spe-
cific nature.
   Are there any sensible qualities by which contagious matter
 can be distinguished from that which is  void of infection ?
   LXIX. The puriform fluid which  is evacuated by mucous
 membranes, from scrofulous glands, from cancerous sores, and
 that which is also contained in various encysted tumours, shall
 be described when we treat upon those  particular diseases.
   LXX.  Chirurgical writers have  divided Abscesses  into the
 simple, where the matter is contained within one circumscri-
 bed cavity; the compound,  when  the pus is  dispersed  into
 several  sinusses ; and the complicated, in which a subjacent
 bone is  carious, or the abscess is connected  with some particu- 
32
OF INFLAMMATION.
 lar virus.  It would, perhaps, be more convenient to consider
 them as, Phlegmonous, Indolent, Gangrenous,  and Scrofulous,
 &c.
   LXXI.  An  abscess  may  be  denominated  idiopathic,
 when it does not appear to be connected with any preceding
 disease.
   LXX1I. If during  the presence of a  local  disease, an  ab-
 scess shall supervene in a  distant  part, without removing, or
 alleviating  the original affection,  it may be termed deuter-
 opathic :  exempli gratia.   A suppuration of the liver some-
 times occurs in cases of inflammation and suppuration  of the
 meninges, or substance of the brain,  &c.
   LXXIII. If a connexion can be traced between an abscess,
 and a preceding  morbid  appearance, so that the  latter is evi-
 dently the cause  of the former, it may with propriety be called
 a  symptomatic  abscess :  exempli gratia,  The wound  of
 an absorbent  vessel in the finger or toe, is sometimes succeed-
 ed by the suppuration of an absorbent gland in the groin, or
 in the axilla.
   LXXIV. If an ague, continued fever, he. shall terminate
 and  disappear immediately upon the apostemation of an ex-
 ternal part, it may be termed a critical abscess.
   How far may such a suppuration  be esteemed  the cause,
 the effect, or  the sign of a crisis ?
   LXXV.  It is not  necessary to consider a  critical  abscess
 as a cavity  into which the Materies Morbi is deposited;  for it
may be doubted  whether the pus  contained within it ought to
be  regarded  as contagious  matter  (No. 68).   If any specific
virus be supposed to be  present, it certainly exists in a diluted
state.
   LXXVI. Those parts of the body which are naturally pos-
sessed of an inferior degree of sensibility, and are scantily sup-
plied with vessels that carry  red blood, as tendons, fascia?
ligaments, &c. do not exhibit the same phenomena when dis-
eased, which  appear in fleshy  and muscular parts.
   LXXVII.  It has been commonly observed, that the  pro-
 cess of suppuration is completed more speedily, when the ab-
 scess is situated  near the centre of the  body,  than when it is
 seated in an extreme part. 
OF INFLAMMATION.
33
                     SECTION  VI.

           OF THE TREATMENT OF INFLAMMATION.

   LXXVIII. There are few diseases that fall within the pro-
 vince of the surgeon,  in which the well-directed efforts of art
 appear to greater advantage, and wherein a  judicious practice
 meets with more distinguished  success, than in the treatment
 of inflammation:  it is a common and highly interesting disease,
 but is happily very much within the power of remedies.
   LXXIX.   An inflammation sometimes admits of a  natural
 cure, and terminates in the manner described at No. 41.
   LXXX. Before any artificial means are used to cure an in-
 flammation, it will be requisite to ascertain:
   1.  Whether the present affection seems to be the cure of
 another and more important disease.
   2.  Whether it be the  consequence  of extraneous matters
 lodged in some part of the body.
   3.  If the means to be  employed will do more  harm to the
 general system, than the  disease will, if it be suffered to  pro-
 ceed and terminate spontaneously.
   LXXXI. During the first four or five days of the disease,
 we are to make attempts  to obtain a resolution of the inflam-
 mation.
  This rule is a general one, and perhaps admits of no excep-
tion in cases of internal inflammation : but it is not an invaria-
ble one, when the inflammation is situated externally.
   LXXXII.  Indication the first.
   To  remove the  remote cause of the disease, if possible.
It is proper however to be  observed, that the  removal  of the
remote cause, is  not necessarily attended with the cure  of the
disease; for  an  inflammation  may act  as a remote  cause of
its own continuance.
   LXXXIII.  The  effects  of  external  stimuli  may  be obvi-
ated, as
   1. Cold, by air of a moderate temperature.
  2. Motion, by a supine posture.
  3. Distention,  by warm vapours, warm  oil,  tepid  baths,
mild cataplasms,  &ic.
  4. Acute pain, by opium.
              5 
34
OF INFLAMMATION.
   The effects of stimulating matters formed, or existing with-
in the body, may be corrected,
   1. By destroying the poison with specific remedies.
   2. Diluting the acrid matters.
   3. Defending the parts affected from their influence.
   4. Diminishing sensibility partially, or generally.
   The application of these  principles will be more fully eluci-
dated when they are applied to the treatment of particular in-
flammations.
   LXXXIV.  Indication  the second.
   To take off that state of  the blood-vessels, in which  inflam-
mation consists (No. 8).
   1. This is to  be  attempted by diminishing  the quantity of
blood that is contained in the body, by bleeding  from a large
vein, or opening an artery.
   2. The velocity and momentum of the blood in the vessels
of a particular part, may be lessened by the application of cup-
ping-glasses, by  scarification, leeches, arteriotomy.
   LXXXV.  The quantity of blood  that  ought to be evacu-
ated, is to be determined by the temperament of the  patient,
the severity of the inflammation,  and the importance of the dis-
eased part to the purposes of life.
   LXXXVI.  Twelve  ounces of blood, taken away suddenly
from a large orifice, will have a more powerful influence in di-
minishing inflammation,  than twenty-four ounces extracted at
three successive bleedings; especially, if several hours be suf-
fered to elapse between each evacuation.
   LXXXVII.  It is probable, that those  reasonings upon  the
effects of local and  general  blood-letting, which  are  merely
founded  upon  the  circulation of the blood ;  by discouraging
topical evacuations, have proved detrimental to the  practice of
surgery.
   LXXXVIII.   3.   To evacuate the  system, and promote
derivation, by purgatives, especially such  as operate with the
least irritation, as
   Manna,  neutral salts, castor oil,  large doses of  cream of
tartar, euemata, &c.
   LXXX1X. The good effects of cathartics are more evi-
dently marked in topical, than in general inflammation ; more
especially in  those cases where some  part of the intestinal
canal is inflamed, or where there is an  affection  of the brain
or its investing membranes. 
OF INFLAMMATION.
35
  XC. To subdue an inflammation by making large evacua-
tions, is not a very scientifical mode of curing the disease; it
were highly to be  desired, that we were in possession of a me-
thod of treatment  which would  cure an inflammation, without
debilitating  the system, and thus laying the foundation of other
diseases.
  XCI.  Indication the third.
  To  diminish the  increased  action  of the blood-vessels, by
such remedies as  do not considerably weaken the actual force
of the  system, e. g. by sedatives, as
   1. Neutral salts in large  doses, but sufficiently diluted, so
as to obviate their effects as direct  stimuli.
  To which may be added,
  2. Abstinence from  all solid food.
  3. The plentiful use of diluents,  in a tepid state.
   4. Where  pain acts as  a  remote cause  of  inflammation,
opium must be given, after  due evacuation of the system : but
on  such  occasions, it ought  to be exhibited in very large quanti-
ties ;  for if it be not  administered in doses sufficiently powerful
to produce  the proposed effect, it will augment the disease.
   XCII. The remedies that  may be employed externally, in
cases of topical inflammation,  are
   1.  Cold  air, cold  water, ice, or snow.
   2.  Preparations of lead,  vitriol, alum,  solutions of differ-
ent neutral  salts, as sal ammoniac,  &tc.
   3.  Relaxants,   as  warm  water, warm  vapour, oil,  mild
emollient cataplasms, &c.
   XCIII.  In the use of substances that are intensely cold, or
highly repellent, great  caution is required/as they have, when
imprudently applied, been followed by gangrene.  There is also
an  important distinction between applications which are actual-
ly cold, and  diminish the action of a part, by  reducing its heat
considerably below  the natural temperature ; and those sub-
stances, that are only potentially cold, and lessen the heat by
restraining  the immoderate action of the blood-vessels.
   XCIV.  Some writers have recommended the  excitement of
another  inflammation in the vicinity of the diseased part; but
this is a mode of practice that ought very seldom to be adopt-
ed early, in cases of acute  inflammation,  unless where the dis-
ease is situated internally.
   XCV. If a resolution of the inflammation does not follow, 
36
OF INFLAMMATION.
after properly using the remedies  enumerated above,  a  sup-
puration may be expected to take place.
   XCVI. A resolution of every phlegmon  ought not to be
attempted, for there are several circumstances which frequent-
ly render it proper to promote  the suppurative process,  from
the beginning of the disease.
   1. When  experience has proved, that a dangerous disease,
situated in a part that  is contiguous to the inflammation, will
probably be  alleviated,  or  cured by the  formation of an  ab-
scess ;  e. g. curvature  of the spine, &tc.
   2. Where we have reason to expect the evacuation  of ex-
traneous substances.
   3. Where a previous disease has  existed in some  viscus,
and there  is reason to  hope  for an evacuation  of matter, &tc.
upon the  surface  of  the  body:  e. g.  abscess  of the liver,
&c.
   4. When  there is reason to suspect  that the phlegmon is a
critical inflammation (No.  74).
   Resolution is not always to be avoided because the inflam-
mation is critical; but very often because the means that ought
to be employed, are contra-indicated by that state of the sys-
tem, in which  critical depositions most commonly take place.
   5. When  a symptomatic  phlegmon  (No. 73)  appears, in
consequence of the wound of a nerve,  absorbent  vessel, &tc.
suppuration  is  generally to  be promoted; more especially  if
any poisonous matter  were  introduced into the wound.   This
rule, however, is not  always applicable, when  we possess  a
specific remedy, that is capable of destroying  the activity  of
the morbid matter.
   6. When the structure of the inflamed part renders  it  pro-
bable,  that by undergoing a suppuration, it will be sooner and
more completely restored  to its functions in the animal econo-
my.
   7. If the inflammation  has  so  considerably  deranged the
organization of the affected part, that its healthy functions can
never be restored.
   XCVII. There is a  certain degree of action requisite in the
vessels of an inflamed part,  in  order to  the production  of  a
good suppuration ; it ought  to be somewhat  below inflamma-
tory action, but the precise point can  only be  ascertained by
experience,  and does not admit of the establishment of a gen-
eral rule. 
OF INFLAMMATION.
37
   XCVIII.  Suppuration is promoted,
   1. By moderating the  inflammation, when it  is extremely
 violent.
   2. By diminishing the severity of pain.
   Large doses  of opium  are  of  distinguished service, when
 suppuration  is disturbed by erethismus.
   3. The vigour of the system is  to  be sustained by a proper
 use of Peruvian  bark,  opium, wine,  and  other fermented
 liquors.
   XCIX. To the part  affected, warm and  relaxing applica-
 tions are  generally  proper;  as  fomentations,  poultices  of
 bread and milk with oil, linseed meal, &ic.  They  ought  to
 be applied warm, and be frequently renewed.
   C.  The  general intentions  of applying the remedies enu-
 merated  (No. 99) are chiefly by way  of lessening  the effects  of
 distention : to preserve an uniform and  moderate heat in the
 part, and thus to alleviate pain, he.    Stimulating applications
 to a highly inflamed part are very seldom admissible, when we
 desire to promote the formation  of pus.
   CI.  Where an abscess is deeply seated in some  important
 part of the body, so that it is of consequence to the welfare  of
 the  patient  that it be conducted speedily to maturation,  and
 that the pus be evacuated at an external opening; heating and
 stimulating applications  may be used with propriety ; as sub-
 tances containing  turpentine, resins,  the warm  gums,  can-
 tharides,  or acrid vegetables.
  CII.   The complete maturation of Indolent and Glandular
 tumours, which  originate  under circumstances extremely re-
 mote from those  which  give  rise to true phlegmonous ab-
 scesses, may  be assisted by,
  1.  Dry cupping,  violent exercise, the  applications men-
 tioned  at No. 101, strong rubefacients, electricity, repeated
 blistering, a proper application of actual heat.
  2.  The internal  remedies that were described at  No. 98,
 to which  may be added mercury and steel.
  C1II.   When the  abscess is completely  formed, the cohe-
 sion of the integuments at the most prominent part is gradual-
 ly weakened ; erosion takes place in  one  or  more points,
 and  the contents are evacuated  spontaneously.
  CIV.   Very  frequently the  spontaneous  rupture of an ab-
scess may be  permitted ; sometimes it must be insisted upon ;
but  it will also in many cases be prudent, or even absolutely 
38
OF INFLAMMATION.
necessary, to  discharge the matter contained it in by  an  arti-
ficial opening.
   CV.  There are certain cases, in which it is neither safe nor
expedient to wait for a natural erosion of the integuments ;  as
in deep-seated abscesses, which are separated by  a thin parie-
tes from an important  natural cavity :—Paronychia ;—where
matter is confined by  an aponeurosis, or the periostoum,, &c.
and in general, where the parts in  the  vicinity of the disease
admit of distention with great  difficulty.
   CVI.   It has been said, that " matter is always ripe, and, as
matter merely, ought to be discharged as soon as possible ; but
as matter seated at some depth  in  the  body, and  confined by
inflamed flesh,  it is  proper that it should work its  way gradual-
ly, and rise to the surface before  it  be let out."  In this propo-
sition, the beneficial effects of pus  upon  the  hardness of the
surrounding  parts;  the  gradual restoration  of  the  inflamed
and obstructed vessels to their natural actions ; and the favour-
able  healing  of the  subsequent  ulcer,  seem to be wholly
overlooked.  Besides, the attention of the surgeon will be di-
rected to the maturity of the  abscess, and not to  any supposed
ripeness of the contained  fluid.
   CVII.   As it is sometimes the duty of  a surgeon, to retard
the premature .rupture of the  parietes of an abscess ;  it is also
proper, when the quantity of  pus is very considerable, and the
patient is weak, to prevent the matter  from  being too hastily
evacuated.
   CVIII.   Three  different methods of opening  abscesses are
employed,  viz.—by
   1.  Simple Incision,
   2.  Erosion,
   3.  Seton.
   Each of these modes possesses its peculiar advantage ;  but it
is  scarcely  possible  to lay down general rules, in  so precise a
manner, that the practitioner  will always be able to take  a de-
cided part.
   CIX.   It will be  sufficient for our  present purpose to ob-
serve, that, where matter is deeply seated;—when it is  in the
vicinity of large blood-vessels  and nerves;—when the matter
is  so widely diffused that a large opening is necessary;—when
the skin  that  retains the  pus  is  soft, thin, and little diseased;
—or when it will not be desirable to keep  the  ulcer open for 
OF THE FURUNOULUS OR BOIL.
39
any  particular purpose,  he.—the knife will be preferable  to
caustic.
  CX.  The application of caustic is to be preferred  before
the knife;—when maturation has proceeded slowly, and the
suppuration is partial;—when the integuments are considera-
bly vitiated ;—when it will be  necessary to keep the  ulcer
open on account of some  disease at the lower surface  of the
abscess; —and generally in the suppuration of glandular parts,
and  in abscesses situated near an articulation, &c.
  CXI.   The seton may be advantageously employed  where
maturation  is complete, and  the  skin is  in a healthy state ;—to
preserve  important parts that are  included  within an abscess,
from much injury ;—to avoid the deformity of a large cicatrix ;
—or where it will be  useful to support an irritation for some
length of time, in the diseased part, &c.
  CXII.   If the spontaneous rupture of the abscess be antici-
pated  by art, and the seton is  not employed, it  is generally
proper, by a free incision, &c. to lay open the whole internal
surface of the abscess.   The treatment of the ulcerated cavi-
ty,  and the doctrine  of  ulcers in general,  will  be discussed
in another place.





                  CHAPTER   II.

                    SECTION  I.

              OF  THE FURUNCULUS OR  BOIL.

  CXIII.   The Boil  is a hard, circumscribed and exquisitely
painful phlegmonous tumor, seldom exceeding the magnitude
of a dove's egg;  the  seat of this  disease is in the skin, it sel-
dom suppurates  completely, and commonly arises from an in-
ternal cause.
  CXIV.   This tumor generally  appears under the  figure  of
a cone, the base of which is considerably below the surface,
but its apex is rarely much elevated above the level of the skin ;
upon the most prominent  part of the boil, there is commonly a
whitish or livid pustule, exquisitely  sensible  to the touch; and 
40
OF THE FURUNCULUS OR BOIL.
 immediately beneath this, is the seat of the abscess; the mat
 ter is sometimes slow in forming, and is seldom found to exist
 in a considerable quantity.
   CXV.  This little  abscess is  most generally  suffered to
 rupture spontaneously; and the discharge  consists  of purulent
 matter, mixed with a portion of the red globules of the blood;
 the  cavity from which the matter was evacuated, contains a
 large quantity of slough, which  must be discharged before the
 ulcer can heal.
   CXVI.   There  is no part of the body that abounds with
 cellular membrane, which is wholly exempted  from becoming
 the  seat of this  disease.   Most commonly  the furunculus  is
 solitary,  but sometimes it appears in considerable numbers,
 especially when  children are afflicted with it, or immediately
 after the termination of some acute disease.
   CXVII.   The  preceding history  is descriptive  of  what
 may  properly  be  termed  the  acute boil;  there  is  also  a
 chronic  furuncle,  which  frequently  occurs  in subjects that
 have  suffered  severely from the  small  pox,  measles, lues
 venerea, scrofula, and in constitutions  that have been injured
 by the use of mercury, &c.*
   CXVIII.   The  chronic boil, is  commonly  situated  upon
 the extremities; it is about the magnitude of the  acute boil,
 and has a hard circumscribed base; its progress is  not attend-
 ed with much pain; there is no  considerable  discolouration of
 the skin, until suppuration be a good deal advanced; and ma-
 turation is seldom completed in less than three, or four weeks.
 This, like the  former, sometimes  appears in a considerable
 number at a time.
   CXIX. The matter  that  is evacuated from this  abscess, is
 an inodorous sanies, and is always of a thinner consistence than
 good pus;  when the  boil has been  large,  and unusually slow
 in suppurating,  a considerable  quantity of the tela cellulosa,
 &tc. will be cast off, from time to time, in the form of sloughs,
so as  to leave a very deep cavity, before  the ulcer assumes a
healthy appearance.
   CXX. The  furunculus is a disease which seldom  occu-
pies the attention of the surgeon,  unless it be of an unusual
magnitude, or accompanied  with very distressing  symptoms.
* Munnicks Praxis Chirurgica.  Cap. iii. p. 19. 
              OF  THE  FURUNCULUS  OR BOIL.            41

It may in general be regarded, rather as a troublesome com-
plaint, than as a dangerous one.
  CXXI. The  acute  and  chronic Furuncle, ought  to be
distinguished, from Phyma,  Phygethlon, Epinyctis,  Anthrax,
&c.
                   SECTION  II.

                THE MODE OF TREATMENT.

  CXXII.  It is  seldom desirable to obtain the resolution of
a boil; and if  it were attempted, the efforts would most com-
monly be ineffectual.
  CXXIII.  Suppuration must be  promoted  by  the  means
enumerated at No. 99-101, &cc.  The  maturation of the chro-
nic furuncle will be  powerfully assisted, by frequent and long
continued exposure to the vapour of hot water.
  CXXIV.  The internal exhibition  of Peruvian bark will be
sometimes advisable ; and also a liberal use of opium.
  CXXV. After the evacuation of the  matter, a common mild
digestive ointment may be  applied to  the ulcer; but where
the quantity  of  corrupted cellular  membrane is considerable,
the hydrargyria nitratus ruber may be  employed with advan-
tage.
  CXXVI.  The general state of the system must be corrected
by remedies suited to its peculiar situation.
  CXXVII.  It  were highly desirable to  remove, if possible,
that disposition of the body which  is favourable to the produc-
tion of boils.   We may sometimes succeed in  this attempt, by
the use of Peruvian bark, sea bathing, acids, iron, he.
   In  some cases, those remedies  which promote a flow of
urine, while they diminish vascular  action, may be successfully
employed; as cream of tartar, nitre,  Rochelle  salt, vegeta-
ble or mineral alkali, in  a diluted state.
6 
42          OF  THE  ABSCESS OF  THE  BREAST.
                  CHAPTER  III.

                     SECTION  I.

              OF THE ABSCESS OF THE BREAST.

  CXXVIII. As the inflammation and  suppuration  of the
Breast is a disease to which puerperal women, at  certain peri-
ods, are peculiarly liable, our attention will  be chiefly  directed
to the history and treatment of what is commonly termed the
Milk Abscess.
  CXX1X. The attack of this complaint is usually preceded
by rigors, which are  soon  succeeded by heat, thirst,  restless-
ness, loss of appetite, and other symptomsof a general affec-
tion of the system.   The skin of the breast is sometimes univer-
sally red; at other times, the redness appears in different parts
of the breast, in  distinct and  irregular patches.  The  breast
enlarges, becomes tense, heavy and painful: if the secretion of
milk continue, that fluid is more or less changed in  its natural
qualities, and it cannot be extracted without pain and difficulty.
  CXXX. The structure of the breast being partly glandular,
and partly cellular,  an  inflammation of this  part may be seat-
ed,  either in the conglomerated gland, which occupies  the cen-
tre of the breast, or in  the  enveloping integuments.   When it
is confined to the skin and cellular membrane, the inflamed part
is uniformly distended ; when the glandular part is  also  affected,
the  enlargement is  irregular,  and seems to consist of one or
more large tumors, situated in  the substance of the breast, and
the  uneasiness is often communicated  to  the glands in the ax-
illa, and  to the back, between the scapulas.   Not uncommonly,
the  whole breast becomes enormously enlarged, and the gene-
ral system considerably  disordered.  The secretion of milk is
not always  suppressed, when  the inflammation is confined to
the  integuments; and  suppuration takes  place  there  more
speedily  than in affections of the glandular part.
  CXXXI. If the inflammatory symptoms regularly  increase
during four or  five days, a suppuration may be expected ; but
where the progress of inflammation has been slow, and its de-
gree  has been  very moderate, a  resolution  may  frequently 
OF THE ABSCESS OF  THE  BREAST.
43
be obtained at the distance often or  fourteen days  from  the
first appearance of the disease.
  CXXXII. The period about which a woman is commonly
attacked with  the mammary abscess is within the first  three
months after parturition;  but it may intervene  at  any period
from thence to the time of ablactation.
  CXXXIII. Of the remote causes which have been assigned
for the appearance of this disease, we shall only enumerate the
following, viz.
   I. Sudden, or violent perturbation of mind.
  2. Repressing the secretion of milk at an early period.
  3. Exposure to cold.
  4. Too  free an use  of the arms, when the breasts are dis-
tended with milk.
  CXXXIV.  The  mammary  abscess   frequently occurs,
where  no evident cause can be assigned for its appearance.
  CXXXV. In  the suppuration of  the  breast, the purulent
matter is not always contained  within one cavity; but several
distinct abscesses form in  different parts, and are perhaps ma-
turated at  different periods.  When the abscess is  permitted
to rupture  spontaneously, the matter is often discharged from
an orifice  that is situated near the  nipple ; or a gangrenous
slough  is formed at the most projecting point of the tumour,
and when that loosens, the contents are evacuated.   It is like-
wise not uncommon to  see  milk  mixed with  the pus which
flows from  the mammary  abscess.
  CXXXVI. The glandular structure  of the breast is some-
times so considerably altered, that after a future parturition, it
cannot secrete any milk : but the prognosis of the milk abscess
(as it is called) is almost always a favourable one, as there is
nothing in its nature at all analogous to Schirrhus, or Cancer.
  CXXXVII.  Where a  scrofulous tumour has been present
in the breast during many months, or even several years, it will
often disappear soon after the termination of the abscess of
the breast.
  CXXXVIII. The breasts of those women that  have never
been pregnant, may be attacked with true inflammation, the
progress and termination  of which  does not  materially  differ
from the mammary abscess.  Nor  are men nor even children
wholly  exempted  from inflammation and  suppuration of the
breast.
  CXXXIX. The mammary abscess ought to be distinguish-
ed from scrofulous affections of this part, and from Schirrhus. 
44
OF THE ABSCESS OF  THE  BREAST.
                   SECTION II.

       OF THE TREATMENT OF THE MAMMARY ABSCESS.

  CXL. If the surgeon be  called at an early period  to treat
this complaint, it will generally be proper to  attempt  a reso-
lution of the inflammation.
  CXLI. To obtain this mode  of termination, a very free use
of general blood-letting has been  often recommended.  This
however is a practice that  can seldom be adopted with  pru-
dence in large cities, or where the patient is of a delicate  con-
stitution.  I do not intend to say, that general blood-letting is
always inadmissible; but 1 never  once saw it necessary, either
in public or in private practice.
   CXLII.   1.  Topical blood-letting by leeches, properly con-
ducted, is a remedy that cannot be too highly recommended.
   2.  Saline laxatives, administered at due intervals.
   3.  Moderate  abstinence.
   4.  A suspension of the inflamed breast.
   5.  Moderate  bandage, by means  of adhesive  plaster, art-
fully  applied.
   6.  Gentle friction of the breast with warm oil.
   7.  The vapour of hot water.
   8.  To obviate the  effects of  excessive distention by milk,
by gently extracting it  at  proper intervals.
   9.  Saturnine applications.
   10. Solutions of neutral salts,  as sal ammoniac, he.
   CXLLI.  If  the inflammation  tend to suppuration  it may
be promoted by the means enumerated at No. 98-99.
   CXLIV. The abscess ought in general to be permitted to rup-
ture  spontaneously;  and  the  use   of the  lancet, or knife,
ought by all  means to  be avoided, unless there be a plain and
absolute necessity.
   CXLV.  The application of a mild digestive ointment, cov-
 ered by a poultice of linseed meal  and boiling water, is gen-
 erally sufficient for the  cure of the ulcer.
   CXLVI.  If  an unpleasant  hardness remains in the breast
 after the termination of this disease, it will commonly  yield to
 saponaceous  applications,—mercurial  ointment__warm  plas-
 ters—assisted sometimes by the internal administration of cal-
 omel, cicuta, bark with burnt sponge, &c. 
OF THE  PARONYCHIA,  OR WHITLOW.          45
                  CHAPTER  IV.

                     SECTION   I.

      OF  THE  PARONYCHIA--PANARIS--OR WHITLOW.

   CXLVII.  The Paronychia is a phlegmonous tumour oc-
cupying the end of the finger; it is generally attended with ex-
cruciating pain.*  The most  usual mode of its termination is
by suppuration, but  not  unfrequently it  is  attended  with a
mortification of the integuments and bone.
  CXLVIII. As the nature and precise situation of this disease
admits of some variety, and the same  mode of treatment does
not apply in every instance, it will be proper to  divide it into
different species. I have adopted the  following mode of divi-
sion as a convenient one:
   1.  The Cutaneous  "]
  2.  The Benign     I D      ,.
  3.  The Malignant   f Paronychia'
  4.   The Venereal   J
  CXLIX. The Cutaneous  Paronychia  is seated at the end
of the finger, immediately below the cuticle,  and it sometimes
surrounds the finger  and  root of the  nail.   The  skin is very
little  discoloured; it  speedily advances to suppuration; and
when this process is  completed,  the cuticle  appears  almost
transparent.  After the" contents of this little abscess are evac-
uated, the ulcer seldom demands any particular attention.
   CL.   The Benign  Paronychia is  situated  in  the  cellular
membrane under the  surface of the cutis : its attack and pro-
gress are attended with a  more  acute and throbbing pain than
the cutaneous;  suppuration proceeds  more slowly, and matter
is frequently  formed under the nail.   The whole hand is more
or less affected  with pain  and tension, and uneasiness is often
felt  along the course  of the  arm.  The  severity of the pain
frequently prevents sleep, and the whole system is thrown into
some disorder.

  * It has been asserted  by different writers, that this disease never at-
tacks the toes ; but this is not correct.  It occurs less frequently, indeed,
in the foot than in the hand. 
46          OF THE PARONYCHIA, OR  WHITLOW.

  CLI. The  Malignant  Paronychia  is  accompanied  with  a
deeply-seated  and intense pain at the end of the finger : the
tumefaction of the diseased  part is  not considerable;  but the
hand, and  frequently the whole arm, is swollen, tense and pain-
ful.   The uneasiness most commonly extends in the course of
the absorbent vessels along the  internal condyle of the  hume-
rus up to the axilla.  The suppurative process advances very
slowly, and is  attended in its  progress with  erethismus, lipo-
thyrnia, delirium,  and other alarming symptoms;  and there
have  been instances  where  this species of paronychia^ has
proved fatal.   The  matter, which is small in quantity, is either
collected within the sheath of one of the tendons, or it is under
the periosteum, in  contact  with the bone, which is generally
found in a carious state; and  sometimes the  superincumbent
integuments  suffer sphacelation.
  CLII. As the Venereal  Paronychia is a complaint  that is
not universally understood, I shall deliver its history and treat-
ment  upon the present occasion,  although it might be referred
to another place.   This disease  generally appears in the form
of a smooth, soft, unresisting tumour, of a dark  red colour, and
is situated in the cellular membrane about the root of the nail.
It is attended with an inconsiderable degree of pain in the in-
cipient state ;  but, as suppuration advances,  the pain increases
in severity:  its progress towards maturation is generally slow,
and is seldom  completed.
  CLI1I.  When the sordid matter it contains is evacuated, the
nail is generally found to be loose, and a  very foul, but exquis-
itely sensible ulcer is exposed ; considerable sloughs of cellular
membrane, &c. are frequently exfoliated, so that the cavity of
the sore is often very deep.
  CLIV. The discoloured and  tumid state of the  skin com-
monly extends along the finger, considerably beyond the mar-
gin of the ulcer :  in such cases,  the integuments that envelope
the finger become  remarkably  thickened,  and the  cellular
membrane is so  firmly condensed as not to  permit the skin  to
glide  over the  subjacent parts.   The bone is not usually found
in a carious  state.
  CLV. This species of paronychia is more frequently seen
among the lower  class of people, when they labour under lues
venerea, than  in the higher ranks of life.  It does not ap-
pear to be connected with  any particular state  of the disease,
nor is it confined to one sex more than to the  other.  In the 
OF THE PARONYCHIA,  OR WHITLOW.
47
Lock Hospital, it occurs  in the proportion  of about one pa-
tient in five hundred.
  CLVI. When 1 adopt the name of Venereal  Paronychia,
it is not with the  design of  implying  that this is a true  vene-
real  abscess, containing a fluid which is capable of communi-
cating syphilis to a sound person.   Its progress and cure seem
to be unconnected with  the increased  or diminished  action of
the venereal poison in the constitution, and to be also uninflu-
enced by the operation  of mercury.  I consider the venereal
disease  as a remote  cause,  which  gives occasion to the ap-
pearance of this, as well as of several other  diseases, that are
widely different from its own specific nature.*
   CLVI1.  The  remote  causes  of  paronychia  in  general,
have been divided into external and internal.
   1. The external:
   A puncture :—a bruise :—the application  of acrid  substan-
ces, &.C.
   The  nature of the internal cause or causes I do not pre-
tend to explain.
   CLVIII. Prognosis.—The  Cutaneous  and  Benign Pa-
ronychia have a favourable  termination ; the worst event to be
expected, is the loss of a part or the whole of a nail; but this
will frequently grow again.
   CLIX.  The  Malignant  Paronychia  seldom  terminates
without  the loss of some part of the bone;  the  last phalanx
of the finger is most commonly separated.   It is also attended
with considerable danger to the whole system.
   CLX. The Venereal Paronychia generally terminates  fa-
vourably, unless it be exasperated by improper treatment.
                    SECTION II.

               THE MODE  OF TREATMENT.

  CLXl. The surgeon is seldom consulted about the cutane-
ous paronychia, until  the abscess be  actually formed.   The
tumour  in such a state must be opened by a lancet, the  sepa-

  * A chronic inflammation is sometimes seen at the extremity of the
finger, which never suppurates.  This has been called Paronychia Sicca. 
 48         OF THE PARONYCHIA,  OR WHITLOW.

 rated cuticle removed by a pair of scissors, and the sore dressed
 with a mild cerate.
   CLXII. In the benign and malignant paronychia, resolu-
 tion must be first attempted,
   1.  By a free  incision, carried through  the integuments to
 the bottom of  the diseased part, and where matter lies under
 the periosteum, the knife must penetrate down to the bone, in
 order to relieve the patient effectually.   The blood may be suf-
 fered to flow for  some  time,  and  the  opening may then be
 treated  as a simple wound.
   2.  The  use of boiling water, of  ardent  spirits,  or strong
 astringents, is of doubtful efficacy.
   CLXII1. If pus be actually forming, we are not to wait un-
 til the abscess be completely maturated ; .an opening sufficiently
 deep and extensive is to be immediately made, that the matter
 may be' evacuated as soon as possible.   When matter is lodged
 under the nail, a sufficient portion of it must be removed so as
 to allow a free exit to the pus.   When the bone is found  to be
 in a carious state, it is seldom  requisite  to expedite its separa-
 tion by  artificial means.
   CLXIV. The  ulcer ought not  to be dressed with greasy
 applications.   Dry lint, or lint  moistened with some native bal-
 sam, may be applied to the  bottom  of the  sore : when it is in
 a healing state, Bates's  camphorated water is a very good ap-
 plication.
   CLXV. Peruvian bark to support  the system,  and opium
 in sufficient doses to alleviate pain,  are almost the only internal
 remedies that will  be found necessary.
   CLXVI. In the incipient  state  of  the venereal  parony-
 chia, when no severe symptoms  are present, it is not advisable
to make use of any external applications;  it  will only require
to be covered with a fine linen rag: by such  gentle treatment,
 it will often disappear gradually, without coming  to suppura-
tion.
   CLXVII. When matter is formed,  the abscess may be per-
 mitted to  rupture spontaneously.   It is very common to see
 every species of dressing give great  pain, and  disagree with the
 sore.   An application composed of equal  parts of balsamum
 copaiba and tinctura thebaica,  may sometimes  be used with
 a good effect.
   CLXVIII.  The principal  object  to  which  our  attention
 ought to be directed is, to keep the patient as easy as possible, 
OF THE EMPYEMA PSOADICUM.
49
by the internal use of opium, until the sloughs be separated, and
the ulcer becomes clean ; it may then be treated as a common
sore.   It will generally be proper  to administer the Peruvian
bark.
  CLX1X. It is never advisable to amputate the finger, when
the integuments exhibit that diseased appearance described at
No. 154 ; for the stump will be in danger of assuming an aspect
similar  to  that of the sore for which the operation  was per-
formed.
  CLXX. After the spontaneous rupture of the benign spe-
cies of the  Paronychia,  the germination of a fungous excres-
cence, or fleshy caruncle, may be frequently observed.  It
most commonly appears at the angle made by the nail and the
skin, on one side of  the finger,  and it  is  seen almost as fre-
quently on one of the toes  as on  a finger.   This morbid ap-
pearance is  usually  attended with exquisite pain, and if it be
treated with emollient and relaxing applications, it will be ex-
asperated and   endered more difficult of cure.
  CLXXI. The mode  of treatment  is  very simple.  That
portion of the  nail  which  penetrates  the fungus  ought to be
carefully removed : the sore must then  be dressed  down to
the bottom, with  small portions  of dry lint;  and a little  lint
must be insinuated, if possible, under the nail,  that by  elevating
its edge, the confinement of matter, and  undue pressure may
be prevented.  The fungus must be reduced by lunar caustic,
red precipitate,  Bates's  camphorated  water, &cc.  This kind
of sore has sometimes had the appellation  of Ulcus  Mali
Moris.
                  CHAPTER  V.


                     SECTION  I.

OF THE EMPYEMA  PSOADICUM,  OR PSOAS  ABSCESS,--LUMBAR
                         ABSCESS.

  CLXXII.  The Psoas Abscess, as it is termed, is seated in
that portion  of the cellular membrane which  is immediately
connected with the psoas muscle, and lliacus Internus.
              7 
50            OF THE EMPYEMA  PSOADICUM.
  CLXXIII. This disease may very often be considered as a
specimen of  chronic  inflammation.   It  is  sometimes  pro-
duced by a violent overstretching, or bruising of the muscles
about the loins :  it has  followed an imprudent  application ol
cold and moisture, as lying upon the damp ground.  Any ol
the remote causes of inflammation that can  be applied, may
give rise to this affection ;  and not uncommonly, it is connect-
ed with some vice in the general habit of body, as scrofula,

   CLXXIV.  The first invasion of this complaint may be at-
tended with symptoms resembling a severe lumbago.  There
will be more or less difficulty in standing with the body erect;
the seat of the pain is  referred to a little below  the  region  of
the  kidney, and it often extends very  low down the outside of
the thigh : the testicle, on that side, sometimes becomes  pain-
ful ; it is drawn close to the body by the eremaster muscle, and
there is an uneasy sense of constriction in the  course  of the
spermatic chord: these  symptoms are accompanied with  a
painful  sense of contraction at the upper part of the thigh, as if
the  limb were  actually shortened.   The  kidney  and ureter
on the affected side, suffer more or less from the vicinity  of the
disease; the secretion of urine is often diminished, and that
which is discharged deposits  a lateritious sediment.  As  this
first order of symptoms abates, it is succeeded by  others of a
 different kind, as rigors, languor, and loss of appetite, hectical
complaints,  wasting  of the  body,  &c.   The  inflammatory
symptoms being seldom severe, the suppurative process takes
place slowly;  and several months will very commonly elapse,
before the abscess appears externally.
   CLXXV. The situation of the external tumour, is not uni-
form ;  most commonly it is at some distance from the original
seat of the disease :  nor is the point at  which the  matter pro-
jects to be considered  as  forming a portion of the abscess.
The fluctuation of  the matter may therefore be most palpable
 about the loins, in the groin, or near the rectum, and some-
times it points  towards the  lower  part of the thigh, in the di-
 rection of the large blood-vessels.
   CLXXVI. During the progress  of suppuration, as there is
 a rem.ssion of  the more severe  symptoms, the patient often
 howIT   a   " TtTer'WA his hea,tn;  ^me degree of pain,
 Pans  af;fland ^ ^V.^ Performing the motion of the
 parts, always remain.  He ,s sooner or  later  alarmed by  the 
OF THE EMPYEMA PSOADICUM.
51
appearance of a soft tumour, which arises in  one or more of
the parts enumerated  above.  At the first, it  is rarely accom-
panied with any discolouration of the integuments, or pain, un-
less it be compressed.   When the person stands erect, the tu-
mour becomes more prominent; but its contents recede, either
in whole, or in part, when he assumes a horizontal posture.
   CLXXVII.  Whether the abscess be  opened  artificially, or
it be permitted to open by a spontaneous rupture, a very  large
quantity of purulent matter, of  the  density of good pus, but
often inclining to a cineritious colour, is generally  evacuated
from its cavity.  The daily discharge of pus also greatly ex-
ceeds the quantity that  might  be expected from  a  tumour of
that apparent magnitude.  The sore frequently puts on a scro-
fulous aspect;  all the hectical symptoms increase, and the pa-
tient is  gradually destroyed.
   CLXXVIll.  As the  purulent matter is situated behind the
peritonaeum, and the erect position of the body is favourable to its
progression downwards, we have no well authenticated instances
of its having been effused into the cavity of the abdomen.  If
such an event should  take place, the most dangerous  conse-
quences are to be apprehended.
   CLXXIX. If the  contents of the abscess be included in  a
firm cyst, the long-continued pressure of so large a body upon
the  lumbar  vertebras will  sometimes  induce  a paralysis  of
the lower extremities.
   CLXXX.  Although the larger arteries have been known to
lie surrounded with purulent matter, for a considerable length
of time, without suffering any injury, yet this is  not universally
the case : there have occurred many instances, where  erosion
has taken place, and  the person has been suddenly destroyed
by the haemorrhage.   The bones also  to which purulent mat-
 ter has had free access, are not unfrequently found  in a carious
 eta t6
   CLXXXI. The empyema  psoadicum  ought to be  distin-
 guished  from  nephritic complaints ;—from  Bubo—Hernia-
 Aneurism—Fistula in  Ano—Haemorrhoids—Iliac Abscess-
 Abscess in the  thigh  joint, &c.  The discrimination of this dis-
 ease is sometimes difficult; and it  ought also to be observed,
 that it  may be conjoined with any of these complaints. 
52
OF THE EMPYEMA PSOADICUM.
                     SECTION II.

               THE MODE  OF TREATMENT.

  CLXXXII. This disease, in the incipient state, may be con-
sidered as  a  local  and  chronic inflammation;   the  treat-
ment therefore in general is similar to that which is appropria-
ted to a common  inflammation ; but the debilitating plan ought
not to be carried to so great an extent.
  CLXXXIII.  First Indication.
  To obtain an early resolution, if possible, by
  1. Topical blood-letting.
  2. Alkalised purgatives.
  3. Antimonial medicines.
  4. Abstinence from animal food, and  fermented liquors.
  5. Perfect quietness,  and a supine posture with confinement
to a bed.
  6. Blistering plasters  applied near the part  affected.
  7. I have found immediate advantage from the  application
of a large caustic near the  lumbar vertebrae, after premising
due evacuations.
  CLXXXIV.  Indication the Second.
  When suppuration has actually taken place, the diet must be
improved  and  rendered  cordial and nourishing.  The Peruvian
bark, vitriolated zinc, vitriolic acid, or  iron, may be  employ-
ed with advantage.   To these tonic remedies it  will be prop-
er to add  a pure air, gentle exercise,  and, with  certain  re-
strictions,  sea  bathing.
  CLXXXV. There have been  various opinions  concerning
the  best mode of treating the abscess when it points external-
ly.   Some  of the  older  surgeons, as Hildanus,  Wiseman,
&c. and the French surgeons in  general, advise a free open-
ing  to be made, or the introduction of a  seton.
  Several of the modern  surgeons  recommend  a very small
aperture to be made and the ulcer to be dressed quite super-
ficially.
  I have treated many cases in this manner with the  greatest
success.   Mr. Abernethy  recommends  the puncture  to  be
closed,  and healed  immediately  after the evacuation of the
matter.   It  has been thought more advisable, by  other sur- 
OF GANGRENE AND SPHACELUS.
53
geons, to permit the abscess to burst spontaneously ;  and on
comparing  the  result of the  different modes of treatment, in
my own practice, I find that a greater number of patients have
recovered,  where this latter method was pursued.
   CLXXXVI.  Some of the older  writers forbid  the use of
injections  in  the  lumbar abscess ; but their reasons seem to
be  founded upon mistaken ideas of  the  true situation of the
disease.
   Solutions of copper,  zinc, or even  tepid sea water,  may
sometimes  be employed in this way,  with considerable  ad-
vantage.
   CLXXXVII. The instances of those who perfectly  recover
from the empyema  psoadicum are few in number, when com-
pared with  those to  whom it proves fatal; hence it will never
be prudent to give a favourable prognostic  at an early period
of the disease.
   When the abscess bursts in the  loins, the patient  is more
likely to recover, than  when the opening is in the groin.
                  C H A P T E R  VI.

                    SECTION  I.

             OF  GANGRENE  AND  SPHACELUS.

  CLXXXVIII. It has  been usual among many of the later
writers, to enumerate Gangrene  as a third  mode, in  which an
inflammation  frequently terminates ; but although custom  and
authority may be sufficient to justify such an arrangement, yet
there certainly is not a  necessary connexion between the two
diseases*.  Gangrene  does  indeed sometimes supervene to
inflammation; but this order is not absolute and immutable, for
it very often originates from  causes, which imply a state of the
part, or of the system, that is the reverse of inflammation.
  CLXXX1X. As a gangrene most  commonly terminates in
sphacelation,  there is some propriety in treating  both of them
under  one head; yet the difference between  a  gangrenous

  "  Morgagni de Sed. et Caus. Morb. Lib. iii. Epist. xxxv.  Art. 19 
54
OF GANGRENE AND SPHACELUS.
 and mortified part is so very considerable, that the terms ought
 never to be  employed as synonymous ones.   The distinctions
 proposed by some  modern  physicians,  which  are  founded
 merely upon  the  parts that suffer, or upon the  profundity to
 which the disease has penetrated, seem inadequate and useless.
 The antient practitioners, who  attended more carefully to  the
 actual state of the morbid parts, than to the quantity of disease,
 have left us more useful definitions.
   CXC. The human body is  but a temporary  fabric, which
 carries, in its composition and structure, the principles of disso-
 lution and decay.  This is not only true of the entire machine,
 considered as an organized whole, but may be applied to  the
 several constituent parts; so  that whatever possesses a vital
 power and action may be deprived of that quality by a variety
 of causes; and when any part has once lost its living powers,
 all relation between the dead portion and the animated machine
 is irrecoverably destroyed.
   CXCI. Although  a mortification implies  the death of  the
 part affected by it, yet every dead part is not in a sphacelated
 state.   The  terms Gangrene and  Sphacelus can only be ap-
 plied with propriety to certain  modes of  dying, in  which  pe-
 culiar alterations, the effects of some  specific and determinate
 disease, have preceded the destruction of life.
   CXCII.  The phenomena which attend the sphacelation of
 different parts of the body, are  by  no  means similar; they will
 be considerably influenced by the  organization of the part; by
 the previous state of the system ; and by the nature of the  re-
 mote cause.
   CXCIII.   As  a knowledge of the remote causes affords
 considerable assistance, in the forming of a  just diagnosis of
 gangrene,  this will  be  the  most proper  time to  enumerate
 them :  the  history and treatment of the disease will be con-
 sequently delivered with less interruption.
   CXCIV.  Among the remote causes that have a powerful
 influence in producing gangrene, may be assigned,
   1.  The  application of severe stimuli,  to a diseased, or de-
 bilitated part.
  CXCV. There is a certain degree of excitement, which the
 nervous system can support,  without  inducing a state that is
 inconsistent with  the welfare of the body: if the stimulating
powers  act beyond a determinate point, they destroy sensibility,
and  induce torpor or death.   It may also be remarked, that 
              OF  GANGRENE  AND  SPHACELUS.            55

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

              THD SYMPTOMS OF  GANGRENE.

  CXCVIII.  The supervention  of this disease  is sometimes
marked by the appearance of symptoms in the following order : 
56
OF GANGRENE AND SPHACELUS.
   1. An exquisitely painful sensibility of an inflamed part.
  2. An intense sensation of burning in the part.
  3. A purple, bluish, or livid appearance of the skin.
  4. Subsidence of an inflammatory tumour.
  5. Flaccidity of the part affected.
  6. Phlyctenae, with a livid circle round their base.
  7. Where  an ulcer exists, the surface  becomes dry  and
discoloured.
   8. Under some peculiar circumstances, a white  tenacious
substance, resembling the  jelly of the serum, when coagula-
ted, is thrown out in considerable quantity upon the surface of
the diseased part, and adheres firmly to it.
    CXC1X.  The termination  of  gangrene in sphacelation
is indicated by,
   1. An effusion of the red globules of the blood under  the
cuticle, resembling diffused petechia?.
   2. CEdema :  sometimes,  emphysema.
   3. A total cessation of pain in the diseased part.
   4. A sense of great weight in the limb.
   5. The affected part becomes black, and the blood is coagu-
lated in the vessels.
   6. Cadaverous smell, and appearance of putrefaction.
    These  phenomena attend  the progress of  the  humid
gangrene; but  occur  with some  variation  in  the dry  gan-
grene.
   CC. A part  of  the body  that  is affected with  gangrene,
does not immediately lose its sensibility : the fluids continue to
circulate in their vessels;  and within certain limits, the part is
capable of being restored to its  former offices  in the animal
economy.   " A  Gangrene,  therefore, strictly  speaking,  is a
mortification not actually  formed, but approaching, being the
intermediate  state betwixt  the height of  inflammation  and
sphacelus."  (See  Kirkland on  Gangrene and Sphacelus.
Also, Chirurgia Francisci Peccettii, fyc.) Sphacelation implies
the total loss of life in the part,  an  absolute derangement of its
structure,  the  abolition of  all  its  functions,  and  an  utter
incapacity of its being restored  to  any  service  in the  animal
economy.
   CCI. It is obvious, that the regular  progression  of an  in-
flammation  into  gangrene  and sphacelus, can  be distinctly
marked in external diseases  alone.  But  the  approach  of a
mortification in  any part,  is not  necessarily  preceded by the 
              OF GANGRENE AND SPHACELUS.            57

clear and evident characters of  gangrene.  A small portion
of the body may suffer  sudden death, as  well  as  the  whole
system.
   CCII.  A sudden attack of severe pain in a part  that is ap-
parently sound, frequently indicates  the  approach,  or accom-
panies the first invasion  of sphacelus.  Sometimes  there is a
small black spot upon the part affected.  The progress  and
extent  of the disease in such cases, is often marked by an
oedema, or an emphysematous inflation of the  tela cellulosa.
   CCIII. A mortification may  frequently be  regarded  as  an
affection entirely local, which depends upon an  external cause
for its appearance ; in such cases,  the effects do not always ex-
tend beyond the diseased parts.
   CCIV. More commonly, sphacelus  is accompanied with a
general and dangerous affection of the  whole  system.   This
state  is indicated by a  remarkable deviation of the  patient's
countenance from its natural and healthy  appearance ; there is
often a peculiar wildness of aspect, anxiety,  vomiting,  diar-
rhoea, great depression of strength, a frequent, soft,  and some-
times intermitting pulse, and more or less of delirium.   When
a severe inflammation of a tense part has proceeded rapidly to
gangrene  and sphacelus, the brain is affected at an  early  pe-
riod, and the delirium is often furious ; but in a languid system,
where sphacelation has  approached more gradually, the  deliri-
um may be moderate, interrupted, and perhaps does  not  ap-
pear, till near the conclusion of the  disease ;  and  sometimes
the patient dies comatose.
   CCV.  In old people,  a  gangrene and  sphacelus  will fre-
quently succeed to the slightest accidents.  Under these circum-
stances, the  disease will sometimes seem  to be almost station-
ary, and continue during several months without producing ex-
tensive mischief;  on the other hand, so variable and uncertain
will be the progress, that the termination shall follow a few.days
after the attack of the disease.
   CCYT.  Many valuable writers, both  ancient and  modern,
have divided gangrene into different species, and their distinc-
tions have been founded upon the various remote causes that
produce this disease ; and as the progress of mortification will
very much depend, upon the perpetual operation of the remote
cause, some practical  advantages  may possibly  attend such  a
mode of division.   It is  probable,however, that, let the remote
cause be what it may, the form  of the disease is an uniform and
              8 
58
OF GANGRENE AND SPHACELUS.
general one;  and  if  it  be,  the  principles  that  we have
delivered are capable of application  to every form of the  dis-
ease.
  CCVII.   As a sphacelated part  no longer possesses a vital
union with the general system, it may be regarded as an ex-
traneous substance, the removal of which is generally essential
to the comfort and welfare of the living parts.
  CCV1II.   If the mortified mass be so situated as to be ex-
posed to the  effects of warmth  and moisture, putrefaction  will
take place, as in dead animal matter separated from the body.
Sometimes a sphacelated  member  becomes dry and incorrup-
tible, as if it had been defended from putrefaction by artificial
means.—La Gangrene Seche*
  CCJX.  The separation of the dead part  from the  living is
a natural process; it  is explicable upon known  physical princi-
ples, and generally takes  place in the following order :—The
living parts that surround  the mortification first appear to be
lightly inflamed, and  they sink  below the level of the sphacel-
ated edge ;  the process  of  suppuration soon commences, a
small quantity of matter issues from the line of separation, and
as  exfoliation  proceeds,  the matter is evacuated in  greater
quantity and  assumes the  form of good pus : while this process
goes on, the  distance between th% living and the dead part be-
comes more  evident  until they cease to cohere.
   CCX.  The inflammation which immediately precedes the
separation of the dead part, and which is essential to the com-
pletion of that process, seems  principally to depend upon the
presence of the eschar:  this  dead  substance stimulates the
surrounding  living solids as an  extraneous body, and  thus  pro-
duces a determination of  blood  to that part; the contiguous
surface consequently suppurates, and the  matter that is found
between the  receding parts is principally furnished by the living
 vessels.
   CCXI.   The period of exfoliation is considerably influenced
by the situation and  structure of the affected  part, and by the
 general state of the constitution.
   CCXU.   Bones are susceptible of inflammation and  sup-
 puration, as  well  as the  softer parts of the  body; they  may

  *  For an account of the Dry Gangrene, see  the writings of Hildanus
 Tulpius, Quesnay, Memoires de la Societe Royale de Medicine, Tom. 1.
 Opere di Bertrandi, Medical Museum, &c. &c. 
OF  GANGRENE  AND  SPHACELUS.           59
likewise be deprived of their vitality by disease.  When a bone,
or a portion of bone, is in this state, it is said to be carious.
   CCXIII.  As there exists a considerable difference between
the sensibility, structure,  and  functions of bones, and those of
the soft parts, so the phenomena of their several  diseases are
not exactly similar: a general and gross analogy obtains, but
it is not sufficiently precise to warrant an equal application of
all the preceding observations.  It is  highly probable however,
that the desquamation of bone is effected by  a process, analo-
gous to that of the exfoliation  of the softer parts.
   CCXIV.  Various explanations have been  offered of the
means by which the dead animal  solid is separated from the
living parts.  It will be sufficient for the present purpose, to
take notice of the three following, viz.
   1.  That the  efficient  cause is a mechanical  one,  the force
with which the new granulations of flesh germinate, being sup-
posed sufficient  to push off the mortified mass.   Plainer, Ten-
on, fyc.
   2.  That the living solids at the line of union are removed by
the mouths of absorbent vessels.
   3.  That a fermentation  and dissolution of  that part of the
eschar, or carious bone,  takes place, which forms the line of
adhesion.
   CCXV. The assignment of the first enumerated cause must
have been  the  result of very gross observation;  it is at once
inadequate for  the  purpose,  and the action assigned to the
granulations is quite inconceivable.   It may account for the
extrusion of a loose eschar, but we are not at all assisted by it
in conceiving of the mode by which  separation is effected in
the middle of a  solid fibre.
   CCXVI. There  is considerable ingenuity displayed, in re-
ferring the process of exfoliation to the  mordicant powers of
absorbent orifices;  but this opinion is not wholly fre^e from dif-
ficulties.
   a.  If the dead part be separated from the  living by the ab-
sorption of the  line of union; as this line  is always of equal
thickness, and  according  to  the  supposition, is studded with
mouths of absorbents, the time in which different portions of
dead  matter exfoliate, ought not to bear any  proportion to the
depth, extent, nor seat of the disease;  but this is contrary to
daily  experience.
   b.   The dead bone acting as an extraneous substance, must 
60
OF GANGRENE AND SPHACELUS.
stimulate the absorbents that are at the point of contact to ac-
tion ; but if these vessels absorb the  line of union, it will fre-
quently be  necessary for them to elongate themselves.
  c.   As there  cannot be  any  given portion  of a bone that
may not become carious and exfoliate, so there cannot be any
point assigned, that* may not be absorbed; and if  any given
point may be absorbed, then every given point may be absor-
bed :  but  if the  smallest  assignable  line  cannot be  drawn
through any part of a bone,  which may not be absorbed, then it
will follow, that no point  can be given, however small, at which
it may not  be affirmed that the orifices  of absorbent vessels
exist:  but  if these  orifices exist in every possible point, where
are their trunks ?   where are the other constituent parts of the
bone ?
  CCXVII.  It is probable, that in the separation of the dead
portion of the animal fibre from the living, the process that ter-
minates in  a solution of continuity first begins in the eschar, or
in the  carious portion of bone ;  for
   1.  Warmth  and moisture expedite the  process of exfolia-
tion ;  and  at the line of union, these circumstances are gene-
rally present.
  2.  A  fetid  sanies, or  sordes, is generally  to be  found
about  the line of separation.
  3.  When bones of a  spongy texture  become carious, there
is not  always  a regular  desquamation,  but the  dead  part  is
evacuated  in  fragments  along with . the discharge,  as  if the
bone had suffered comminution.
  4.  The presence of putrefaction is  very evident,' and the
effects of  that process in  destroying the cohesion of animal
fibres, is too  generally known, to require insisting upon ; and
although the most inferior stratum of the  mortified substance be
not exposed to the action  of atmospheric air, so as  to permit
the putrefactive fermentation to go on regularly;  yet we know,
that decomposition and dissolution of animal substance can take
place,  where the access of air is excluded.
  5.   The suppuration  of the living surface, immediately in
contact with the dead  part, has a very  considerable share  in
the process of exfoliation.
   CCXVIII.   Mortification should  be  distinguished  from
ecchymosis, and large extravasations of  bloody fluids into the
cellular  membrane.  But  the  diagnosis  and  prognosis  will
be more conveniently  delivered, when we  treat on particular
diseases. 
OF GANGRENE AND SPHACELUS.
61
                    SECTION  HI.

              THE TREATMENT OF  GANGRENE.

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

                 THE LOCAL TREATMENT.

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

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

             THE  TREATMENT  OF SPHACELUS.

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

         THE LOCAL TREATMENT  OF SPHACELUS.

  CCXXIII.  Where a mortification arises from compression,
or any other external remote cause, and  the  general health
seems  to  be wholly unaffected, the  removal  of the  remote
cause will be generally succeeded by  a termination of the dis-
ease.   In such cases, the mortified  part requires no more at-
tention than what is usually paid to an eschar made by a caus-
tic..  But  a  sphacelus  is  not  necessarily  local, [because  it
originated from  an external  cause; the judgment  must here
be determined.by the consideration of several  other  circum-
stances.
  CCXXIV.  As the sphacelated  part is dead, no benefit  can 
OF GANGRENE AND SPHACELUS.
63
be derived to it from any external applications whatever; the
living parts that surround it are the only proper objects of at-
tention.
   CCXXV. The external remedies that have been principally
recommended, are
   a.  Scarifications of the part.
   b.  Applications actually or potentially warm.
   c.  Antiseptic cataplasms, &c.
   CCXXVl. The chief advantages to be derived  from scari-
fying a mortified  part,  seem to be, an  evacuation of putrid sa-
nies,  or confined  air, and the affording an opportunity of apply-
ing proper dressings to the  living parts that  are beneath the
eschar.  When  there is a large  mass of ragged  and putrid
slough, it will be  proper to remove  it, without wounding the
living parts.
   CCXXVII. The surrounding parts may be invigorated, by
the application of alcohol, oil of turpentine, poultices made with
oatmeal and  stale beer, to which may be added,   cataplasms
containing  Theriaca Londinensis,  &fc.  Lixivial  applications
are wholly improper, unless we mean  to do.no more than wash
away the offensive matter from the diseased part.    The actual
cautery is very seldom  used;  and it may be  doubted how far
the vapour of hot water can be applied to a sphacelated part
with  perfect  propriety.  Great  attention  should be also paid
to maintain a due degree of  warmth in a limb affected with
sphacelus.
   CCXXVI1I.  Antiseptic  applications, as the powder of Pe-
 ruvian bark  made into a  cataplasm :—charcoal  mixed with
 farina lini, or oatmeal—mineral* or vegetable acids diluted :
 —mephitic   gas.:—carrot   poultice:—the  fermenting  cata-
 plasm, he. may be used with advantage, as  they  correct  the
 fetor,  and do  no injury to the living parts.   I have seen  the
 most pleasing effects to follow the use of the  fermenting poul-
 tice, and also the application of the fresh leaves of cicuta, to
 gangrenous ulcers.
    CCXXIX. It is sometimes necessary to remove the morti-
 fied  part by a chirurgical operation ; but  excision  ought  not
 to be attempted until  the separation of  the living part from the
 dead be in some forwardness.   This rule may be  admitted as
 being generally  true, yet it is  not absolutely without exception.
 But this subject will be prosecuted with more propriety under
 the  head of Amputation. 
64          OF THE ANTHRAX,  OR CARBUNCLE.
  CCXXX.  A  sphacelated  limb  is sometimes separat
from the body by a natural process, and the cure will be com-
pleted without any assistance from art.   This takes place most
frequently in the dry gangrene.
                 CHAPTER  VII.

                     SECTION I.

              OF THE ANTHRAX, OR CARBUNCLE.

   CCXXXI. The Anthrax  is  a deeply-seated, hard,  im-
 moveable, distinctly circumscribed  tumour,  attended  with an
 intensely painful sense of. burning in the part, and considerable
 discolouration of the skin.
   CCXXXII. This disease is  rarely  idiopathic;  it is as-
 signed by writers, as a very common  appearance in  pestilen-
 tial  diseases :—and when there is no  reason to  suspect the
 plague as a cause, that state of the system is commonly pres-
 ent which  is characteristic of putrid fever.
   CCXXXIII. The Carbuncle is often sudden in its appear-
 ance, the tumour is very little elevated above the surface of the
 skin ; about the centre, it is of a dusky  red colour, but is much
 paler, and  often variegated towards the  circumference.   Small
 prurient vesications or  pustules appear  upon its surface, which,
 when they are ruptured, evacuate a dark coloured sanies, and
 discover a sphacelated base.   The commencement of the dis-
 ease is sometimes accompanied with symptoms resembling gen-
 eral  inflammation ; but most commonly, it  is attended  with
 rigors, sickness, great restlessness, and depression  of strength,
 fainting,  delirium, &c.    A  miliary eruption  or even  pete-
 chia?, are sometimes found dispersed in different  parts of the
 body.
   CCXXXIV.  It hath been  usual  to divide the  anthrax
into  two species,  the  benign, and  the  malignant:   this  dis-
tinction, however, seems to  be merely applicable  to  the  vio-
lence  and extent of the disease, and implies no real  diversity
in the species. 
            OF THE ANTHRAX,  OR CARBUNCLE.          65

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

               THE TREATMENT OF ANTHRAX.

  CCXL. From the preceding  history  of carbuncle,  it is
evidently a disease so very analogous to gangrene and sphace-
Ius,that  the treatment  which was appropriated to these mor-
bid affections,  is perfectly applicable  in the present  instance.
The extirpation of the tumour, or the  application of  cauteries
and caustic, are  modes of practice justly exploded.*  It  has
been said, that  opening the superficial abscess, in the  centre of
the anthrax, early, has checked the progress of the disease.
  CCXLI. It ought to be constantly remembered, that no ex-
ternal applications are to be depended upon alone.  The vigor-

  * M. Pouteau, who was extremely fond  of the actual cautery, recom-
mends the application of it in the  anthrax.— Oeuvres Posthumes.
             '9 
66
OF THE PERNIO,  OR CHILBLAIN.
ous and decided  use  of those  remedies which operate upon
the general system, is of the  greatest importance.
   CCXLII.  Where considerable sinusses remain after the ex-
foliation of the sphacelated part, injections  made  with solu-
tions of vitriol, copper, lunar caustic,  &c.  will be sometimes
serviceable,  in promoting the separation of  the  dead portions
of cellular membrane, &c.
                 CHAPTER  VIII.

                     SECTION I.

              OF THE PERNIO, OR  CHILBLAIN.

   CCXL1II.  The Pernio is a painful  tumefaction, and some-
times ulceration of an extreme  part,  in consequence of expo-
sure to a great degree of cold.
   CCXLIV.  This is  a disease to  which the inhabitants of
temperate climates are more  peculiarly  liable;  its  produc-
tion seems to depend  rather  upon the  successive  alternations
of warmth and coldness, than to be the effect of the long-con-
tinued action of severe cold.   In  the frigid zone, congelation,
and the total  death of the part, is almost always the conse-
quence of incautious exposure to  the atmosphere  in the more
inclement seasons.
   CCXLV. Although the Chilblain is a  very common com-
plaint, and is not generally the  object of chirurgical treatment,
yet it ought  not to be overlooked as a disease of no importance,
for it sometimes proves destructive to the part that is affected:
it is always slow in its progress towards amendment; and those
that have once been sufferers,  are subject to have a return of
the disease in  every succeeding winter.
   CCXLVI.  In our  attempts to  investigate  the effects of the
application of cold upon the  human body, in the production of
this, or any  other morbid alteration, we cannot reason from its
known action upon inanimate substances; since the phenomena
are not similar, except in some  very gross instances.   No par-
ticular alterations are produced  in dead matter by exposure to
a cold atmosphere, &tc. until it  be frozen; but the congelation 
OF THE  PERNIO, OR CHILBLAIN.
67
of a living part is usually attended  with the loss of its vitality,
and it then ceases to fall under our consideration as a proper
subject of disease.
   CCXLVIl.  The effects of  cold  upon the living  body are
more sensible  and intense,  in proportion as the transition is
more sudden,  from a very high to a very low degree of tem-
perature.   But even in the  coldest seasons of northern cli-
mates, a sudden increase of its severity, especially if there be
much wind, will occasion  internal or external  mortifications,
and not  unfrequently sudden death.—See Boyle's History of
 Cold, &,c.
   CCXLVIII. The natural standard of  heat generally found
in the living  body  is about 98° of Fahrenheit's thermometer,
and this degree can be supported when the surrounding atmos-
phere is in very different  states of temperature,  by the original
 and inherent powers of the system.  The application of a cold
 atmosphere, &c. to the  living body,  has not an unrestrained
 power of reducing it to  its own  state of temperature;  for as
 long as the vital powers  are vigorous and active, it can sub-
 tract little more  than  the excess of heat that may  be present
 above the natural standard.   But where the cold is  excessive,
 and its application is Jong-continued, a morbid alteration will be
 induced in the sensibility and motion of the part,  and conse-
 quently there  must be an unnatural  reduction of the state  of
 animal heat.
    CCXLIX. Those parts of the body  that are naturally pos-
 sessed of little or no  sensibility, and  where there is a languid
 circulation of the blood, or perhaps none at all, may be frozen,
 and undergo the same changes that take place in lifeless mat-
 ter, while the  system  in general shall suffer little or no injury :
 exempli gratia, the cuticle, hair, and extremities of the nails.
    CCL. The proper  and  direct effects of cold upon solid in-
  animate bodies, are dryness and contraction ;  but it is said, that
  fluids suffer expansion at the instant of  congelation.  When it
  is considered, that the experiments which seem to prove this,
  were made with nearly incompressible fluids inclosed in a hol-
  low vessel, and that the sides of the vessel would contract with
  <rreat force upon an  elastic substance :  when  it is  also taken
  into  consideration,  that high degrees of cold separate the  air
  naturally combined with  water, and thus augment its bulk, and
  diminish specific gravity : when the different degrees of specific
  gravity, of different masses of ice, and of the same portion at 
68
OF THE  PERNIO, OR  CHILBLAIN.
different  periods, the phenomena attending  the absorption of
vitriolic acid air by water,*  the effects of the  air-pump, &c.
are added to the account, and also the change that takes place
in the figure of liquids by the act of  congelation, perhaps our
general position, that  cold by its  proper effects, contracts  all
bodies,  may be capable of  application to fluids, as well as to
solids.
   CCLI. The proper and  direct effects of cold upon living
bodies, are, a diminution of  insensible perspiration, a dryness,
corrugation, or fissured state, of the cuticle, and sometimes of
the skin : the sensibility is more  or  less impaired ; there is a
languid circulation  of the blood, especially in the smaller ves-
sels ;  these are succeeded by a considerable diminution of heat
upon the  surface of the body; respiration is often  painful,  or
laborious ;  and there is  a general diminution of the tonic action
of the moving fibres, accompanied with actual debility.
   CCLII. As the  human body is an organized whole, where
the combined parts exert a perpetual and reciprocal influence
upon each other, a powerful application is never followed by a
solitary effect.  Animal heat depends greatly upon the state of
the brain, and the sensibility of the  nerves, and vice  versa;
both these  conditions  are  intimately connected  with  the due
transmission of blood ; and the tonic state of the moving fibres
depends  upon the  joint operation of all these, and  perhaps of
other causes.—See Observations on Animal Heat,  in  the
London  Medical Journal, vol. 7. p. 169.
   CCLIH. When the sensibility, tone, he. (No. 251), of any
portion of the body is  greatly impaired, if it  were to be  still
longer exposed to the action of intense cold, a  livor,  rigidity,
brittleness, and death of the part,  would be  the consequence.
   CCLIV. The firmness which is produced in a body by con-
gelation, ought to be distinguished from that state of contraction
in living muscular fibres, that is called Tone  : nor ought it
to be assumed as  certain,  that cold, while it contracts bodies,
also augments the attraction of cohesion between the particles
of matter.   But whatever may be its  effects  upon  dead sub-
stances,  it was long ago observed by Lord Bacon, that  " Cold
has a relaxing effect upon the living body."
   CCLV.  In robust  and athletic  constitutions,  where  intense
and long-continued refrigeration can  be sustained  without  in-
jury, from the influence of habit, or the effect of exercise, a
* Nicholson's Chemical Dictionary. 
             OF THE PERNIO,  OR CHILBLAIN.           69

cold atmosphere may be said  to  increase the general strength
of the system.   Upon the same principle, transient changes of
temperature, (as cold-bathing, &c.)  repeated within certain
limits, will have  a tendency to invigorate  the feeble and debili-
tated ;  but these  secondary effects of cold, which are the con-
sequence of re-action, no more prove  it to be tonic in its
own nature, than the debility that succeeds inebriation demon-
strates the primary properties of alcohol  to be relaxing.
   CCLVI. That degree of heat which is most grateful to  the
healthy state of sensation, is about the medium point, between
the heat of human blood and the freezing point.  But when  a
part is considerably refrigerated, if a degree of heat not greater
than would be pleasant to a healthy body be suddenly applied,
the effect will be as fatal  as absolute congelation.   It must be
very obvious, however, that the  manner in which death is oc-
casioned by these two opposite causes, is very diverse : in the
latter instance, vitality is destroyed, by arresting all motion ; in
the former, by  the violent incitation  of the moving fibres of  a
part to a velocity and force of action, which their debility ren-
ders them unable to perform.
   CCLVII. The general principle,  by which many of the ef-
fects of actual cold  are produced by  substances that  are poten-
tially cold, may perhaps receive some elucidation from an  ap-
plication of the preceding observations.
   CCLVIII. The  first symptoms of the  pernio, are a pale-
ness of the refrigerated part,  which  is quickly  succeeded by
more or less of redness, and a troublesome  pruritus, or some-
times pain'; the skin gradually acquires  a purple hue : the cu-
ticle separates, and this separation is often preceded  by a se-
rous effusion between that and the cutis; beneath the cuticle,
there appears a  painful  ill-conditioned  ulcer, irregular in its
figure, and difficult of cure.
   CCLIX.  The foregoing account may  be considered  as  a
very general  description of the chilblain;  but  as  there  is
some variety in  the  appearance and progress of the disease, it
may be  proper to divide it into two species:
   The simple, and the ulcerated pernio.
   CCLX.  The simple  pernio  is  characterized by redness
of the part, accompanied with a pruritus and sense of tingling,
especially on being suddenly  exposed  to  heat; more or  less
of cedema possesses the surrounding parts,  and sometimes all
the fingers and back part of the hand will have an  anasarcous 
70
OF THE PERNIO,  OR  CHILBLAIN.
appearance; very frequently there is also a livid colour, which
extends to a considerable distance.   This  species may  re-
main  in its  simple  state during the whole  winter, and gradu-
ally disappear as the summer  advances.
   CCLXI.   The  ulcerated  pernio  is  frequently  preceded
by the simple species, to which, there supervenes a vesication,
or simple  separation of the cuticle ; below  this, there appears
a painful,  foul,  irregular ulcer, which by neglect will increase
to a considerable magnitude ;  sometimes the ulceration pene-
trates as low  as the tendons, or  even exposes  the  su rfaceof
the bone.   In a severe winter, there are generally  several in-
stances of a total sphacelation of  one  or both the  extremities,
from the application of cold.   A  sudden and imprudent appli-
cation  of heat to a  benumbed limb,  may prove  equally  de-
structive of the life  of the part.
   CCLXII.  A long-continued and partial exposure to a cold,
not much  below the freezing  point,  will sometimes produce
the dry gangrene;  especially  if there be a previous state of
debility in the system.
   CCLXIII.   It is worthy  of  observation,  that the  simple
chilblains  do not so often appear  during  the  continuance of
frost, as during the thaw that succeeds it; and it is a well-known
fact, that frequent alternations  of heat  and cold, within short in-
tervals, have  a very  pernicious effect upon parts  that are al-
ready debilitated.
   CCLXIV.   The ulcers that appear  in  consequence of the
application of cold,  very much resemble those that are seen on
the lower extremities of  cachectic patients,  and of those in
general, where the  circulation  of the blood in the extreme ves-
sels is  remarkably languid.
                     SECTION  II.

              THE TREATMENT OF CHILBLAINS.

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

                     SECTION  I.

           AMBUSTIONES.--OF BURNS AND SCALDS.

  CCLXIX.  A burn, is a solution of continuity from the,appli-
cation of fire.
  CCLXX.  In our attempts to investigate the  operation of
various active  powers upon the human  body, we are not to form 
72
OF BURNS  AND  SCALDS.
an estimate of their proper and  absolute  effects, by means of
analogical reasonings founded upon the changes they produce
on inanimated matter ; their action upon the living fibres, with-
in certain limits, is relative, and  is connected with the present
and immediately preceding state of the system;  for every ap-
plication  that does not immediately destroy the vitality of the
part to which it is applied, scarcely extends its primary action
beyond  the  organs of  sensation.    These  observations are
eminently true when applied to the operation of heat and cold,
communicated within a certain degree to the living system.
  CCLXXI.  It is a well known fact, that a living healthy ani-
mal is endowed with an inherent power of generating and sup-
porting a certain degree  of heat, in a great measure  indepen-
dently  of the state of temperature of surrounding bodies.   And
when the body is placed within the sphere of action of masses
of matter, considerably heated beyond its ordinary  standard,
there will be an accession of heat exceeding  the natural quan-
tity ; but in proportion to the adventitious heat that is commu-
nicated, the inherent powers of the system will be less vigorous-
ly exercised in  the generation  of  animal heat: hence there
ought to  be a  distinction constantly made, between innate, and
supervenient heat.
  CCLXXII. When heat is  considered  with  relation  to the
senses  of an animal, it may be  regarded  as  a very  powerful
stimulant inciting the moving powers of the living fibres to ac-
tion ;  but when it is viewed with reference to its absolute ef-
fects on matter in  general, it  will  appear to be a very active
and potent chemical agent, capable of destroying the  contex-
ture, and separating the component parts of bodies.  The effect
therefore resulting from the  application of heated substances to
the human body, will be different  according  as their  action
chiefly terminates on the organs of sensation, or as they destroy
the vitality and  subvert the organization of the machine.
  CCLXXIII.  The  effects produced by high degrees of actu-
al heat, and by caustic substances applied to  the living body,
are very analogous ;  and the  sensations excited by actual and
potential heat are so extremely  similar, that  it perhaps  merits
inquiry how far their effects depend upon a principle common to
both.
  CCLXXIV.  If a substance possessed of above 120° of heat
be applied to  the living  body, it will accelerate the motion of
the blood-vessels of that part,  increase the contractility of their 
OF  BURNS  AND  SCALDS.
73
parietes, produce  redness, and augment  sensibility.   Increase
this degree of heat to 213°, and there will follow a serous effu-
sion under the cuticle ;  and  a still greater  accession  of heat
will coagulate the fluids and  solids, deprive the part of its vitali-
ty,  and be attended with other  consequences  of combustion,
more  or less extensive, according to the  intensity  of  the heat,
and the duration of its application.
  CCLXXV.   As the quantity of heat  which  different sub-
stances are capable of receiving, and the  readiness with which
they transmit it, is very various; so the effects that result from
the application  of  heated vapours and ardent metals  are  very
dissimilar.   If an intensely heated  metallic  substance,  he. be
suddenly applied, the burning effects will  be more extensively
injurious, but the painful sensation  not so severe as that which
immediately  follows  the application of  boiling  water.  And
when heat is communicated  in a gradual  manner, very  consid-
erable medical effects may  be  produced ; for  the pain occa-
sioned by a light substance  in the state of actual combustion, is
by no means insupportable.
  CCLXXVI.  Heat produces more or  less of an  expansive
motion in  all  dead  matter;  whereas,   such  a  degree as is
consistent with life and health, occasions  a  contraction  and
increase of tone in  the living fibre.  But we  are not to con-
found the expansion and condensation of  inanimate substances
with the contraction and relaxation of the vessels,  &c. of a liv-
ing animal :  the former effects are in proportion to the degree
of heat that is applied ; the latter are not in the ratio of its  ac-
tual temperature ;  for the  thermometer  may  demonstrate  the
animal heat to  be uniform in winter, and in summer,  while  the
state  of tonic contraction shall be widely dissimilar.*
   CCLXXVII.  If a living animal be confined in a degree of
heat a little below  that which would produce coagulation,  al-
though the primary effect would be  a contraction of the living
fibre, yet, by supporting a violent and unnatural degree of  ac-
tion in the moving  parts, the powers of the system  would  be
gradually exhausted.  And it is no more extraordinary,  that

  * A greater attention seems to have been paid to the temperature of the
atmosphere in different climates, than  to the  density of the air;  but
this last circumstance ought not to be  overlooked, for daily  experience
demonstrates the great and important changes  that are produced in the
tonic  state of the system, by variations  in the  degree of atmospheric
pressure.
10 
74
OF BURNS  AND SCALDS.
 the application of different degrees of heat should be  attended
 with  varying effects, than that the exhibition of different  doses
 of the same medicine should be followed by very unequable op-
 erations.
   CCLXXVIII. In judging of the morbid effects  and probable
 consequences of fire when applied to the living body, it is ne-
 cessary to inquire into the degree of heat that was brought into
 contact; the duration  of its application ; the situation of the
 injured part, and the  extent of the  injury : exempli gratia, a
 burn  upon  the head is more dangerous than upon an extremity;
 and even the application of a strong caustic  to the  scalp de-
 mands circumspection.—A considerable portion of the integu-
 ments may be destroyed, so as to produce an ulcer  that will
 be cicatrized with difficulty.—The situation of the injury  may
 be such, as to be followed by inconvenient  adhesions, contrac-
 tions, or great deformity.—The subject of the accident, may
 possess a habit of body in which gangrene and sphacelus read-
 ily supervene.—The age of the patient is also a  circumstance
 of moment, as extensive burns in old people, and in children,
 are extremely dangerous.
   CCLXXIX.  Burns may be divided into
     The Superficial,
     The Ulcerated,
       and  the
     Carbunculous.
   In  the superficial burn, the connexion between the epidermis
 and cutis is  generally  destroyed, but there is no serous effu-
 sion,  nor does the injured cuticle separate until  a new one  is
 nearly formed  beneath it.  This is  attended  with  moderate
 pain,  and no danger, except the injury be very extensive.
   The ulcerated burn  is accompanied with effusion  under the
 cuticle, and very commonly the cutis is  considerably injured,
 so that a deep and foul ulcer is formed.   The heat of boiling
 water may  produce these effects.
   In  the carbunculous burn, the whole organization of the in-
jured part is destroyed, and a perfect eschar or dead crust is
 formed,  the  profundity and diameter of which  will depend
 upon  the degree of heat that was applied, and the duration of
 its application.   Ignited  or melted metals, burning coals, boil-
 ing oil, &c. will produce these  effects.
   CCLXXX.  The danger to  be apprehended from a burn, or
 scald, cannot always be estimated from its profundity, or mag- 
OF BURNS AND SCALDS.
75
nitude; for as superficial burns are now and then extremely
painful, so a very slight injury from fire upon a lower extremi-
ty, sometimes terminates in gangrene  and death.
  CCLXLXXI.  When the body is extensively injured by the
explosion of gun-powder, or inflammable gas, when  the burn
has been  inflicted by a fiery meteor, or the application of  hot
vapour, the accident is often immediately succeeded by rigors,
and a  temporary depression of strength : but the  subsequent
symptoms are commonly such as  indicate the presence of in-
flammation.
  CCLXXXII.   Heated vapour, or boiling water, more fre-
quently produce ulceration when they pass to the body through
the clothes, than when they  are  immediately applied  to  the
naked surface.
                     SECTION  II.

         THE TREATMENT  OF BURNS AND SCALDS.

   CCLXXXIII.   The first indication :
   To obviate the effects of inflammation, by employing the re-
medies recommended in the first chapter.
   CCLXXX1V.   Indication  the second :
   In the superficial burn, to prevent if possible a hasty separa-
tion of the cuticle, by the application of rectified spirits of wine,
vinegar, the heat of a moderate fire, cold water, ice, prepara-
tions of lead, &c.
   CCLXXXV.   In tbe  ulcerated burn, to  apply oil,  sapo-
naceous lotions—preparations of lead—ice cataplasms of white
bread and  milk with oil—linseed poultice, he.  The applica-
tion  of warm oil of turpentine and  warm  digestives,  during
some of the first days after the injury has been inflicted, have
been strongly recommended by Dr. Kentish.*
   To dress the ulcer, after  the inflammation  is subdued, with
mild digestives.  When it heals with difficulty, the Ungt. Basil.
Nigr. may often  be used with advantage.

  * Mr. Birch, surgeon of St. Thomas's hospital, informed me, that he
uses with great advantage, a strong solution of soap in water, agitated in-
to a foam, or lather. 
76
OF THE ERYSIPELAS.
   CCLXXXVI.  Indication the third :  .
   The effects of pain are to be obviated by the use of opium;
and  if a considerable portion of the integuments be removed,
to support the  strength, by Peruvian  bark, wine, he. and the
tonic remedies formerly recommended.
   CCLXXXVII.   The treatment of the carbunculous  burn
must be  conducted according to  the  directions given in the
chapters  on Gangrene and Anthrax.
   CCLXXXVIII.   Indication the fourth :
   To prevent, as much as possible, contractions, unnatural ad-
hesions, and  great deformity, by mechanical means properly
adapted to the situation of the part affected.
                  CHAPTER  X.

                     SECTION I.

                  OF  THE  ERYSIPELAS.

  CCLXXXIX.  Medical and chirurgical writers have gene-
rally classed Erysipelas under the head of inflammation, and the
principal difference between this affection and pure inflammation,
has been supposed to consist,  chiefly, in the seat of the disease.
The erysipelas is commonly seated on the  skin, which is an  ir-
ritable surface :  a phlegmon  is situated  more  deeply, in  the
substance  of the part; and this difference of situation  hath
been esteemed fully sufficient to account for the very dissimilar
phenomena that  are exhibited by the two diseases.
  CCXC.  A long and careful attention to this disease, hath,
however,  induced  me to suspect  that  the relation between
erysipelas and inflammation is  extremely remote.  It appears to
me  proper and justifiable  to  consider  erysipelas  as a genus
the  specific characters of  which are as widely differing from
inflammation, as those of inflammation are dissimilar from  the
phenomena proper to fever.   This opinion will receive further
illustration, if we advert to the  mode of treatment that is an
propriated to each; the very different manner in which  the
two  diseases terminate ; the  analogy between erysipelas and
those exanthematous diseases which have a  determinate period • 
OF THE ERYSIPELAS.
77
and also to this remarkable fact, that the two diseases are not
reciprocally convertible  into each other.  To propose trivial
or verbal innovations into  science, through an  affectation of
novelty, or to attract the public attention, is unworthy the in-
terpreter of nature ; but it is hoped  that the present instance
will not incur such a censure  from the  candid and intelligent
practitioner.
   CCXCI.   As there is a considerable similarity  in the phe-
nomena which constitute erysipelas, wherever it is seated^ the
general history of the disease will be less interrupted if a de-
scription be first given of its appearance and progress in some
one particular part; and we shall, afterwards, deliver such ob-
servations as  will be applicable to  the  various  circumstances
that may accompany the disease.   We propose  therefore, first
of all, to speak of erysipelas in the  face, when connected with
general affection of the system.
   CCXCII.   This complaint is very frequently sudden in its
attack, but sometimes it  is  preceded by shiverings, nausea, and
symptoms that resemble the approach of an intermittent.  The
forehead, cheeks, nose, or eye-lids are tumefied ; the eleva-
tion is smooth  and equal,  but not distinctly  circumscribed.
The skin is of a bright  scarlet colour,  or it is tinged with yel-
low, or it approaches to a dusky redness :  on pressing the part,
this discolouration  disappears, but it returns  again  a^ soon as
the finger is removed.  The  redness  comonly  terminates ab-
ruptly, and does not gradually lose itself in the colour of the sur-
rounding parts, as in the phlegmon.  These symptoms are ac-
 companied  with  an ardent heat, and an uneasy  sense of ting-
 ling in the part, rather than with acute pain ; sometimes the pa-
 tient  complains  of  a distressing  pruritus.   The  tumefaction
 generally presents  a shining, and perhaps a semi-pellucid ap-
 pearance, but is without  tension,  hardness, or  a  sensation of
 throbbing.   The eye-lids  are often so  considerably tumefied
 as to obstruct vision, and  the whole face is  extremely disfigur-
 ed.   Small  pustules, containing a  transparent fluid, and  very
 much resembling  those that  are produced by  boiling water,
 occupy more or less of the surface affected  with this disease ;
 and if they burst, the effused  fluid will excoriate the neighbour-
 ing parts.  There  is frequently some degree of exulceration at
 the base of these vesications, which  sometimes proceeds rap-
 idly into gangrene, or sphacelus.   When the disease terminates 
78
OF THE ERYSIPELAS.
favourably, the pustules dry, and a furfuraceous desquamation
takes place in a period from about eight to twelve days.
   CCXClII. The seat  of the erysipelas  is said  to be in the
rete mucosum; and without doubt this  membrane is  consid-
erably affected ; but it is not confined to this part,  for the tela
cellulosa is  always, and to a considerable  degree, the subject
of the disease; the situation of the complaint, therefore, is not
that which discriminates erysipelas from phlegmon.   And on
the other hand, it is equally certain, that internal irritable  sur-
faces, (as they are called) are as  frequently attacked  with in-
flammation as erysipelas.
   CCXC1V. But although the  cellular membrane is more or
less  interested in this complaint,  the progress of the disease and
its mode of termination, are widely different from the progress
and  general  termination  of a   phlegmon.  A circumscribed
cavity containing  laudable pus is never seen in legitimate  ery-
sipelas ; and  where a purulent effusion happens in  any consid-
erable degree, when the part is examined, it affords a sensation
similar to that which is excited  by a quagmire or  morass.  In
that  sort of suppuration which sometimes supervenes to erysip-
elas, the cellular  membrane suffers  great  injury,  and not un-
commonly the part is in a gangrenous condition.
   CCXCV.  It is not an easy task,  distinctly to ascertain  the
remote  causes that give rise to this disease.   From among
many others  we have selected the  following:
   1. Violent passions of the mind, as anger, &c.
  2.  Undue  exposure to the rays of the sun, or to the action
of fire.
   3.  A blast of cold moist air.
  4. The application of poisons, vegetable, mineral or animal.
   5. Wounds, punctures, he. of the periosteum, pericranium,
and of a tendinous expansion, or a nerve in phlebotomy.
   6.  Fractured bones.
  7. Abscesses  formed  under an aponeurotic expansion, or
any other very tense membrane.
  It often appears, when we are  unable  determinately to as-
sign  any particular cause.
  The erysipelas is sometimes a congenital disease.
  The  efficacious action of the causes enumerated above in
the production of  this specific form of disease, will be greatly
influenced by the  previous state of the system.
  CCXCVI. The erysipelas ought to be carefully distinguish- 
OF THE  ERYSIPELAS.                 79
ed from phlegmon ; and the following criteria will assist towards
forming a just diagnosis.
   1.  In the erysipelas, the tumefaction is less prominent, and
is never evidently circumscribed.
  2.  The skin often looks as if it were scorched or burnt.
  3.  The redness is distinctly circumscribed, and often inclines
to a yellowish colour;  it also vanishes on pressure.
  4.  It is not commonly  attended with the lancinating  pains,
and sense of throbbing, that attend the formation of a phlegmon.
  5.  The part affected is almost wholly free from tension, and
gives  the sensation of an  oedematous, or of an emphysematous
state,  except that there  is no crepitation.
  6.  That hardness  of the pulse,  which  is a distinguishing
character  of inflammation, is not present in erysipelas.
  7.  The general state of the system verges rather to debility,
or depression of strength,  than to increased strength and vigour.
  8.  The  erysipelas is  susceptible of metastasis.
  Some  of these  criteria will  occasionally require  qualifica-
tion ;  but never to  such a degree, as to invalidate  the general
conclusion.
  CCXCVII.  From the  foregoing narration of the phenomena
of erysipelas, it seems  warrantable to form the  following pro-
position :
  In a part that is affected with an erysipelas, there is a mor-
bid sensibility of the nerves with  a preternatural irritability of
the diseased  parts; arterial contraction is performed  with  an
increased velocity, but with diminished vigour; and the parietes
of the blood-vessels give less resistance than natural to the vis
a tergo.
  CCXCVIH.  The  erysipelas is not a disease that is simple
and uniform in its appearance,  nor does it always admit of a
similar mode of treatment:  it will be therefore proper to divide
it into different  species, and to  appropriate to each its method
of cure.  The following division is adopted as a convenient one :
   1.  The Acute Erysipelas.
  2.  The QCdematous Erysipelas.
  3.  The Malignant, or Grangrenous Erysipelas.
  Each of those species may  be an
  Idiopathic, or symptomatic  disease.
  The erysipelas indeed  is susceptible of metastasis, but this
property does not seem to be sufficiently limited, so as to jus- 
80
OF THE ERYSIPELAS.
tify the admission of it as a foundation for establishing a fourth
species.
  CCXCIX. The acute erysipelas is most commonly seen in
those of a sanguine and choleric temperament; it  is gener-
ally sudden in its attack, and usually affects the  face.   Symp-
toms resembling  those of general inflammation  are often pre-
sent immediately after the accession of the  disease;  but  they
gradually diminish, as the erysipelas  becomes more  distinctly
formed :  there is a considerable heat, and  great  uneasiness in
the part affected ; the skin is of a brighter scarlet colour than
in the other species; if pustules appear, they are distinct, but
sometimes there are no vesications on the surface.
  CCC. There is very seldom any matter formed in this spe-
cies of erysipelas, and  the violence of the  disease commonly
subsides in three or four days.   The part then grows yellowish,
and throws off furfuraceous  scales, and the  disease terminates
about the tenth  day.  A tenderness of the  hairy scalp  will
often continue for a considerable time after the disease has dis-
appeared.
  CCCI. In order to understand the reason of some of the phe-
nomena enumerated at No.  299, it will be  proper to consider
erysipelas in a twofold view; as a morbid affection of the sys-
tem, and as a stimulus, capable of acting as the remote cause
of another disease.   When jt is situated in the face, an inflam-
mation of the brain may be  produced by its  determining  a
preternatural flow of blood to the head ; but such an accident
no more proves the  erysipelas  to be properly inflammatory in
its own nature, than it proves that every effect is the  copy and
resemblance of its cause.   When contagious matters are ad-
mitted into the system,  a temporary train of symptoms  resem-
bling general inflammation, commonly appear ;  but it is never-
theless thought proper to distinguish exanthematous diseases,
from simple inflammation.
  CCCII. The acute  erysipelas  may be an  idiopathic affec-
tion, and the same person will often have one or more regular
attacks at certain  periods  of  the year,  but more especially
about the time of the equinoxes.  This disease  is also a  com-
mon symptomatic attendant on wounds of the membranes that
cover the bones, &c.
  CCCIII.  The cedematous erysipelas is not,  in general, so
sudden in its attack, nor so severe on its accession  ; the disease
increases gradually, is more diffused, and attended with less of 
OF THE ERYSIPELAS.
81
 ardent pain : if symptoms resembling general inflammation ap-»
 pear, they never run high, nor are they of long duration ; most
 commonly there is a depression of strength, and  a  soft,  fre-
 quent, or perhaps irregular pulse.  But in  this species of the
 erysipelas,  the system is  not relieved on the appearance of the
 local affection;  on the contrary, the danger  increases with the
 progress of the external disease.
   CCCIV.   When the face is  the seat of oedematous erysipe-
 las, the whole visage has  a bloated appearance;  the  red  col-
 our of the skin is mingled with yellow or brown ; it is accom-
 panied with rigors, vomiting, and more or less  disturbance to
 the functions of the sensorium commune.  The vesications are
 often small and numerous, and when they have been exposed
 for a few days to the air,  the countenance will be covered with
 a dark coloured crust, very much resembling the  appearance
 of the confluent small-pox.  Although  the face appears to  be
 much inflated, yet  it gives a very slight resistance to pressure,
 and excites the peculiar sensation we described before.
   CCCV.  This species of erysipelas is attended with consid-
 erable danger; the patient  often dies delirious, or  in a coma-
 tose  state,  about the seventh  day ; the fatal termination is
 sometimes protracted a  few days longer.
   CCCVI. When  this species of erysipelas appears, it is com-
 mon to see many people afflicted with it about the same period ;
 and, in hospitals, I  have seen several persons in the  same ward
 successively attacked with it: there is also some reason to con-
 clude, that it is occasionally an  epidemic disease ; but I  am
 unable to decide how far  it is, or is not  contagious.*
   CCCVII. The oedematous erysipelas may attack persons of
 any age, or temperament; but those are chiefly affected  by
 this species, whose  constitutions are  debilitated by age, or ex-
 cess : we also frequently meet with it in  dropsical  patients, in
 children, and in new-born infants.
   CCCVIII.  When this complaint is symptomatic, it is not
 nearly so dangerous as when it is idiopathic ;  but whenever the
 face is considerably affected by this  species of erysipelas, it is
 always to be regarded as a serious disease, whatever be the  re-
 mote cause.  There is seldom much  danger or inconvenience
 when it attacks an extremity, except it be treated improperly.

  * A paper by Dr. Wells, in  the Transactions of a society for the im-
provement  of medical  and chirurgical knowledge,  Vol. II.  may be con-
sulted on this poitit.
              11 
82
OF THE ERYSIPELAS.
I have seen this species of erysipelas make its first appearance
upon the face,  and by a gradual and regular progression, pro-
ceed downwards  to  the  extremities, successively  appearing
upon an inferior portion of the body, as it disappeared from a
superior  part;  each renewed accession of the complaint was
less and less severe, as it receded to a greater distance  from
the part that was primarily affected.*
   CCCIX. The  erisypelas  is a  disease which is subject  to
sudden and dangerous translations from the external to the in-
ternal parts of the body.  I have  also known it to affect  each
leg alternately, and be  transferred suddenly from one to the oth-
er, several times, during the continuance of the complaint.
When ^metastasis takes place from an extremity to the  brain,
it will immediately be followed by a delirium and other alarm-
ing symptoms.  I never  saw an  instance of metastasis in the
acute  erysipelas.
   CCCX.  The first appearance  of the malignant or gangre-
nous erysipelas is  somewhat similar to that  of  the oedematous
erysipelas,  but it is much more rapid in its progress.   Phlyc-
tence with a livid base very quickly appear upon the surface of
the  skin, and  gangrenous symptoms  speedily supervene.  A
state of the system  similar to that which is present in  putrid
fever, makes an early appearance in this complaint.
   CCCXI.  This  species of the disease  is most frequently
seen upon the face, neck, breast,  or shoulders; the  degree of
danger attending it must  generally be estimated by the state of
the  system.
   CCCXII. The gangrenous erysipelas is often a fatal disease,
but it is irregular in  the period   of its termination.  When it
terminates favourably, we often  meet with little caverns, and
intercurrent sinusses in the tela cellulosa, containing an ill-con-
ditioned pus, and  in those cases,  considerable  sloughs formed
by cellular membrane, &ic.  are evacuated from the ulcer.
   CCCXIII.   The  erysipelas  is  sometimes  deuteropathic,
 and not uncommonly it may  be regarded as the critical termi-
 nation of  another disease : exempli gratia, obstructed  men-
 struation,  quartan ague, suppressed  suppuration, spasmodic
 and  convulsive diseases.   Indeed,  exanthemata in  general,
 seem to have a remarkable  efficacy in suspending or carrying
 off convulsive diseases.

   * A  case  somewhat  resembling this  may be found  in AUx:  Observ ;
 Chirurg : Fascic : iii. 
OF THE ERYSIPELAS.
83
   CCCXIV. After the  favourable termination of erysipelas,
especially when the lower extremities have been affected, more
or less of oedema will often remain about the ankles for a con-
siderable time, and be very difficult to remove.


   CCCXV. The Zoster,  Zona, Herpes miliaris,  or Shingles,
is a disease that was well known to the  ancients :  it has been
considered  by some moderns as a species  of erysipelas; but
this  arrangement  would be extremely improper,  for the  two
diseases are very diverse from each other.
   CCCXVI. That eruptive complaint to which we give  the
name of shingles,  appears in the form  of small  vesications,
which are  filled  with  an almost transparent fluid : when they
are  large and distinct, there is very little redness in the inter-
stitial spaces between their base ;  but when confluent, there is a
more considerable discolouration of the surface.   The erup-
tion  is  usually, but not  invariably, preceded  by slight  rigors,
sickness, and even vomiting; the pustules are  more commonly
situated about the breast, back, abdomen, or  loins, and some-
times they form  a portion  of a circle ; at other times, they
are seen in distinct  and distant clusters upon different parts of
the body.  The  feverish symptoms do  not wholly disappear
on the eruption of the pustules, but they gradually subside, as
the contained fluid acquires a denser consistence ; the surface
of the pustules then begins to dry ; they fall off in the form of
dark-coloured  crusts ; and the  disease  terminates in a period
of from eight to twelve days.
   CCCXVII.  Although the shingles derive their origin from an
internal cause, and  the eruption is usually connected   with  a
general affection of the system, more or  less severe, yet it is  a
disease very seldom dangerous in its consequences.  A vulgar
notion indeed prevails, that if the eruption forms a  circle round
the body, the termination will be certainly fatal.  1 never saw
it encompass the body ; but it is more than probable that  this
prognosis  is  as  well  supported  as the  generality of  vulgar
opinions.
   CCCXVIII. This disease  ought to be  distinguished from
erysipelas—from  ignis sacer—varicella—herpes—and  esse-
ra.  A history of the  nettle-rash is  given in the  second vol-
ume of the Medical Transactions, by the very  learned and res-
pectable  Dr. Heberden. 
84                 OF THE  ERYSIPELAS.
                    SECTION  II.

                 THE MODE OF TREATMENT.

  CCCX1X.  As the same  method  of treatment is not appli-
cable to each species of the erysipelas, it will be proper in the
first place to speak of the general remedies that are to be em-
ployed, in the order of our division, and  afterwards  we shall
deliver the local treatment.
  CCCXX.  Indication the first:
  To diminish increased vascular action in the acute erysipelas,
and to take off particular determination  to the head, by
  1.  General and topical  blood-letting.
  General bleeding is not recommended in this place as a cure
for erysipelas, in the same sense in which it may be said to re-
move an inflammation ; it  is advised with the intention of ob-
viating the effects produced in the system by so severe a stimu-
lus  as acute erysipelas.  Indeed cases very rarely  occur in
large  towns, where bleeding is at all admissible ; and a repeti-
tion  of the  operation will very  seldom be  necessary or ad-
visable.
  2.  Gentle aperients of the saline and acid  class.  The ex-
hibition of emetics  and  severe purgatives  have  sometimes
been  succeeded by  the most fatal consequences.
  CCCXXI.  Indication the second :
  To promote  an equable  determination of  the  blood to the
surface of the body, and to  support a gentle diaphoresis, by
   1.  Nitre and antimony—sweet  spirit of  vitriol—saline
draughts with volatile alkali—Dover's powder—wine whey, &c.
  CCCXXII.  Indication the  third :
  To allay irritation, and remove uneasiness, by camphor and
opium.
  CCCXX1II. It has been maintained by the most respecta-
ble authorities, that  the early and liberal exhibition of Peruvian
bark  will commonly  shorten the period of erysipelas.
  The patient ought to abstain from animal food, and  to avoid
exposure to a cold atmosphere. 
                   OF THE ERYSIPELAS.                 85



                   SECTION  HI.

       THE TREATMENT OF ffiDEMATOUS ERYSIPELAS.

  CCCXXIV. Indication the first:
  To obviate the  effects of topical determination, when neces-
sary, by local blood-letting.
  When this species of erysipelas is symptomatic, e. g. the
consequence of a wound of the head ; the application of cup-
ping-glasses between the  shoulders,  so as to extract a few
ounces of blood,  may sometimes be proper in an early stage
of the disease ; but it will be very seldom advisable  to  repeat
the evacuation.   General bleeding is inadmissible, almost with-
out exception.  The propriety  of topical  bleeding  is chiefly
applicable to those cases where there  is danger of an affection
of the brain :  but very  great nicety is required in determining
upon this evacuation, where there is the least disposition to a me-
tastasis.  I have seen the most dangerous symptoms immedi-
ately  supervene to the loss of a very  small quantity of blood.
   2.  To keep  the body  soluble  by the remedies prescribed at
No. 320.   The  same  observation with  respect to the use of
emetics and purgatives  is also, applicable here.
   CCCXXV. Indication  the second :
   To promote a diaphoresis by  the  medicines recommended
No. 321.
   CCCXXVI. Indication the  third  :
   To excite irritation in a distant part, by rubefacients,  vesica-
tones oLC-
   These remedies  are chiefly  applicable in the transposed
 erysipelas; or in cases where the brain is affected : they ought
 to be employed with caution upon  other occasions.
    CCCXXV1I. Indication the fourth :
    To relieve pain and  irritation  by Hoffman's anodyne liquor,
 camphor, opium, London  treacle.
    Opium  is a very valuable and necessary remedy in the oede-
 matous erysipelas,  and when  given  with a prudent freedom it
 often produces the happiest effects.
    CCCXXVI1I. Indication the fifth :
    To support the vigour of the system, and prevent a termi-
 nation  of the disease in  gangrene and sphacelus, by  tonic rem- 
86
OF THE ERYSIPELAS.
edies, as  Peruvian bark, wine, brandy, confectio cardiaca,
volatile alkali,  &c.
  CCCXXIX. The plan of treatment to be  adopted in the
malignant erysipelas,  is  the same with that which is recom-
mended in the treatment of gangrene and sphacelus.
                   SECTION  IV.

    THE LOCAL APPLICATIONS TO BE USED  IN ERYSIPELAS.

  CCCXXX. The medicaments that have been recommend-
ed as suitable applications to a part affected with  erysipelas
have been extremely various  and dissimilar :  I will enumerate
a few  of the principal ones, and  deliver some general re-
marks.
  1. Repellent and astringent applications; as cold water, vin-
egar, lead, vitriol, &tc.
  2. Unctuous substances.
  3. Rubefacients; as  diluted volatile  alkali,  spirituous  and
lixivial applications.
  4. Farinaceous or earthy matters sprinkled upon the surface.
  5. Warm emollient cataplasms.
  CCCXXXI.  The  indiscriminate use of the remedies men-
tioned at No. 1,  will certainly be often attended with great dan-
ger.  There are cases of acute erysipelas in which they may
sometimes be used with safety, but I do not recommend them.
  2. Mere unctuous substances ought never to be used.
  3. Rubefacients may be commonly employed  with  safety,
and often with considerable advantage.   It is of importance not
to apply  them in such a  concentrated state as to produce ex-
coriation.
  4. The use  of  farinaceous substances,  earths, he.  coun-
teracts one of our  most principal indications, which is,  to pro-
mote a gentle perspiration in the part:  their application is also
attended with the further inconvenience of forming hard irrita-
ting crusts upon  the diseased part.   I have seen very disagree-
able and dangerous consequences to ensue from their use.
  5. Mild, warm cataplasms, are the applications which a very
extensive experience hath induced  me to  prefer.   They may
be composed of the powders of aniseed, fennel, camomile flow- 
                   OF  THE  ERYSIPELAS.                87

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

                THE TREATMENT OF ZONA.

  CCCXXXV. The Zona very often admits of a natural cure;
but when it requires medicinal treatment, the indications are,
   1. To promote an equable determination of blood to the sur-
face of the body, by
   a. Living in a warm atmosphere.
   b. Gentle diaphoretics, and light cordials with opiates, when
the irritation is very distressing. See No. 317.
   Indication  the second  :
   To exhibit a gentle purgative when the pustules are drying.
   Diuretic medicines are also proper.
   No particular external applications are necessary. 
88
OF THE SCIRRHUS AND CANCER.
                  CHAPTER  XI.

                     SECTION  I.

             OF  THE SCIRRHUS AND CANCER.

  CCCXXXVI.  A Scirrhus  is a  circumscribed  induration,
usually attended with tumour, and most commonly situated in a
glandular part:  it is generally moveable, without redness, and
possessed of a very low degree of sensibility.
  CCCXXXVII. It is not certain,  that any of the soft parts
of the body  are  wholly exempted  from this  disease; but  it
chiefly occurs in the conglomerated  glands  and those  surfaces
that are covered with a secreting membrane.
  CCCXXXVIII. The remote causes of  scirrhus have been
rendered very numerous by different writers upon the  subject:
we intend to  take notice of those only that are more generally
insisted upon.
  1.  The inflammation of a glandular part.
  2.  The repulsion or the coagulation  of milk in the breast.
  3.  Contusion.
  4.  Pressure.—Attrition.
  5.  Obstructed  or suppressed menstruation.
  6.  Depressing  passions of the mind ;  as fear,  grief,  melan-
choly, &ic.
  7.  An hereditary contamination.
  CCCXXXIX. It has  often  been  doubted, whether an in-
flammation ought ever to be regarded as the remote cause of
a scirrhus; and indeed  the propriety of admitting it cannot
easily be demonstrated.  Ancient and modern writers of great
authority have asserted,  that an inflammation of the liver fre-
quently terminates in  scirrhus;  and  it has been supposed,"that
a similar cause  has often been  productive of a scirrhus in the
uterus.   The nature  of this work,  however,  does not admit
of a full discussion of the propriety  or impropriety with which
the remote causes are  assigned; it  will therefore be sufficient
to observe in the  general,  that an  inflammation seated in an
external part, is probably never a proper cause of scirrhus.
  CCCXL.  The share  which  other  remote  causes  have in
producing a  scirrhus, cannot  always  be  clearly ascertained, 
                OF THE SCIRRHUS AND CANCER.          89

 since it is certain that this disease will often appear without the
 evident operation of any cause whatever.
   CCCXL1. Many  facts have occurred, which render it pro-
 bable, that scirrhus and cancer are hereditary diseases.
   CCCXLII. Scirrhous tumours of the breast very frequently
 occur in  women  that lead  a sedentary life; in  cases of ob-
 structed menstruation; and  about  the  period when the cata-
 menia cease to appear.  It hath also been observed, that the
 uterus is frequently attacked with this disease, in  those women
 that have been  accustomed to menstruate  in a large  quantity,
 when that evacuation  ceases to flow.
   CCCXLIII.  Scirrhous affections of one kind or  other have
 been found in the brain,  eye,  oesophagus, parotid gland, neck,
 tongue, lip,  breast, stomach,  colon,  rectum, liver, pancreas,
 kidney, bladder, uterus, penis, testes, he.
   The symptoms and effects of this  disease when situated in
 these  different parts  of the body will vary considerably ;  and
 can only be well understood  by studying  the  history of each
 particular complaint.
   CCCXLIV.  It may  be offered as a general observation,
 that the presence of a scirrhus in any part  of the  body, will be
 accompanied with all  the ill consequences that can  result from
 a derangement of its particular organization ;  from an interrup-
 tion to the due performance of its peculiar functions;  and from
 an undue  compression made upon the neighbouring parts.
   CCCXLV.  When a scirrhous tumour is removed from the
 body and subjected to examination, it exhibits an almost uni-
 form appearance ; for all the constituent parts seem to be so in-
 timately blended together into one  mass, that no distinct  ves-
 sels, cells, &c. can be traced  : sometimes, a small  quantity of
 a yellowish, or dark-coloured  fluid, is found near  the  centre of
 the tumour;  on other occasions, this fluid is met with nearer
 the circumference.   By  long  boiling, a quantity of a coagula-
 ble fluid is obtained, which  appears to have been contained in
 cells that now become rather visible;  there are few, or no tra-
 ces of blood-vessels to be seen, nor is there any distinct re-
 semblance of the primitive  structure of the  part.  The sub-
stance that remains after  boiling is hard and elastic, and not
very unlike a portion offish, boiled  till it becomes firm.
   CCCXLVI. Pathologists of great eminence have described
a scirrhous tumour, as consisting of a hard centre with radiated
12 
90
OF THE SCIRRHUS AND CANCER.
lines, like ligamentous bands,  proceeding in  every direction.*
This appearance is not, I believe,  peculiar to scirrhus, since I
have seen similar alterations in diseased  portions of the breast
and testicle, where appearances of a scrofulous affection existed
likewise.
  CCCXLVII. Scirrhous tumours ought to be distinguished
from inflammation and suppuration of the  breast: from tumours
occasioned by milk, struma, hernia  humoralis, chronic inflam-
mation of the testicle—tumours containing hydatids, and  those
which consist chiefly of vesicles—encysted tumours, &ic.
  Those tumours which contain phosphate of lime, or any such
saline concretions  as  are  usually found  in  the animal  body,
ought not to be regarded as scirrhi.
  CCCXLVI1I. The Prognosis of Scirrhus.   All scirrhi have
a tendency to terminate in cancer.   Some  tumours however,
apparently of this class, have happily been discussed ; and more
especially such as have been situated internally.
  CCCXLIX.  The hardness that sometimes remains after the
termination of an inflammation, and the callosities that surround
the edges of ill-conditioned ulcers, fistulae, See. differ materially
from a true scirrhous affection.
  The progress of a scirrhus in the breast.
  CCCL. The tumour that has remained,  for some  space of
time, hard, insensible, and  almost stationary, gradually increases
in magnitude and sensibility, a gentle  pruritus is first per-
ceived, which gradually changes to an obtuse  throbbing sensa-
tion ; and the uneasiness continues to increase, until it rises to
an acute, lacinating pain.   The diseased part loses its mobil-
ity, and becomes irregular in its figure ;  the skin is in folds, or
puckered, at some particular part,  and contracts an adhesion to
the subjacent tumour; not uncommonly,  little, hard, red  tuber-
cles appear  on different  parts of  the breast;  the  cutaneous
veins enlarge, and often  become  varicose; the glands  under
the axilla, and about the clavicle enlarge, and become hard and
tender;  and in  one  or more parts the  skin acquires a flaves-
cent, purple, or livid  hue : beneath these discoloured spots an
acrid and malignant fluid is contained, that will  speedily erode
the integuments and  produce  ulceration.  The general  health
of the system is, at this period, more or less affected.   When
the disease has arrived at this  state, it assumes the name of
Cancer.
* Baillie's Morbid Anatomy.  Home on Cancer. 
OF THE  SCIRRHUS  AND  CANCER.           91
                    SECTION II.

   CCCLI.  A Cancerous ulcer is irregular in its figure, and
commonly presents an unequal  surface :  it is usually attended
with a sense of ardent pain, which is subject to remissions and
exacerbations1: it discharges a sordid, sanious, and often  fetid
matter:  the edges of the  sore  are thick, indurated, and ex-
tremely painful : they often exhibit a serrated appearance, and
are sometimes  retorted,  at  other times  inverted.   The  ulcer
sometimes spreads with great  violence to a very considerable
extent, and in  the course of its progress produces frequent
haemorrhages,  in consequence of the erosion of blood-vessels.
There is  commonly considerable pain  in the arm of the side
affected ; it becomes highly oedematous, and sometimes an ab-
scess, accompanied with erysipelatous appearances, takes  place
in the vicinity  of the shoulder,  or at the angle formed by the
arm, and the scapula.  The ulcer formed by the rupture of
the abscess is not cancerous.
   CCCLII.   The cancerous ulcer often remains small  in its
dimensions, and penetrates  to no considerable depth ; it is sur-
rounded  by skin contracted into folds, nor is it always accom-
panied with acute  pain.  At other times, a fungus of a cauli-
flower-like appearance germinates from the bottom of the ulcer,
and several sores of this  description will occupy the breast at
the same time.
   CCCL11I.   The manner and  comparative rapidity  with
which cancerous ulcers proceed,  admits of considerable variety ;
in some cases, the  breast is destroyed, and life is terminated, in
the space of a few months.   It  sometimes happens that a spha-
celus supervenes, and the whole diseased part falls off, leaving
a smooth and apparently healthy surface;  but the sore is always
cancerous.  And I have known  cancers,  attended with moder-
ate haemorrhage, to proceed slowly, without  exciting any  pain
or uneasiness,  and  gradually wear out the patient by the  hec-
tical symptoms that supervened.  There  are  also many cases
upon record, where cancers have remained in a dormant  state
during many years, attended with little uneasiness,  and produc-
tive of no derangement in the general health of the system.
   CCCLIY.  It  has been  thought advantageous in treating
onthis disease, to  arrange cancers under different species; 
92
OF THE  SCIRRHUS  AND CANCER.
but whatever be the reason, it does not appear that any division
which has yet been proposed, has met  with universal appro-
bation ; nor,  indeed,  is  it to be  expected that  a satisfactory
arrangement can be formed, until we are better acquainted with
the natural history of the disease.
   CCCLV.   As a specimen of the divisions that  have been
proposed, I shall exhibit the following :
   It hath been divided into,
   1. The occult cancer.
   2. The ulcerated cancer.
   But  whether by the former of these, we are to understand a
cancerous affection of an  internal part, or a scirrhous tumour
concealed by  the integuments, is a point  not yet fully agreed
upon.*
   If a part be suddenly attacked with the symptoms of cancer,
it has been denominated
   A primitive cancer.
   When a scirrhous  tumour has terminated in  this disease,
it has been called
   A secondary cancer.
   They have also been  divided into,
   1. Cancers originating from an  external cause.
   2. Cancers originating from an internal cause.
   When the disease appeared to be unconnected with any evi-
dent constitutional affection, it- hath been called
   A simple cancer.
   If the person were previously  affected  with  lues venerea,
scurvy, &c. it was called
   A complicated cancer.
   The siluation, the  figure,  or the remote causes have also
been severally adopted by  various systematic writers to char-
acterize  what have been termed  different  species of this dis-
ease.
   CCCLVI.  I  shall not offer any observations upon the  merit
or demerit of the several divisions enumerated above; but  if
the term scirrhus be  employed until the  disease assumes  the
appearances described at No. 350, and  if afterwards we  apply
the term cancer, perhaps our distinctions will be sufficiently ac-
curate for every practical purpose.

  * See the Works of Hildanus, Peccetti, Wiseman, Van Swieten, Pouteau,
Le Cat, &c. and the Prix Memoires, de l'Academie Royale de Chirurgie,
&c. &c. 
OF THE SCIRRHUS AND CANCER.           93
  CCCLVII. The  breast is sometimes attacked so suddenly
with scirrhus, that an acute pang in the part shall give the first
notice of the presence of a small, hard tumour.  A retraction
of the  nipple, an adhesion of the gland to the subjacent parts,
and a contraction of the skin into little folds, frequently  pre-
cede  or accompany  the appearance of this disease.   Some-
times there will be an occasional evacuation  of a bloody serum
from the nipple, during several months, before any other com-
plaint appears;  but in these cases the subsequent disease  is
usually  very rapid in its progress.
  CCCLVIII. A cyst  containing a  dark-coloured liquor  is
very often met with  in some part of the substance of  a malig-
nant scirrhus (No. 350).  This fluid  hath  been found  to be
so extremely acrid, that  a very transient application of it  to a
part covered with cuticle, left perpetual darting pains for seve-
ral hours after it  was washed off.   When applied to a  surface
devoid of cuticular covering, it has produced ulcers that exhib-
ited the common appearances of cancerous sores.  An insup-
portable and fatal nausea has been  the consequence of  impru-
dently tasting it; and even the fetid effluvia arising from a can-
cerous ulcer will sometimes produce  very disagreeable effects
upon the attendants.
  CCCLIV.  It has been observed, that in certain cases where
suppurating plasters  or cataplasms had been used, an impost-
hume, containing a very large quantity of a  bloody serum, was
found in that part of the breast which had been previously oc-
cupied by a scirrhus tumour; and in all these instances the dis-
ease terminated fatally.   Monro.
   CCCLV. The imposthumated cancer, (if the term may be
allowed) appears  also under other circumstances.  After the
very  free use of leeches, where  the strength was considerably
reduced by the  loss of blood, I have found a large quantity of
fluid, apparently contained in different cysts, within the breast.
By frequent discharges of a bloody fluid from the nipple, during
many weeks, the  enlargement was entirely reduced, and the
patient finally  recovered.  In every instance  that has fallen
under my observation, where the contained fluid was evacuated
by an artificial opening,  the patient died in  a very short space
of time.
   CCCLVI. The breast sometimes exhibits the several char-
acters of the imposthumated  cancer, where there is no fluid
effused.  This form of the disease is always attended with ex- 
94
OF THE SCIRRHUS  AND  CANCER.
 cruciating pain, and the general health is greatly  disordered.
 An opening made into the breast, under  these  circumstances,
 greatly aggravates the sufferings of the patient, and accelerates
 the fatal termination of the disease.
   CCCLXII. When  a cancer  attacks the surface  of the skin,
 it very frequently makes its first appearance in  the form of a
 wart, or small excrescence ;  very often it will give little  dis-
 turbance until it  be irritated by improper treatment;  and un-
 der these circumstances, it will very quickly change its aspect,
 and assume all the appearances of a cancerous sore.   These
 appearances most frequently take place upon some part of the
 face,  upon the skin  that covers the  tibia, or upon  the parts of
 generation.
   CCCLX1II. The lupus, or noli me tangere, commonly ap-
 pears first under the form of  a small scaly tubercle, of a light
 brown colour; and at  an early period, it  is not  surrounded by
 any redness.   When this tubercle  bursts, the ulcer  spreads
 gradually, sometimes in a circular  direction, but more common-
 ly the figure is irregular,  and  the surface  unequal. When  it
 attacks a  part abounding with  sebaceous glands, as the  face,
 nose, upper lip, &tc. the  ulcer often exhibits an  elevated sub-
 stance in its centre,  resembling fungus, but of a  firmer texture,
 and less disposed to bleed.  The spreading of this ulcer is usu-
 ally attended with a thickening and comparative induration of
 the surrounding parts ; but the edges do not acquire that thick-
 ness which is so frequently seen in cancer, nor is the sore com-
 monly accompanied with much pain.  When it  is   shunted  on
 the leg or foot, there is often considerable sloughing of the sur-
 face of the ulcer : it penetrates more deeply and  extensively,
 and greatly resembles the noma, or ulcus  depascens.  The lu-
pus frequently removes large  portions of the substance of the
 part which it  attacks, and leaves considerable deformity.
   CCCLXIV. When the lip, alee  nasi,   or  the  eye-lids, are
 affected with a cancer, the disease most  commonly contami-
 nates  the  whole substance of the  part in which it  is seated;
 and it is not unusual to  meet with diseased  absorbent  glands,
 and carious bone, in the vicinity of carcinomatous ulcers.
   CCCLXV.  If  a part  of the body that is naturally  covered
 with a secreting membrane, as the inside of the nose,  mouth,
 stomach, &c.  becomes the subject of a  cancerous affection,
 the disease often appears in the form of  polypous  excrescen-
 ces,  or of  fungi, possessing different characters.   And, indeed, 
OF THE SCIRRHUS AND CANCER.
95
fungi very commonly vegetate  in  cancerous ulcers, wherever
they are situated.  The  fungus and polypus  like substances,
that are occasionally seen in the uterus, intestines, bladder of
urine, &tc.  do not  always exhibit an appearance sufficiently
uniform to render their real nature capable of accurate discrim-
ination.
  CCCLXVI. A cancer  of the uterus is generally preceded
by leucorrhoea, and sometimes by repeated haemorrhages from
that organ.  The patient complains of pain in the bones of the
pelvis,  especially  about the  os sacrum  ; and also  about  the
groins,  and the  hypogastric, and  umbilical regions.   When
the uterus  adheres to the posterior part of the vagina, the pa-
tient often complains of a  weight and painful sense of hardness
in the perinaeum.   The natural functions  of the  stomach  and
intestinal canal are more or less deranged ;  and very common-
ly, a state of the system somewhat resembling hectic fever is
present.  The patient will often complain of an unnatural sense
of heat about the uterus ; and  at certain times, she will have
pains accompanied  with involuntary expulsive efforts, as if the
uterus were descending through the vagina.   This disease is
often accompanied  with a frequent and. painful excitation to
void the urine ;  but when the uterus descends lower down in
the pelvis, this  symptom is  frequently  alleviated.  The  dis-
ease may be seated  either in the cervix or in  the corpus uteri.
As the  uterus enlarges, it gradually loses its natural  mobility,
and  becomes  hard, inelastic, and more   rotund,  especially
about the os uteri.   As these morbid  alterations proceed, the
pungent sense of heat  and pain increase  in  proportion ;  and
these are attended  with a considerable discharge  of a  flaves-
cent or cineritious coloured matter, offensive to the smell,  and
very acrimonious :  yet in many  cases, there is  no particular
discharge from the uterus, until a very advanced period of the
disease.  The matter is frequently mixed with blood, especial-
ly when there is a fungus, or  an ulceration of the  uterus.
Sometimes the  patient is attacked with  considerable haemor-
rhages from the uterus,  at  uncertain intervals, which  usually
confer  a temporary  relief.  On examining the state of the  part
affected, it  excites such  sensations as might be expected from
an ulcer possessing the characters described  at  No. 351.  In
this dreadful disease, the bladder and rectum are  sometimes
eroded, so that their contents  are evacuated  through the va-
gina. 
96
OF THE SCIRRHUS AND CANCER.
  CCCLXVII.  The vagina frequently partakes of the cancer-
ous affection at the same time.   This may be known, by the
induration and contraction of this part, and fissures may be like-
wise observed on examination,   in cancers of the uterus, we
sometimes meet  with a discharge of a clear aqueous fluid, from
the first appearance of the disease to its fatal termination.
  CCCLXV1II. Cancer of the uterus is occasionally accom-
panied with cedema of  the prolabia, which sometimes extends
to one or both of the  lower  extremities; at other times the
patient will be subject  to erysipelatous appearances about the
groin and upper  part of the thigh.
  CCCLXIX.  The cancer  of the scrotum, to which chim-
ney-sweepers  are peculiarly liable, was first  described by
Mr. Pott, to whose valuable writings I would refer the reader,
not only for an account of this complaint, but also for the sake
of many important observations on  cancerous diseases, which
are interspersed  in different parts of his works.
  CCCLXX. A cancerous affection of the penis may first
appear on the  internal surface of the praetutium, or on the  glans
penis.   It is more commonly seen  in the form of excrescences
arising from one or fcoth of these parts; although it is some-
times met with in the form of an ulcer, on the internal surface
of the prepuce, or on some part of the  glans penis.  I  have
known the cancerous ulcer of the penis several times mistaken
for a venereal  chancre.
  CCCLXXI.  Some  surgeons of high reputation  suppose,
that it usually  originates from the under surface of the prepuce,
and that it is  commonly connected  with a natural  phymosis.*
My own experience has not induced me to make a similar ob-
servation.   I have seen  so  many cases  of painful verrucose
like  excrescences,  connected  with a phymosis,  which  were
neither  cancerous nor  venereal,  that I still entertain   some
doubts on this particular part of the subject.
  CCCLXXI1. Where  the  cancer of the penis pursues  its
natural  course,  the glands of the  groin, and the  skin of the
scrotum become  extensively diseased,  and sometimes  the in-
teguments of the regio  pubis.
  CCCLXXIII. The cancer ought to be distinguished from
  1. Venereal affections of the organs of generation.
  2.  From venereal ulcerations of the lips, alae nasi, tongue,
&c.
►  See Hey's Practical Observations; and Home on Cancer 
              OF  THE SCIRRHUS AND CANCER.           97

  3.  From ulcerations of the tongue in consequence of the use
of mercury ;—from enlargement of the  papillae, and excres-
cences of a doubtful nature about the root of that organ.
  4.  From ulcerations about the gums, inside  of the cheeks,
fauces, &c. from various causes.
  5.  From a peculiar affection of the uterus, in consequence
of lues venerea : *
  6.  And  from  phagedenic ulcers in any part of the body.
  CCCLXXIV. The prognosis of cancer.  The natural ten-
dency of a cancer, is to terminate in the certain destruction of
those patients  who are unhappily afflicted with  it.   The pow-
ers of the constitution  can  exert but  a feeble  and  unavailing
resistance against its ravages; nor are  we at present in posses-
sion of any remedy, external or  internal, that merits the name
of an  antidote against the dreadful effects of this fatal disease.
                     SECTION III.

OF THE LOCALITY  OF A CANCER J AND WHETHER THE PRES-
  ENCE OF THIS DISEASE IN ANY PARTICULAR PART, IMPLIES
  A CONTAMINATION  OF THE GENERAL SYSTEM.

  CCCLXXV.  By  a  local disease may be  understood, a
morbid alteration in a particular  part of the body, the existence
of which is not necessarily connected with a similar morbid al-
teration, nor  a certain tendency  to such a state, in the general
constitution :  e. g. simple ulcer, encysted tumour.
  CCCLXXVI. By a general  or  universal  disease may be
understood, that state of the system in which a similar morbid
condition occupies the whole or the greater  part of the living
body ; or where there is a certain and invariable  tendency to
such a state: e.g. small pox, lues venerea, &c.
  CCCLXXVII. It is probable, that the cancer  cannot with
strict propriety be included within either of these divisions ;  for
as  on the one  side,  we  cannot prove  that the  cancerous
virus is susceptible of an indefinite  multiplication,  and a con-
sequent power of contaminating  every part of the  system ; so
on the other side, there frequently appears so evident a dispo-

  * See Practical Observations on Cancerous Complaints, by John  Pear.
son. &c.
               13 
98           OK THE SCIRRHUS  AND  CANCER.

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

  * 1 have often seen cancer of the breast and of the uterus occur at the
same time ; also cancer in each breast; and cancer of the breast with can-
cerous affection of the skin in  the epigastric region.   Sometimes an appa-
rently cancerous affection of the uterus  will disappear, and after the lapse
of a considerable time, the breast will become cancerous. 
OF THE  SCIRRHUS AND CANCER.           99
   CCCLXXXI.  As the extirpation of a cancerous part, at
any period, does not confer an absolute security upon the sub-
ject of the operation, the reason of this uncertainty hath been
anxiously  sought  after,  but I  fear with  more  diligence than
success.   Some practitioners  have conjectured  that  a  certain
fluid, capable of communicating a cancerous affection, was al-
ways floating in the blood-vessels of those that laboured under
the disease, and that it was from time  to  time deposited in
parts of  a glandular structure.   The existence of such a lea-
ven, or ferment, hath been confidently denied by the ingenious
Monsieur  Le Cat,  M. Pouteau, and  others ; and  they have
maintained, that the disease is propagated from  a cancerous
sore, &c.  to distant parts of the body, by an  irritation  sui ge-
neris, which is excited  by the  cancerous  matter  acting  as a
peculiar stimulus.*   As there is little probability in the former
of these opinions, and the latter is scarcely intelligible, we shall
not take any further notice of them at present.    Vide Gaubms.
Instit: Pathol: Medicinalis.   De  Potentiis, qua  virus ha-
bent, § 500.
   CCCLXXXII.  It is probable, that the  cancer, at  some
period  not easily ascertained,  acquires the power of contamin-
ating the circumjacent parts to a distance considerably beyond
the points of contact.  But we possess no unquestionable proofs,
that the cancerous matter, when applied to a sound person, is
capable of acting as a contagion, so  as  to produce a disease
similar to that  by which it was formed.   Cancerous  matter,
applied to an abraded surface, or to one  destitute of the com-
mon cuticle, will  sometimes produce  an ill-conditioned and un-
tractable sore,  but not a sore  truly cancerous.
   CCCLXXXIII.  In cancerous affections of the breast, the
 absorbent glands in the axilla  are very frequently contaminated
 with the disease ; and professor Camper  discovered some ab-
 sorbent vessels,  passing from the breast into  glands  situated
 under the sternum, which  exhibited the same diseased appear-
 ances with those  seated in the  axilla.   Now, as the absorbent
 elands that lie  on each  side of the under part  of the sternum.

   * Monsieur Pouteau is so extremely attached to explanations founded
 upon the stimulating powers of contagious matter, to excite a peculiar ir-
 ritation, similar to that which produced the poison, that he applies the
 same mode of reasoning to small pox, lues venerea,  &c. and strenuously
 contends that the progress of these diseases is only from local to general
 irritation—Voytz. Les CEuvrcs Posthnnes. 
 100         OF  THE  SCIRRHUS AND CANCER.

communicate with each other by means of absorbent  vessels,
it will be easy to understand in what manner the disease may
be  propagated  from one breast to the other.*  As a cancer
may therefore  be reproduced in a part apparently cured;  or
propagated  to a distant part, by means of diseased  absorbent
vessels; and as these are exceedingly numerous, and often ex-
tensively affected, we may be assisted  by considerations  form-
ed upon the preceding narration, to form an  opinion, in what
sense a cancer  may be regarded  as a local or constitutional
disease.
                    SECTION  IV.

                        DESIDERATA.

  CCCLXXXIV.  To know distinctly the characters of that
scirrhous  tumor, which will  remain in a mild  quiescent  state,
unless it be exasperated by improper treatment.f
  CCCLXXXV.   To be able to ascertain the precise period,
when a scirrhus assumes a malignant and cancerous nature.
  CCCLXXXVI.  To  be able  to decide  upon the cases in
which the extirpation of the morbid part will be attended with
success; and also  to  know  whether  in other  cases  there  be
any criteria, and what  they  are, by which  we  may be certain
that the operation performed at any period of the disease will
be improper and hurtful.
  CCCLXXXVII.  Is the scirrhus, or the cancer, in any  sense
susceptible of metastasis ?
                     SECTION  V.

       OF THE TREATMENT OF SCIRRHUS AND CANCER.

  CCCLXXXVIII. It hath  already, been delivered as a de-
cided opinion, that there is no remedy yet made public, which

  *  Each of the breasts maybe attacked with cancer, in quick succession ;
but it is not meant to be asserted, that the disease is always propagated by
the absorbents below the sternum.
  +  Peccetti and Wiseman have said, that if hair grows upon the skin
covering a sci rhous tumour, the  disease will not terminate  in cancer.
This remark, however, I am sorry to say, is not correct. 
OF THE  SCIRRHUS  AND  CANCER.
101
justly merits the name of an antidote against the dreadful effects
of the cancerous virus.   If this opinion be true,  it is of great
importance to caution our patients against placing  there confi-
dence in impotent or noxious medicines, at a time when  the
diseased part is so situated, that it can be safely  and perhaps
completely removed.  The delusions of hope may be sweet under
such afflictive  circumstances; but if they lead to   experiment,
or delay, they  add malignity to  the poison, and give swiftness
and certainty to the fatal  termination of the disease.
   CCCLXXXIX. When a scirrhus, or cancer, is situated in-
ternally, medical asistance alone can be employed.    Sometimes
it seems to be employed with advantage, by diminishing the dis-
ease, or retarding its progress;  but at all times remedies may
be exhibited, that will alleviate  the tortures of  pain, and  thus
render  the  approaches of  death  less insupportable.  But we
would protest  against the man, who, by  trusting to or  trifling
with any remedies, in an external scirrhus, where all appear-
ances favour the expectation of permanent advantage from the
removal of it,  makes his  patient  lose an opportunity that can
never be recalled.
    CCCXC.   Indication the first:
   To preserve a benign  scirrhus from  assuming  a malignant
form, by
    1. Low and vegetable diet:
   2. Saline purgatives, at due  intervals :
   3. The application of leeches, under proper regulations :
   4. Avoiding all violent emotions of the mind :
    5. Supporting, or defending, the part  from injury and irrita-
 tion, by means properly  adapted  to the situation of the disease.
    6. Solutions of lead, combined with alcohol,  have been found
 beneficial in alleviating pain.
    7. Great attention must be paid to the supporting of an uni-
 form and agreeable temperature in the part.
    All  applications which tend to  increase sensibility and action
 in a scirrhous tumour, are to be carefully avoided.
    CCCXCI. The term scirrhus, is frequently applied  to cer-
  tain diseases  of  the liver, mesentery, ovaria, &c. and in these
  cases, it is not always to be taken in the strict sense to which it
  is confined in the present chapter.   It is also proper to be ob-
  served, that in these cases, the use of internal remedies  i* often
  followed by the happiest effects.   The remedies  which 1 have
  administered  with the greatest advantage, in these morbid affec- 
102
OF THE SCIRRHUS AND CANCER.
tions, have  consisted of mercury, in a  simple  or a  combined
state, joined with digitalis, nicotiana, cicuta, mercurial frictions,
&tc. vegetable and fossile alkali, moderate friction, gentle and
frequent gestation, electricity.   When there is  much pain,  a
plaster, composed of the warm gums with a large quantity  of
opium, applied to the abdomen, will frequently give  a tempo-
rary relief.
   CCCXCII.  When the oesophagus, intestinum rectum,  or
parts of a similar structure become scirrhous, mechanical means
seem to be  best adapted to the relief of the disease; but the
expediency  and advantage of employing them in every case, is
not yet sufficiently ascertained.   It scarcely need to be observ-
ed, that  if  the diameter of  a canal be  diminished, in  conse-
quence of compression from an enlarged neighbouring  gland,
mechanical  means will in general do more harm than good.   It
is not improbable, that in some  cases of obstructed deglutition,
where the introduction of mercury into  the system  removed
the disease,  the complaint had originated  from the compression
of a gland, &ic.
  CCCXCIII. When we enter upon the mode of treating can-
cer, there are three indications which naturally present them-
selves :
   I. To remove, if possible, the external disease.
  2. To prevent a relapse, or reproduction of the complaint.
  3.  If it be not thought advisable to attempt a removal of the
disease by an operation, to palliate the symptoms, and endeav-
our to retard their progress.  We shall treat each of these heads
in its order.
  CCCXCIV. As we are not possessed of any medicines that
will  certainly  cure a legitimate cancer,  the only resource of
art will, consequently, be to remove  the diseased  part by  a
chirurgical operation.   There are  two ways in  which this end
may be obtained :
  1. By the application of a caustic.
  2. By the use of a cutting instrument.
  CCCXCV.   If a caustic be  preferred for the removal of a
cancer, it ought to possess  the  power of suddenly destroying
the whole diseased part; otherwise the malady  will be  exas-
perated, and perhaps the use of other means will be rendered
less effectual.   The difficulty of removing a breast by  such an
application must be obvious ; and where this is  accomplished,
the method  does not appear to  possess any peculiar efficacy. 
              OF  THE  SCIRRHUS  AND  CANCER.          103

When the whole breast sphacelates and falls off from the body,
although the  granulating surface, for a time, will look firm  and
healthy, yet the disease has never failed to renew its  ravages.
If it were necessary to reason against  this mode of practice,
we  should urge the severe pain that is produced ; the necessi-
ty there is of frequently  repeating the application ; the uncer-
tainty of its removing the whole  disease,  and that  where the
whole disease has been apparently removed by the caustic, it is
no  less liable to recur, than when the part has been extirpated
by  the knife, &c.
  CCCXCVI.  In a cancer of the lip, or when the disease oc-
cupies but a  small extent of depth and  surface in any conveni-
ent part, the application  of a caustic is  not liable to the  same
objections ;  but it ought always  to be so applied, as  to produce
the sudden and complete destruction of the morbid part.*
  CCCXCVI1.  The ulcers that are often termed  cancerous,
but which are more properly classed under the heads of lupus,
noli me tangere, he. (No. 363), may frequently be cured, by
the application  of arsenic, corrosive sublimate, and  even by
some of the milder mercurial ointments, &c.—Cancerous fungi
have been often successfully destroyed by the actual cautery.
   CCCXCVIII.  The excision of  a cancerous part with the
knife, hath so  many advantages over the  use of a caustic, that
this mode is generally preferred by  the  best  surgeons.   The
general rules to be observed in  the extirpation of this disease
are these, viz.
    1. To remove the whole  affected  part, with every gland
or  fibre in its vicinity, that exhibits the least mark  of disease :
e. g.  When the  breast is extirpated,  the  glands in the axilla
are to be examined:  if the penis be amputated, the state of the
inguinal glands, or those situated on the pubes,  must be ascer-
 tained, &£C.
    2. To save as much of the sound skin as possible, that the
 surface of the  sore may be rendered small, and its healing  be
 expedited.
    CCCXCIX.  In the  extirpation of a scirrhus, where the skin
 is  not diseased, the operation may  frequently be performed by
 means of a simple incision long enough to permit  the tumour

   ■* It may be worthy of observation, that the quality of the caustic we
 employ, is by no means an indifferent circumstance.   The acid and arsen-
 ical caustics, and, on particular occasions, even the actual cautery, will bs
 found most proper in cancerous diseases. 
 104          OF THE SCIRRHUS AND CANCER.

 to be dissected out: as soon as this is effected, if  the  lips of
 the wound are kept  in Contact by the means of sutures, or ad-
 hesive plaster, the patient will be perfectly well in a few days.
 As the suppuration of the wound does not at all  contribute to
 the security of the patient,  it is proper to heal the  wound  by
 the first intention, wherever this is possible.—See Garengeot,
 Traite des Operations de Chirurgie,  Ed. seconde, tome second.
 chap. vii. p. 390, <y- Suiv.
   CCCC. If the situation and circumstances of the disease be
 such that it cannot be completely  extirpated,  it will be by  no
 means advisable to propose  an operation.   Or if from the pres-
 ence of a cough, attended with difficult respiration, an expec-
 toration of matter,  and hectic fever, there be  reason to appre-
 hend that the lungs are in a  diseased state, no particular advan-
 tage is to be expected from the  excision of the  breast.   But
 the mere attachment of the breast to  the subjacent parts can
 never constitute a valid  objection against its extirpation, provi-
 ded that the surface of attachment can be wholly  removed.
   CCCCI.  When the lip is the subject of a cancerous affection,
 the mucous  membrane is generally discoloured to  some  little
 distance beyond the  circumference  of the hardness, with a
 tinge of deeper red than natural.  Monsieur Le Dran has al-
 ways observed, that this is a sure indication of the presence of
 disease, and therefore advises, that the incision be made in the
 sound part, beyond this  discoloured surface,  lest the  operation
 shall prove unsuccessful.  After  the extirpation of the cancer-
ous part, the sides of the wound  are to be brought into contact,
 and the same mode of treatment is to  be followed, as after the
operation for the hare-lip.
   CCCCII. In  aged  persons, and where the cancer has been
of long continuance, the submaxillary  glands are commonly  in
 a diseased  state, or  soon become  evidently  cancerous  after
 the extirpation of the  morbid part of the lip.
   CCCCIII.  Portions  of the tongue, in a  cancerous state,
 may be safely extirpated  by the application of a  double liga-
ture.—Home on Cancer.
   CCCCIV.  Indication the second :
   The means  that are to  be employed in order to  prevent a
 return  of the  disease, are of very doubtful  efficacy; but as
 several eminent  surgeons have thought  it proper to  attempt
something of this kind, it is necessary  to hint, that  among other
 means they have recommended, 
OF THE  OZJENA.
105
   1. The insertion of issues, at a convenient distance from the
cicatrix.
   2. An abstemious course of diet.
   3. Proper evacuations at due intervals.
   4. Sea bathing.
   CCCCV.  Indication the third :
   The use of internal or external  remedies, as palliatives  in
this dreadful  disease.   Among  these, we  shall first enume-
rate some which have  been supposed to possess powers capa-
ble of correcting the cancerous virus—as mercury; cicuta; bel-
ladona;  arsenic ;  a solution of iron in  a  mineral  acid; a
course of diet consisting of water  only ;  decoctions  of sarsa-
parilla, Peruvian bark, &tc.—Pain is to be moderated  by the
use of opium.
   CCCCV1. The exhibition of mercury will commonly ex-
asperate  the  disease,  and it is  certainly no antidote.   I have
administered  arsenic in considerable doses, for a very suffi-
cient length of  time  to ascertain its  powers; and although no
disagreeable effects attended its use, I never saw it  exhibited
with the  least advantage.
   CCCCVII.  Among the external applications that  have been
recommended we  shall mention,
   1. Preparations of lead.
   2. Arsenic.
   3. Solutions  of  iron.—Solutions of mercury.
   4. Carrot  poultice.—The fermenting  cataplasm.—Cicuta.
   5. Peruvian  balsam.
   6. Oily mucilages, or pure oil.
   7. Carbonic acid gas.—Carbonate of lime.—Rust of  iron.
   8. The electric aura.
                 CHAPTER  XII.

                     SECTION I.

                      OF THE  OZ.ENA.

  CCCCVIII. The Ozaena is an ulcer that is situated within
the cavity of the nose, discharging a fetid, purulent matter, and
is sometimes accompanied with carious bone.
               14 
106
OF THE OZiENA.
  CCCCIX. The term ozaena is used by some writers to ex-
press a  carious ulcer within the nose : it has  been defined by
others, " as a sordid carious ulcer within the maxillary sinus :"
but as the word was used by the Greeks, before  the nature of
the abscess within the Antrum Highmorianum was understood,
we shall confine the name, nearly, to  its original signification.
  CCCCX.  At the first appearance of this disease, it is some-
times attended with many of the common symptoms of a  ca-
tarrh ;  there will  be a trifling  tumefaction  and  redness about
the ala nasi, accompanied with a discharge of mucus, partly in
a fluid and partly in an inspissated state;  the air is transmit-
ted through the affected nostril with difficulty, especially during
sleep, and the orifice is often quite obstructed in the morning
by a viscid mucus.
  CCCCXI.   As  the disease  advances,  the matter that is
evacuated assumes  more of a purulent appearance: it flows in
the greatest quantity in the  morning; the  discharge is some-
times accompanied  with sneezing, and a slight haemorrhage oc-
casionally takes place.  The ulceration often  proceeds until  it
appears externally,  and then gradually spreads like a  herpetic
ulcer round the  angle of the ala nasi upon the cheek ; but it
very rarely destroys the ala nasi, or extends to  any considerable
distance from the nose.
   CCCCXII.   This  disease  is  very often  connected  with
scrofula, and with venereal complaints ; and in the  latter case,
more frequently than in the  former, some portions of  the ossa
spongiosa generally come away in a carious state.   Many vene-
real patients whose  complaints have been treated very proper-
ly,  will,  nevertheless,  sometimes complain  of a discharge of
fetid matter  from  the  nostrils,  and troublesome incrustations
within their cavity, for a considerable length of time after the
perfect cure of their orignal disease.
   These symptoms generally indicate the presence of carious
bone; and when that is exfoliated, the complaints will disap-
pear.   In a few cases, where  the quantity of carious bone  was
very considerable, I have seen the whole  ala nasi totally de-
stroyed.
   CCCCXIII.   When fungous or polypus-like excrescences
are connected with  the ozaena, the disease commonly originates
from scrofula.
   CCCCXIV.   The ozaena  frequently occurs as a symptom
of the  cachexia syphiloidea.   It will perforate the septum nasi, 
OF THE OZ.ENA.
107
destroy the ossa spongiosa, and sometimes render the ossa nasi
completely carious.   The depression of the nose, from  the
loss  of the ossa  nasi,  is more frequently  the effect of  the
cachexia syphiloidea, in the present day, than of lues venerea.
   CCCCXV.   When  purulent matter  is formed within  the
frontal, sphoenoidal, or maxillary sinus, the  symptoms will fre-
quently bear  a near  resemblance  to those which  occur in  the
ozaena ; and  indeed, the precise seat of the  disease cannot al-
ways be distinctly ascertained at an early period  of the  com-
plaint.  It  is  however necessary to be very careful, that we do
not mistake  an abscess within the antrum  highmorianum for
an ozaena.
   CCCCXVI.   As ulcers in those parts  that are employed
in  the function of respiration, frequently contaminate the breath
with  an offensive odour; when we  attempt to ascertain  the
cause of this inconvenience,  it will be proper to  examine  the
state of the nasal cavity, as well as the condition of the mouth
and fauces.
   CCCCXVII.    The  ozaena is generally  connected with
some disease of the whole system.
                     SECTION  II.

           OF  THE  TREATMENT OF  THE OZJENA.

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

vis  sternutatorius—mercurial  fumigations—diluted  vitriolic
acid, &c.
   The older surgeons advise the  use of the actual cautery ;
but I never saw its application necessary.
                 CHAPTER  XIII.

                    SECTION  I.

             OF  THE  CANKER  OF THE  MOUTH-

                        SYNONIMA.
  Apthae  Serpentes.  Sennertus.
  Labrosulcium, seu Cheilocace.  Arnoldus Bootius.
  Oris Cancrum.  Mays.  Stalpart vander Wiel.
  Gangrsena Oris.   Van Swieten.
  Gangrene Scorbutique des Gencives.  Auctores Gallict.

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

                 THE MODE OF TREATMENT.
       #
  CCCCXXVI. It  will be proper,
  1. To  remove  the diseased teeth, and carious bone, &c. if
possible.
  2. To  prescribe a milk and vegetable diet, and to allow a
prudent use of fermented liquors.
  S. It will be advisable to exhibit such remedies as
  Peruvian bark—sarsaparilla—elm bark—mineral acids.
  CCCCXXVII.  The  external applications that I have gen-
erally  found successful  have consisted  of  such  as  the  fol-
lowing :
  Preparations of copper—a  diluted mineral  acid—burnt al-
um—decoction of bark with white vitriol—tincture of myrrh—
lime water with alcohol, &c. 
110
OF THE CEDEMA,
                  CHAPTER  XIV.

                     SECTION   I.

                      OF THE CEDEMA.

   CCCCXXVIII. The term GSdema was employed by some
 of the ancient writers, in a sense synonymous with eminence, ex-
 tuberance, or tumour; but since the time of Galen, it has been
 more strictly confined  to those tumefactions which are derived
 from the effusion of a fluid into the cells of the reticular mem-
 brane of a particular part.
   CCCCXXIX.  A part may be said to be preternaturally  en-
 larged, when there is either an actual addition of substance made
 to  the solid contents of  the mass; or, when the volume of  a
 part is increased, the weight remaining nearly the same.  Obesi-
 ty will afford us an illustration of the former, and rarefaction of
 air in the intestines, an instance of  the latter.  There  is like-
 wise a third case, in which the contained fluids being propelled
 with an  increased  velocity  through their  elastic canals, these
 become unusually  distended, and produce  an augmentation  of
 bulk : this state, probably, takes place in phlegmonous tumours.
   CCCCXXX. Where there exists an addition of substance,
 this may consist of an increased quantity of fluid  in a particular
 part, and consequent dilatation of  the containing solids;  as in
 aneurism, varicose tumours, obstructed receptacles of secreted
 fluids, dropsies, he.  Or, there may be a secretion  of new matter,
 as fat, the contents of encysted tumours, exostoses, he.   Or, the
 augmented bulk may depend on  an additional quantity of solid
 and fluid matter; as in cases of polypi, fungi, and the  several
 kinds of sarcomata, and all preternatural enlargements of parti-
 cular parts, where the vessels which convey nutriment are  in-
 creased  in  number  and magnitude.
   CCCCXXXI. The tumour which constitutes an  essential
part of the disease termed oedema, consists of a  distention of the
solids, from the accumulation of a preternatural quantity of the
interstitial fluid in the cells of the reticular membrane : hence,
the oedema appears as a diffused tumefaction of the common in-
teguments, in some particular  part of the  body, unattended  by 
OF THE CEDEMA.
Ill
inflammation, yielding easily to pressure,  and retaining, during
some time, the vestige of the impressing body.
  CCCCXXXU. Among the supposed causes of oedema, the
following have been enumerated :
  1. Obstruction to the returning venous blood.
  2. Obstruction to the passage of lymph in the absorbent ves-
sels.
  3. A debilitated or inert state of the absorbent vessels.
  4. Loss of tone in the exhalent arteries.
  5. An inordinate action of the exhalent arteries.
  CCCCXXXIII. The agency of the two first assigned causes
in the production of oedema, is too well established to admit of
controversy.  But, that atony of the absorbent vessels is a cause
of oedema, has never been proved satisfactorily  by any experi-
ments yet made  public.  Indeed, a considerable  number of
facts connected with the history  of dropsy—as  the  abundant
absorption which is continually taking place on the surface of the
body—the celerity with which the water is absorbed and evacuat-
ed, under peculiar circumstances;—the great emaciation which
usually attends hydropical cases—the very partial effusion of fluid
which takes place in dropsies  of  particular parts, as  of the tu-
nica vaginalis testis, &c. and the enlarged  and distended state in
which the absorbent vessels are commonly  found in  dropsical
subjects, on dissection, militate strongly against the correctness
of such an opinion.  How far a morbid determination of fluid
to the exhalent arteries in those cases of dropsy, which are not
obviously the effect of  an alteration in the structure  of some
part connected with that which is  the seat of the effusion, will
afford an adequate solution of the phenomena, may be  deserving
of further inquiry.
  CCCCXXXIV\ As the  oedema  is the  effect of different
causes,  and appears under some variety of circumstances, it
may be convenient and useful  to arrange  it  under the following
heads:
   1. m,      .   ,    (flaccidum.
  _ OHdema simplex < ,  •
  2.                  (. durius.
  3. CEdema symptomaticum, vel tumor cedematosus.
  4. CEdema deuteropathicum.
   5. GCdema cum erythemate.
   6. GEdema purulentum. 
112
OF THE CEDEMA.
                    SECTION  II.

           OF THE  CEDEMA  SIMPLEX  FLACCIDUM.

  CCCCXXXV.  This form of the oedema is characterized by
a tumefaction of the integuments, commonly about the feet, an-
kles,  and  anterior  surface of the tibia : there is no particular
discolouration of the parts; it is unattended with pain; but
there  is usually a sense of weight and tightness, and the free-
dom of motion is more or less impaired:  firm pressure upon the
tumefied part produces a little cavity, which is not very quickly
effaced, and the feet are commonly somewhat colder than natu-
ral.   The  oedema usually increases towards the  evening, but
in consequence of  rest, and a horizontal position, it generally
subsides during the  night.
  CCCCXXXVI.  Of the remote causes of the oedema sim-
plex flaccidum.
  1.  Compression of the larger  veins,  or of the trunks of the
absorbent  vessels.
  a.  Obesity.  Gravid uterus.   Tumours within the  abdo-
men.  Sitting long on a hard seat.  Riding long in a carriage, or
on horseback.  Tight bandages,  not carefully applied.  Une-
qual pressure  from  splints, &c.
  2.  Whatever diminishes the powers which propel the return-
ing  blood.
  b.  A sedentary life.   Long exposure to cold, where no ex-
ercise is used, especially where persons  are advanced in years.
Long exposure to cold and  moisture,  at any period of life.   It
is often attendant on old age ; but chiefly where the person has
been  accustomed to inactivity.
  3.  Injurious effects produced on the stomach.
  c.  The excessive use of diluting liquids, as cold water, he.
  d.  The taking freely of spirituous  liquors, whether diluted,
or  undiluted.  Intemperance  in  the  use of  any fermented
liquors.   Intemperance in eating.
  4.  Profuse haemorrhages.  Hyper-catharsis.
   5.  Those  diseases of the  heart and lungs which obstruct the
due transmission of the blood through the pulmonary vessels.
   6.  Local injuries, as blows, sprains; also  inflammation, or
erysipelas, of the lower extremities. 
OF THE CEDEMA.
113
  CCCCXXXVII.   The oedema  simplex  flaccidum is com-
monly slow and gradual in its progress, unless when induced by
some of the causes  enumerated at  Nos. 3 and 4; but where
great violence has been done to  the stomach by intemperance,
it will sometimes appear  suddenly and  affect the body to a
very considerable extent.   More or less of this  form  of  the
oedema is commonly seen in the  skin covering the anterior sur-
face of the tibia, in the greater number of persons who are  be-
yond the age of fifty years.   Where the skin has been a long
time distended  with lymph, maculae of  a dark yellow colour
are  often seen upon  the lower parts of the legs.
  CCCCXXXVIII.  The  prognosis of the oedema  simplex
flaccidum.    The comparative  danger or unimportance of  this
form of  the oedema  is  influenced principally by  the nature of
the  remote cause.   It  may,  however, be stated in general, that
when an oedematous state of the ankles is not connected with
any general disease  of the system, it may continue during many
years without indicating a tendency to general dropsy, or pro-
ducing any material inconvenience.
                    SECTION III.

  OF  THE  TREATMENT OF  THE CEDEMA SIMPLEX FLACCIDUM.

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

               II. (EDEMA SIMPLEX DURIUS.

   CCCCXLI.   This form of the disease  appears in one or
 both of the  lower  extremities: it is accompanied  with  pain,
 and some degree of lameness;  but there is no discolouration of
 the  skin,  nor preternatural increase  of temperature.  The
 tumefaction is pretty  uniform, and extends from a little below
 the knee to the ankle ; but seldom molests the foot:  the affected
 parts are much firmer than in the oedema simplex  flaccidum,
 and yield  very little to pressure.
   CCCCXLII.  This disease is evidently  connected with  a
 morbid state of the deeper seated absorbent vessels, about the
 calf of the leg.  The  patient commonly refers to the posterior
 part of the leg, as the principal seat of his pain; on  pressing
 firmly on the gastrocnemius  muscle, the absorbent vessels can
 be felt  in an enlarged  and indurated state, and the pain  is much
 aggravated by compressing them.   Sometimes, indeed, the pa-
 tient complains of pain in the posterior part of his leg, espe-
 cially on walking and standing, before any tumefaction of the
 limb makes its appearance.
   CCCCXLIII.   In the oedema simplex durius, there is pro-
 bably very little effusion of the interstitial fluid into the cells of
 the reticular membrane :  the intumescence never ascends quite
 so  high as the knee  joint;  nor do the absorbent vessels, or
 glands  in the ham participate in the disease.  The general ap-
pearance of the limb excites  the idea of turgescence  from an
increased quantity of fluid, contained within its natural canals,
 rather than that of tumefaction from effusion.
   CCCCXLIV.  This disease may exist in only one of the
lower extremities  ; but more commonly both legs suffer from
it, at the  same time.  It occurs more frequently in  women
than in men;  and is seen as often in young persons, who have 
OF THE CEDEMA.
115
attained to adult age, as in those  who  are  more advanced in
years.
  CCCCXLV.  The remote causes of this  form of the oedema
are not very numerous, nor are they always so obvious, as to
remove all doubt from the mind, of their agency.   1 have seen
it connected  with  amenorrhoea in  some plethoric habits; it
may arise from  inaction, in those  who are  disposed to corpu-
lency ; and very frequently it attacks those  whose occupation
obliges them to stand many hours every day.  I have also met
with this  disease, where 1 could not discover any evident cause
of its appearance.
                    SECTION V.

  OF  THE  TREATMENT  OF THE CEDEMA  SIMPLEX  DURIUS.

  CCCCXLVI.  a. The remedies which confer the  most
speedy  and  permanent  relief  are  brisk  purgatives.  These
should be administered once in four or five days, as the powers
of the constitution will permit.
  b. Small doses of calomel with alkaline salt, may be given
on the intermediate days.
  c. Rest and a recumbent posture must be enjoined, until the
pain shall have abated considerably.
  d. The vapor of camphorated spirit of wine and  volatile al-
kali may be employed with advantage.
  e. When  the  hardness and extraordinary tenderness of the
absorbent vessels are considerably reduced, friction  with the
linamentum  ammoniae may be used.
  /. A flannel bandage must be applied, as soon as the leg can
bear moderate pressure ; and it  ought to be continued during a
few weeks, after the disease has been removed.
                   SECTION  VI.

  III. (EDEMA SYMPTOMATICUM,  SEU TUMOR CEDEMATOSUS.

  CCCCXLVII.   This is not a distinct form of the oedema,
nor does it differ in its symptoms from the oedema  simplex 
116
OF THE  CEDEMA.
flaccidum.  It is arranged under a separate head, because it
occurs as a sign of some other disease, without absolutely con-
stituting a part of it.
   CCCCXLVIII.   Without attempting to include all the dis-
eases of which the oedema symptomaticum often indicates the
existence, the following enumeration may suffice :
   1.  Simple fracture.
   2.  Fracture of the cranium.
   3.  Collections of  fluids in natural cavities : as extravasation
of blood within the thorax: effusions of pus within the abdo-
men,  &c.
   4.  Suppuration in natural cavities—within the  capsules  of
glands—under strong fasciae   and  aponeuretic  expansions—
deeply seated in muscular parts.
   5.  Gangrene.
   6.  OZdema frequently occurs in the prepuce, from gonorrhoe-
al  irritation, and in the glans penis, from disease of the prostate
gland.
   7.  In parts  afflicted with large  and ill-conditioned sores.—In
cases of varicose ulcers.*
   8.  Diseases of the periosteum  and of the bone.
   9.  Irregular appearances of the oedema in different parts of
an upper  or lower  extremity,  sometimes indicate  a failure of
the general powers of the constitution.
   CCCCXLIX. The most important matter which is attached
to the history  of  this form of the  oedema, is the circumstance
of its sometimes indicating the presence of another disease, the
symptoms of which may not  be sufficiently clear to conduct
us immediately to the knowledge  of its existence.  So,  like-
wise, where  this symptom is usually connected  with any par-
ticular morbid alteration, an attention to it becomes  necessary
in studying the  natural  history of the  disease.   The  cure of
this complaint evidently  depends upon the removal of the cause.

   * When the oedema  surrounds a varicose  ulcer, or an ill-conditioned
sore, on the leg, the ulcer cannot be healed, as long as this morbid  affec-
tion of the integuments remains.  A tight bandage, with the occasional use
of purgatives, will commonly empty the loaded  cells, and facilitate the
cure of the ulcer. 
OF THE CEDEMA.
117
                    SECTION VII.

    IV.  (EDEMA DEUTEROPATHICUM SEU  PUERPERARUM.

  CCCCL.  That swelling of a lower extremity, which some-
times attacks lying-in women, being attended with some  par-
ticular circumstances which  distinguish it from all other tume-
factions,  seems to be connected  with  certain modificatioiis of
the system, peculiar to the puerperal state.   It may be doubted
whether a disease exactly similar has ever occurred to women
who have not been  pregnant.
  CCCCLI. The  period at which the oedema  puerperarum
makes its appearance after parturition, is not constant and uni-
form ; most commonly it occurs in about twelve or fifteen days;
although  it has  sometimes been seen as early as the day  after
delivery, and at other times, three or four weeks have elapsed
before the attack.   It usually commences with pain about the
calf of the leg,  succeeded by tumefaction in the labium pudendi
and groin, which  gradually descends down the thigh, leg and
foot, so that, in the  course of two or three days, the whole  of
the lower extremity acquires a very considerable increase of
bulk.  The limb is  painful,  preternaturally warm,  and  admits
of no motion without exciting great uneasiness; but the colour
of the skin is either unaltered, or it becomes whiter than natu-
ral.   The integuments  are  firm,  elastic,  and  do not yield to
pressure  as in the oedema simplex flaccidum ; no water is usu-
ally discharged on scarifying the part,  nor is the tumefaction
of the limb at all reduced by a horizontal  position.  This dis-
ease is also commonly attended with the usual concomitants of
symptomatic inflammation.
   CCCCLll.  It is not usual to see both the lower extremities
affected by his  disease  at the  same time; although instances
are not wanting of such an occurrence.  It has been supposed,
that a woman cannot be  afflicted with  it in the same limb more
than once; but although 1 cannot controvert this opinion  from
my own  experience, yet, I have  attended women in this dis-
ease, who have assured  me, that the same complaint had oc-
curred to them before, in the same extremity.*

  * £)r. Denman  asserts the possibility of the same woman being affected
with this disease more than once.  Introd. to Midwifery, p. 622. 
118
OF THE  (EDEMA.
   CCCCLIH. The oedema puerperarum does not appear to
be confined to any particular  temperament,  form of body, or
habit of living.  It has no connexion with the paucity, or abun-
dance of the lochial discharge, nor with the secretion of milk,
nor with the  suppression of that secretion;  although some of
the French writers have asserted, that it sometimes  appears
subsequently to weaning the child.*  The disease never sup-
purates, nor  does it leave any permanent  induration or lame-
ness, although, in some cases, several weeks  elapse  before the
patient recovers the use of the limb entirely.
   CCCCLIV. The  oedema  puerperarum must  be carefully
distinguished from the iliac abscess; from  the tumefaction, in-
duration, and suppuration about the calf of the leg, which are
incident to lying-in women ; and from that inflammation of the
absorbent vessels which is attended with  enlargement of the
whole limb,  and  which will be described in a subsequent part
of this chapter.
   CCCCLV. There  are no  instances upon record in which
this form of the oedema hath  proved directly fatal; f nor are
we possessed of any satisfactory account  of the  state of the
limb, from an accurate anatomical examination  of the parts
after death. J  The remote cause of the disease is likewise in-
volved  in  considerable  obscurity.  In some  instances, 1 have
seen it apparently derived from imprudently exposing the limb
to cold ;  but  in other cases, it has occurred without the evident
intervention of any assignable  cause.§   There is no good rea-
son for supposing, with the French writers, that  any thing like
a metastasis takes place.
                   SECTION VIII.

     OF THE TREATMENT OF THE CEDEMA PUERPERARUM.

  CCCCLV1.  The symptomatic inflammation may be re-
lieved  by  such medicines  as promote  a diaphoresis:   e. g.

  * Levret, &c.
  t Dr. Denman is of opinion, that it does sometimes prove  fatal.  In-
trod.  to Midwifery, p. 656.
  t The account given by Zinn is far too imperfect to require any qualifi-
cation of this language.
  § Upon the subject of the remote  cause of the oedema puerperarum, the
writings of Mr. White, Dr.  Ferriar, Dr. Hull, Dr. Denman, and the au-
thors referred to by those gentlemen, may be consulted. 
OF THE CEDEMA.
119
James's  powder—saline draught with  volatile alkali—Minde-
rerus' spirit—small doses of the pulvis ipecacuanhae composi-
tus—camphor with opium, he.
   CCCCLVII.   When the violence  of the first  symptoms
have somewhat abated,  the free  exhibition of purgatives, espe-
cially such as are combined with calomel  and alkaline salt, are
highly beneficial.  They should be repeated as frequently as the
strength of the system will permit.
   On the intermediate days, when the purgatives are not ex-
hibited, the Peruvian bark, cascarilla, myrrh, vitriolic acid, and
similar tonics may be administered.
   CCCCLVI1I.  Of the local treatment.
   a. When the pain is very severe, leeches may be  applied to
the upper part of the thigh, with advantage.
   b. Anodyne fomentations.  Camphorated  oil,  with tincture
of opium.   Linimentum  ammoniae  and linimentum saponis
compos—in equal  quantities.  A flannel  bandage, as soon as
the tenderness of the limb will allow of its application.
   c.   Small blistering plasters have been  recommended by the
most respectable practitioners.
   d.  When the limb can permit motion  and pressure without
exciting great uneasiness, moderate exercise and the prudent
use of friction will  be highly conducive  to recovery.
   Some  degree of lameness may remain during many weeks
after all external appearances of  the disease have vanished.
                   SECTION  IX.

               V. CEDEMA CUM ERYTHEMATE.

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

              OF THE MODE OF TREATMENT.

  CCCCLXIII.  The general and local modes of treatment,
which were recommended for the cure of the oedema deutero-
pathicum, seu puerperarum, may be employed with success in
the  removal of this disease. 
OF THE CEDEMA.
121
                    SECTION  XI.

                VI.  (EDEMA PURULENTUM.

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

             * Principia Systemat: Chirurg: Vol. II.
16 
122
OF THE (EDEMA.
                    SECTION  XII.

              OF THE MODE OF  TREATMENT.

  CCCCLXVII.   I am  doubtful whether a resolution of the
tumefaction, &c. ought to  be attempted ; no endeavours that I
have yet used have been successful, and it is more than proba-
ble, that the patient is rather injured than benefited by a steady
adherence to the antiphlogistic mode of treatment.  During the
first period of the oedema purulentum, such medicines as deter-
mine to the skin, joined with opium to  allay the pain, seem the
best  adapted to  relieve the  distress of the sufferer.
  CCCCLXVIII.  As  soon as the process of suppuration is
indicated, the patient must  take Peruvian bark, with opium ;
this must be continued after the rupture of the abscess, with a
plentiful diet,  and  country or  sea air.  The diluted sulphuric
acid  may be likewise administered  with  advantage.   The pa-
tient generally recovers, and regains the use of his limb ; but
he will seldom be  found  completely restored  to his health in
less than three or  four months.
  CCCCLXIX.   The local treatment.
  No application to the diseased iimb is attended with any pe-
culiar advantage, during the first stage of the disease ; when the
abscess has burst,  the  ulcer may be dressed with  dry lint and
common digestive, washing  the part with the Aqua Catnpho-
rata Bateana, at each time  of renewing  the dressing.   As there
is generally a  remarkable  flaccidity of the limb, after the dis-
charge of the  matter, the use of a flannel or calico roller will
be attended with many advantages.
  The patient will be generally benefited by sea-bathing, dur-
ing the  healing of the ulcer. 
SURGICAL   OBSERVATIONS
THE  CONSTITUTIONAL  ORIGIN  AND TREATMENT OF
LOCAL   DISEASES;
AND ON
ANEURISMS.
                BY JOHN ABERNETHY,  F. R.  S.
Honorary Member of the Royal Medical Society of Edinburgh, and of the Medical Societies
      of Paris, Philadelphia, &c, Surgeon to Christ's Hospital, Assistant Surgeon
          to St. Bartholomew's Hospital, Teacher of Anatomy and Surgery,
                and Professor of Anatomy and Surgery to the Royal
                            College of Surgeons.
" Chirurgo necessariam esse cognitionem Physices, Chimiae,
   Logices, omnia (fere) ambitus Medicine ; neque solo manui
   exercitio veros chirurgos fieri."
                               Herm. Boerhaav. Method.
                         Stud. Med. locupletata ab Alb. von Haller. 
 
PREFACE.
   The best mode of obtaining and extending medical and sur-
gical knowledge is, in my opinion, to pay  that strict attention
to diseases, which qualifies us to note even the slightest shades
of difference that distinguish them from each other.  Such dis-
crimination leads us to form some regular arrangement of them,
which, even if it be not correct,  may  ultimately  enable us to
discover their  natural series and order.  This  method  I have
pursued from  the beginning of my professional studies.  When-
ever the opinions on subjects of importance, which an attention
to cases had  impressed upon my mind,  differed from those
which seemed to prevail  amongst other practitioners, I pub-
lished the  facts,  and the  inferences which I drew from
them; because I thought that  the former at least  deserved at-
tention, and that the latter would either be confirmed or con-
futed by the result of general experience.
  It is more, however,  on  account "of the cases,  than  of the
conclusions which they  suggested, that I am desirous of repub-
lishing my surgical writings.   Various  advantages result even
from the publication of opinions ; for though  we are very liable
to error in forming them, yet  their promulgation,  by exciting
investigation, and pointing out the deficiencies of our informa-
tion, cannot be otherwise than useful in the promotion of sci-
ence.
  The  publication  of  the  opinions  which  naturally  arise
in the mind  of the surgeon, from the cases  submitted to his ob-
servation, possesses  the  further utility of rendering a prolix de-
tail of circumstances unnecessary.   It would  be almost impos-
sible to relate  every minute occurrence, that tended to impress
certain conclusions on the mind of the  observer;  or  to relate 
126
PREFACE.
every trifling particular of treatment, by which the surgeon en-
deavored to accomplish his  object.  Such a dull and tedious
narrative, which would weary and disgust the reader, may in-
deed be well spared;  because the practitioner may, and must,
repeatedly peruse the  case  at  large in the book of nature.
The writer merely points out those signs by which any disease
may be discriminated from others, and identified as one of the
particular class to which he is desirous  of exciting the public
attention.
   With regard to the cases, which I consider as the valuable part
of the book, I may observe, that it is not to be  expected that
the records of them will make so strong an  impression on the
minds of the readers, as the observance of them has done on
that of the writer; but  when the same occurrences are met
with in practice, then will the impression become more vivid,
and knowledge arise, as it usually does, from personal expe-
rience.    If  the  facts  contained in this volume occurred so
rarely, that others could not be expected to meet with them,
their  relation  would be of little  value.   They may, however,
not improperly be compared to certain species of plants, by no
means uncommon, which are liable to be confounded with oth-
ers by an  inattentive  observer;  but when their  discriminating
characters are once pointed out, they may be so readily dis-
tinguished, collected and examined, as to render  a more minute
description of them unnecessary.  If diseases  could, like  oth-
er objects which we  mean to delineate, be placed in  various
points of view, and illuminated at pleasure, so as  to show dis-
tinctly their different parts, one accurate representation  would
suffice ; but we see them obscurely, and as knowledge increas-
es, it serves, like light shining from different places, to illumin-
ate the various parts of the objects of our examination.
  For, as I have  expressed it in the first edition of these  wri-
tings, " in proportion as we  advance in knowledge, we are led
to remark many circumstances in the  progress  of a  disorder
which had before passed without notice ; but which,  if known 
PREFACE.
127
and duly attended to, would clearly point out the nature of the
complaint.   Hence the records of former cases  are of much
less value ; as the symptoms about which we are now anxious to
inquire, have in them been entirely overlooked."   It, therefore,
becomes necessary that each writer should state those circum-
stances to which he has been particularly attentive ; nor  need
he further delineate the case than by a general outline, so as to
render it intelligible.
  The relation of cases may be compared  to  the representa-
tions which an artist gives of natural  objects,  and which are
valuable  only inasmuch  as they  are  correct or  vivid  deline-
ations of reality.   Such portraits, sketched by a person of dull
perception, or by one whose optics  are perverted by prejudice
and theory, are either valueless or deceptive; and hence, per-
haps, has arisen that objection to books of cases which  I  find
to be very prevalent.   In the imperfect sketches which I have
laid before the public, my chief object has  been  to touch  up
and bring into view some parts of the  subjects  which have not
been so clearly seen or strongly  delineated by former drafts-
men.
  When books of this kind are published, mutual forbearance
is requisite on the part both of the writer and the reader.  The
former should not expect his work to  be  approved of,  till the
latter has examined whether his  representation  of diseases be
correct, and his conclusions legitimately drawn from the facts
which  he has  observed and  collected.  Neither should the
reader condemn the work till he has examined the subject, and
is in consequence able to point out the errors of  the premises
or conclusions.  The author's view  of a subject may indeed be
correctly formed  from the facts which he himself has witnessed ;
but it may differ from that  which more  extensive experience
would have suggested.   For this difference no blame can prop-
erly be attached to him;  he relates  what has fallen under his
own  observation, and  invites  others to attend  to the same
facts. 
128
PREFACE.
  I have been induced thus to offer my sentiments  respecting
the design, mode, and probable advantages of recording cases,
not with a view of vindicating the plan which  I  have pursued,
for  that indeed  cannot  be necessary, since it is the same that
has been followed by the best authors on surgery.   My object,
by these  remarks, has been to induce others to reflect how they
may most effectually promote medical  knowledge.   No one
can have thoroughly studied his profession without  perceiving
how susceptible it is of improvement, without discerning how
inadequate  the efforts of an individual must be towards the ac-
complishment of this purpose, and consequently without feeling
an earnest  wish to engage general co-operation in this desirable
object.
   In republishing my former writings, I have left out ail that
part which relates to physiology.   The surgical facts contained
in them,  will now be found incorporated with my later publi-
cations, under the same general head of Surgical Observations.
I have also made those alterations and  enlargements  which  a
greater share of experience  has  dictated.   The subjects have
likewise  been transposed.  I have put at the  beginning  of the
book those cases which show how much local diseases depend
upon the general state of the patient's  health, because I shall
have frequent occasion to refer to this subject in the  succeeding
parts of the work.
   1 feel much  gratified in finding, that, though  a larger portion
of experience has enabled me to add some new and striking facts
 to  this edition, it has not shown me any thing  that I ought to
retract or materially to alter.  This, indeed, must be the case
in a book containing only facts,  and  opinions not  incautiously
deduced from  them.   Several of the papers contained  in this
volume met  with very general and strong objection, which 1
considered as the greatest compliment which could  be paid to
them.    For if the views which I had taken of various practical
 subjects were different from those of others, and were ultimate-
ly  found to be correct, the  greater was the necessity for their
 publication. 
SURGICAL   OBSERVATIONS.
                          ON THE

CONSTITUTIONAL ORIGIN  AND  TREATMENT

                            OF

             LOCAL   DISEASES.

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

             * Treatise on the Blood, Inflammation, &c.
               17 
130
ON  THE CONSTITUTIONAL  ORIGIN AND
fever : if the nervous system be chiefly affected, a state of vig-
ilance or of delirium may be  produced : convulsions and  teta-
nus take  place, when the functions of the muscular system are
more particularly deranged.  Though the disorder of particular
organs thus gives a character  and denomination to  the disease,
it  is  sufficiently evident, in the  instances  adduced, that the
whole constitution is disturbed ; while  certain parts are chiefly
affected, perhaps from unknown  circumstances relative to the
nervous system, or from a predisposition to disorder existing in
the affected parts.   It seems  to be ascertained, that psrsons of
particular constitutions are predisposed to those febrile actions
of the sanguiferous  system, which constitute the inflammatory
fever; that there is a propensity to  convulsions  in  children;
and to tetanus in the inhabitants of warm climates.
  It may be  a fit subject  for  inquiry, whether it be possible
for particular  organs to become affected otherwise, than through
the medium of the  nervous system in  general.  Though some
instances  of sympathy are  strange, and perhaps inexplicable,
there are  strong reasons for believing that the  inflammatory fe-
ver, the state of vigilance and delirium, convulsions and tetanus,
which arise in consequence of injuries of the limbs, are pro-
duced by irritation imparted to the brain, which, by a kind of re-
flected  operation,  occasions a greater  disorder of some of the
organs of the body than  of others, and thus gives a  character
and denomination to the disease.*
  That the stomach and bowels are disordered by injuries and
diseases of parts of  the  body, has been remarked  by various
persons;  but  the subject has never been extensively  surveyed,

  *  Mr.  Hunter, who, with that patience  and industry for which he wag
so remarkable, collected and examined all thefact.-s which he had observed
relative to the subject of sympathy, lias divided it into continuous, contig-
uous, and remote. It is the remote sympathies, according to his division, of
which I am now speaking.
  The observations of Dr. Darwin on ocular  spectra, and indeed the con-
sideration of the.nervous functions in general, render it highly probable that
sensation is not  produced merely by impulses made on the nerves, but by
means of actions excited by such impulses,  which actions are continued
to the sensorium.  Nervous actions, then, may take place without the usual-
ly exciting causes ; such actions may be continued through the mediujii
of the  reticular communications of nerves, and ttius physiologically we may
explain the continuous and contiguous sympathies.  Actions also produc-
tive of sympathetic sensations may be supposed to take place through the
media of ganglia or plexuses.  in remote sympathies, however, we must
suppose the actions which originate in an injured or  diseased part  of the
body to be continued to the sensorium, and there to excite the actions of
other nerves, &c. 
TREATMENT OF  LOCAL  DISEASES.
131
nor  viewed with that  accuracy of observation which its high
importance  merits.  It has been observed that sprains of ten-
dinous or  ligamentous  parts produce  sudden sickness; and
Mr.  Hunter has attributed that shivering which  is consequent
to accidents, and  attendant on some diseases, to the state of
the stomach.  It is known that, in some local injuries from ac-
cident or  operations, the stomach has appeared to  be the part
principally affected. But remarks on the affections thus induced
in the  digestive organs have been made only in a cursory man-
ner ; and  it  is my intention to examine the subject more partic-
ularly.  It also appears to me that the connexion of local dis-
eases with the state of the constitution in general is either not
sufficiently understood,  or not duly regarded by the generality
of practitioners ; and I also mean to claim their particular atten-
tion to this subject.  I shall  in the first  place select a case to
show how the stomach and bowels, or, to speak yet more exten-
sively, the digestive organs may be affected from local disorder.
SUDDEN  AND VIOLENT  LOCAL  IRRITATION WILL SOMETIMES
  PRODUCE  AN EQUALLY SUDDEN AND VEHEMENT DISORDER
  OF  THE DIGESTIVE  ORGANS.

                         CASE  I.
  A healthy gentleman, about twenty-five years of age, was
induced to  submit to an operation for the return of an adhe-
rent omental hernia, rather in order  to remove the inconve-
nience and  apprehension which the disorder occasioned, than
from any urgent necessity ; for any increased exertion in walk-
ing or riding  produced the descent of a portion of intestine
behind the  thickened omentum, and obliged him to stop, and
replace it:  and he frequently could not accomplish the reduc-
tion without considerable difficulty.  The application of trus-
ses had been quite  ineffectual in  obviating these alarming in-
conveniences.
  The patient's diet on the day preceding the operation  was
scanty,  and consisted  of fluid  substances.  He  took  on the
morning  of the operation   some Epsom  salts  and  manna,
which purged him twice and seemed to have emptied his bow-
els.   A portion of the omentum was cut off, and the remainder 
 132        ON THE  CONSTITUTIONAL ORIGIN AND

was returned, after two vessels had been tied.   The operation
was followed by general disorder of the constitution, manifested
by  a full  and strong pulse, furred tongue, great anxiety, rest-
lessness, and  total want of sleep.   The  stomach was part cu-
larly affected, being distended, uneasy on compression, and re-
jecting every thing that was swallowed.   He  was bled largely
in the evening, and took saline medicines, but could not be pre-
vailed on to swallow any thing else, except some toast and wa-
ter.   The sickness had in some degree abated on the next day.
A solution of sulphate of magnesia in mint water  was  prescribed
in small  occasional doses, in order to  relieve the disorder and
distention of the  stomach, by procuring  some discharge from
the bowels.*   In the course of the day he took an ounce of the
salts, which were not rejected by the stomach, yet he could
scarcely be prevailed upon to take any thing else.  The tongue
was still covered by a thick yellow fur ;  the skin was hot and
dry, and the pulse frequent.   As there was no particular tender-
ness about the hypogastric region, he was not again bled.   The
second  night  passed  without any sleep.  As   the  salts had
produced no effect,  the same medicine was ordered  in an effu-
sion of senna, with the addition of some of the tincture, which,
by  being  given  in very small doses, was retained.  When,
however, it seemed likely that no  effect  would result from this
medicine,  a grain of calomel was  given at night, and repeated
on  the following morning.  Still the loathing of food continued.
The third night passed, like the former ones, without  sleep, and
in  great anxiety.  On  the next morning, two pills,  containing
five grains of the pil. colocynth. and the same quantity of the
pil. aloet.  cum myrrha, were given every fourth  hour.  These
procured no stool, nor produced any sensation  which inclined
the patient to  believe that they would operate.   Again he pass-

  * It is most probably the disorder of the brain which affects the stomach ;
but the reaction of the latter affection is liable to increase and maintain
the  former, by which it had itself been produced.   The effects that result
from the sympathy of  the  whole constitution with local disorder vary
greatly both in nature and degree.  Sometimes the brain is the  part chiefly
affected;  on these occasions the nervous  energy appears to be  much
impaired; and in some instances of this description, the  patient  gradual-
ly sinks, little fever or reaction of the constitution being observed; in
other instances, however, there is a low delirium, with a slight degree of fe-
brile action;  and in others again, the delirium is more violent, and is ac
companied with a proportional increase of fever, subsultus of the muscles,
and convulsions.  Sometimes other parts of the body or  particular organs
seem to be principally affected ; indeed the variety of effects produced un-
der  the circumstances alluded to is such as to baffle description.
i 
              TREATMENT OF  LOCAL DISEASES.          133

ed a sleepless night;  but, towards the morning, he felt his bow-
els apparently filling, to use his own expression, and a profuse
discharge ensued.  A dozen copious, fetid, and black evacua-
tions took place between five and ten o'clock, and he had sev-
eral others in the course of the day ;  after  which his  appetite
returned, his tongue became clean, and a sound and continued
sleep succeeded.
  That the chylopoietic organs were the parts chiefly affected
in this case, can scarcely be  questioned.   The  sickness, the
tenderness of the parts in the epigastric region, the aversion to
food, and the state of the tongue, all indicate that the stomach
was much  disordered.  The  insusceptibility of the bowels  to
the action of medicines, which  would ordinarily have produced
discharges from  them, and the profuse evacuations which sub-
sequently relieved the patient,  prove  that these viscera partici-
pated in the  affection.  The  black  colour of the discharges
shows, I think, that  the secretion of the bile was not healthy,
and  that the liver  was affected with the  other chylopoietic
viscera.
   It  may be supposed, that the injury done to  the omentum
might contribute to produce the disorder of these organs, rath-
er than of others.  We do not, however, find that such effects
commonly succeed  to similar  operations.  The  consequences
in the present case were more  severe than might have been ex-
pected, if it were not known, that an operation performed  on
a healthy patient is more  apt to produce considerable disorder,
than when performed on one whose constitution has previously
sustained the  irritation of a disease, for which   the operation
becomes necessary.
   It  is probable also that the  restlessness and anxiety of the
patient were aggravated, if not principally caused, by the  state
of the chylopoietic viscera ; since the relief which took place in
those parts on the renewal of secretions into them, certainly re-
moved the nervous and febrile  symptoms.   That the discharges
were the effect of secretion is proved by the absence of alimen-
tary matter in the bowels, in consequence of the  action of the
purgative administered on the  morning of the operation,  and
the abstinence both before and after  that period.*

  * Two instances are recorded in  Mr. Pott's Works, of the operation for
the reduction of an hernia being performed where no strangulation exist-
ed   See Pott's Works, Vol. III. pp. 295, 299, edition of 17d3
  The operation in the case just related was undertaken upon the authority
of these cases, which were both successful.  I oerformed a similar operation 
134         ON THE  CONSTITUTIONAL ORIGIN  AND

   I could relate  numerous cases  in support of  the  inferences
which I have drawn from  the preceding history; that local ir-
ritation  acting on the  nervous system may affect the digestive
organs in a very serious manner, and thereby create great gen-
eral disorder of  the system, which is  afterwards alleviated in
proportion  to the amendment that ensues  in the state  of those
viscera.  Such consequences of great  local irritation must fre-
quently occur to every one ; it is therefore unnecessary to ad-
duce  more instances to support  the opinions here delivered.
   With respect to the treatment of cases of this description  it
may be right to add, that the primary object  should  be to pro-
duce  secretion from the irritable organs.   In the case which
has been related, and in many others recorded in this  volume,
the effect of secretions  occurring from the  disordered organs
in relieving their irritable state is very manifest.  In  many in-
stances  opium will not prevent continual  efforts to  vomit, yet
when by magnes. sulphat. or purgatives  administered in the
form  of pills, and  clysters, stools  are  procured, the vomiting
ceases,  the stomach retains both food and  medicine,  and gene-
ral tranquillity of constitution is  as suddenly restored.
A  SLIGHTER DEGREE  OF CONTINUED LOCAL IRRITATION WILL
   PRODUCE A  LESS VIOLENT  DISORDER OF  THE  DIGESTIVE
   ORGANS.

   If  then vehement local irritation can produce a violent dis-
turbance of the chylopoietic organs, it may be expected that a
less degree of a similar cause will produce slighter effects of the
same  nature.   Indeed, the foregoing case was related not mere-
ly because it seemed worthy of record by itself, but chiefly to
prepare the reader for the observations which are to  follow.
   The slighter degree of derangement occurs in the advanced
stages of lumbar abscess, diseased joints, compound fractures,

on a patient, whose life had been twice in imminent hazard from strangula-
tion in a case of adherent epiplocele, in which a truss did not keep up the
hernia, and the operation was followed by violent peritonitis, which could
only be subdued by such copious and repeated venesection as endangered
the patient's life.   These two cases have made such an impression on my
mind,  that I should be very averse in futuve to undertake similar experi-
ments. 
              TREATMENT  OF LOCAL DISEASES.         135

and all kinds of local disease, which impart considerable and con-
tinued irritation to the whole constitution.   We also find a less
important disease, as  for instance, a fretful ulcer,  keep up  a
disorder of the system in general, and of  the  digestive  organs
in particular, which subsides as the irritable state of the ulcer
diminishes.   But as practitioners in general may  not perhaps
have so  attentively remarked  these  circumstances  as to be
familiarly acquainted  with them,  it may be useful to mention a
very common occurrence, which  cannot have escaped observa-
tion.   I allude to the effects of the irritation of teething upon
the health of children.  The brain is  sometimes so affected  as
to cause convulsions ;  the digestive organs are almost constantly
disordered.   The  appetite  fails ; the tongue is  furred ; the
secretions of the liver are either suspended, diminished,  or vi-
tiated.   The bowels are either purged or costive, and the fasces
fetid.  The faecal matter is often  mixed with mucous and other
secretions.  There is also frequently a very troublesome cough.
Such symptoms  generally  subside  when  the  local  irritation
ceases, but sometimes the disorder of the digestive organs, thus
excited, continues and disturbs the general health of the pa-
tient.
   If local irritation  be capable  of disordering the bowels,  it
seems natural to conclude that it acts upon them through the me-
dium of the brain.  If also the brain and nervous system should
be disordered,  without any apparent local  disease,  similar
derangements may be expected to take place in the  functions
of the digestive organs.  In  cases, where some morbific poison
has been absorbed, producing effects similar to those of syphilis,
we usually find the irritation of the constitution which  ensues
to be accompanied with this slighter disorder of the chylopoie-
tic organs.
   Whenever, also, the  nervous energy and general powers  of
the constitution have been  weakened and disordered  by any
violent  disease, as fever, small pox, measles, hooping-cough,
&c. the digestive organs are  frequently affected in consequence,
and such affection becomes, as will afterwards be explained, the
cause of many secondary diseases.
   In persons, likewise, who  have naturally a weak or irritable
state of the  nervous system, we find the digestive  organs dis-
ordered in a similar  manner.  Improprieties  in diet will also
produce a similar state  of irritation, weakness,  and disorder  of
the functions of the digestive organs. 
136        ON THE  CONSTITUTIONAL  ORIGIN AND
   This slighter disorder of the chylopoietic organs is, in gen-
eral, manifested by a diminution of the appetite  and digestion,
flatulence, and unnatural colour and  fcetor  of the excretions,
which are generally deficient in quantity.  The tongue is  dry,
whitish, or furred, particularly at the  back part;  this symptom
is most apparent in the morning.   The fur is greatest at the back
part, and extends along the middle of the tongue to the tip, the
edges remaining clean.  As the disease advances, a tenderness
is felt when the epigastric region is compressed, and the  pa-
tient breathes more by the ribs,  and less by the diaphragm than
in  the  healthy state.  The urine is frequently turbid.
  In this general enumeration of the symptoms, several circum-
stances are omitted which occur occasionally, and which  may,
when the subject shall be better understood, denote peculiarities
in  the disease,  and require  corresponding peculiarities in the
medical treatment.   I shall here notice a few of them.   The ap-
petite is sometimes  moderately good,  when the digestion is im-
perfect ;  and the latter  may not be defective, although the  dis-
ease still exists.   In some i, stances,  indeed, the appetite is in-
ordinate.   Tenderness of the   epigastric region  on pressure,
is not always an attendant even  in advanced stages of the  dis-
ease.   The bowels are alternately costive, and  lax even to purg-
ing.*    The urine is sometimes  pale coloured and copious like
that of hysterical patients.
  Patients affected  in the manner above described, commonly
declare they are in  good health, except that they feel disturbed
by their local complaints; yet they are  found, on  inquiry, to
have all the symptoms, which characterize a  disordered  state
of the  digestive organs.  The mind is also frequently irritable
and despondent; anxiety  and   languor  are  expressed in  the
countenance.   The  pulse  is frequent  or  feeble ; and slight
exercise produces considerable perspiration and fatigue.   The
patients are sometimes restless at night,  but  when they  sleep
soundly they awaken unrefreshed,  with  lassitude,  and  some-
times a sensation, as if they were incapable of moving.   Slight
noises  generally  cause them to start, and they are, to use their
own expression, very nervous. These circumstances seem to me
to indicate weakness and irritability of the nervous and muscu-

 * I have  known persons whose bowels  were ordinarily costive,  and
whose general health was much  deranged  by disoder of the digestive
organs, though they were unconscious of its existence, feel pleased that
their bowels were in a comfortably lax state; yet on observing the stools,
they resembled pitch in colour and appearance. 
TREATMENT OF LOCAL DISEASES.
137
lar systems ;  which, in addition to the disorder of the digestive
organs, that has been described, are the chief circumstances ob-
servable  relative to the general health of those patients, whose
cases are related in the following part of this paper.   By cor-
recting the obvious errors in the state of the  digestive organs,
the local disease, which had baffled all attempts at cure by  lo-
cal  means, has speedily been removed, and the patient has ac-
knowledged that such an alteration has taken place in  his gen-
eral health, as excited his surprise.
 A REVIEW OF THE NATURAL  FUNCTIONS OF  THE  DIGESTIVE
   ORGANS,  AND  AN  INQUIRY INTO  THE  SIGNS WHICH  DE-
   NOTE THEM  TO BE IN  A HEALTHY OR DISORDERED STATE.

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

    * In  hectic fever, although the stomach may be  very weak, the tongue
 is generally clean ; it is therefore probable that the foulness of the tongue
 denotes irritation of the stomach, and not mere weakness when accompa-
 . nied  with tranquillity. 
              TREATMENT OF  LOCAL  DISEASES.          13(J

 from food, or a state of irritation arising from  too  long fasting.
 The tongues of many persons with disorder of the stomach look
 moderately healthy during the  day, though they have  been so
 much furred in the morning, that it has been deemed necessary
 to scrape them.
   A disordered state  of  secretion,  either as  to quantity or
 quality, will be the natural effect of irritation of a secreting or-
 gan.  This is evidently the case with the tongue;  and we may,
 with great probability, conjecture  that the same  consequence
 also takes place in the stomach.   Since the juices of the stom-
 ach are the immediate agents in digestion, that process must be
 disturbed in  proportion  as its  secretions are  deficient  or vi-
 tiated.
   If undigested matter  pass from the stomach into  the  intes-
 tines, it can scarcely be supposed that their powers  are  capa-
 ble of converting it into chyle;  and it may become irritating to
 those organs in consequence  of the  chemical  changes,  which
 it may then undergo.  When digestion is imperfect, animal and
 vegetable substances experience considerable chemical changes
 before they leave the stomach; and similar changes  may con-
 tinue to take place during the time they  are  detained in  the
 bowels, unless counteracted by the powers of the digestive or-
 gans; powers which seem  chiefly to belong to the  fluids  which
 are secreted into them.
   The extent of the power which the intestines  possess of con-
 verting what they receive from the stomach into chyle, or of pre-
 venting chemical changes, is unknown.  It is probable that
 much undigested matter is absorbed by the lacteds,  when  the
 digestive powers fail in  their functions.  This  is apparently the
 case in diabetes, where the vegetable matter floats in the serum
 of the blood, rendering  it turbid, and afterwards combines so as
 to form sugar in its passage through  the kidneys.  The strong
 odour, which  various  kinds of  food  impart to  the   urine,
 indicates that different substances are absorbed indiscriminately
 from the intestines.    It  is probable  that a turbid state of  the
 urine, and variations from the natural odour of healthy urine,
 may very frequently arise from a similar  cause,  viz.  from  the
 imperfect action  of the  digestive  organs,  in  consequence of
 which, unassimilated matter is taken up by the lacteals, and
 afterwards separated from the blood  in the  kidneys.   It may
 be reasonably conjectured  that the  same  powers, by  which
the kidneys convert the  old materials of our body into that pe- 
140       ON THE  CONSTlTUTiuNAi, ORIGIN AND

culiar modification of animal matter, which  is dissolved  in the
water of the urine, and which has been  called by the French
cjiemists uric, may  also enable it,  in a  healthy and vigorous
state, to  dispose of much unassimilated substance  in  the  same
way.  The further consideration of this subject would, however,
lead to a discussion foreign to the purpose of the present paper.
It will be sufficient to remark at present, that the state  of the
urine may  afford assistance  in  ascertaining the  existence  of
disorder  of the digestive organs,  and  in  indicating its  nature.
It has been  already  mentioned,  in  the brief account  of the
symptoms, that the urine is frequently turbid.  It should, how-
ever, also be observed, that the quality  of the urine greatly de-
pends on the state of the nervous system.   It is frequently,  in
the disorders of which I am speaking, pale  coloured and copi-
ous;  which is probably owing to a state of nervous  irritation,
such as exists in hysteria.   It is not improbable that disorders of
the digestive organs, by causing the frequent  secretion  of un-
natural urine, may produce irritation, and subsequent disease of
the kidneys, and other urinary organs.
   Modern physiologists seem to  agree  in the opinion that the
succus gasiricus is the agent,  by which digestion  is effected;
but they are not so unanimous  as to the  immediate cause  of
chylification.   It is not improbable that the succus intestinalis is
a principal agent,  although its qualities  have not yet been  in-
quired into; for, indeed, the  investigation would be attended
with difficulties almost insuperable.
   Since the bile and pancreatic liquor are poured  into the  in-
testines at a small distance from  the stomach, it is natural  to
consider these fluids as useful in affecting  the change,  which
the alimentary matter undergoes  in the  small intestines,  name-
ly, its conversion into chyle.  The chyme, or aliment digested
by the stomach, being  viscid, the  pancreatic juice  has been
considered  as an  useful and necessary  diluent,  and perhaps
this fluid may have other properties with  which we are  unac-
quainted.
   The uses of the bile have of late much engaged the attention
of physiologists.   Mr. Hunter observed that it did not seem to
incorporate with the chyle ;  and it certainly cannot  do so and
retain its own  nature, since its colour and taste are so  intense,
that it would  impart these properties to the  chyle, if mixed with
it in the smallest  quantity.   The difficulty of conceiving that
the two  fluids can be agitated together by the peristaltic motion 
TREATMENT  OF LOCAL DISEASES.
141
of the intestines, without  becoming incorporated, has led to an
opinion that the bile may combine with the alimentary matter,
and lose its original properties ; but nothing of this  kind is  as-
certained.   Fourcroy thinks  that  the alkali  and  saline ingredi-
ents of the bile may  combine  with the chyle, and  render it
more fluid, while the albumen and resin may combine with  the
excrementitious matter.  It is, indeed,  evident  that the  bi'e
combines  either totally or partially with something  separated
from the chyle, and exists formally in it, and in a state of health
uniformly dyes it of its peculiar colour;  and therefore it has of
late been supposed, that the bile may serve to purify the chyle,
by precipitating and combining with its feculent  parts.*
   It has been said in  the brief and general recital that has been
given of the symptoms, which characterize disorder in the chy-
lopoietic organs, that  the stools are of an unnatural colour and
odour.  Medical men entertain various opinions respecting the
colour of the  fteces:  to  me  this  property seems generally to
depend on the kind and quantity of the bile.   All the secretions,
which  are poured  into the  alimentary  canal, except the  bile,
 «re colourless or white 5  if, therefore,- this fluid were wanting,
 the residue of the aliment  would be of the colour, which might
 be  expected  to result  from  its undigested parts  combined
 together.   When, for instance, the  secretion of  bile  is stop-
 ped  by the  irritation of teething  in  children,  whose diet  is
 chiefly bread and  milk, the faeces are  white; when this secre-
 tion is obstructed in adults, the stools are pale like whitish-brown
 paper.                                         .           .
    In cases of disease, however,  coloured excretions may take
 place  from the bowels.   There  is great reason for ascribing
 The discharges in the disease called melaena to a vitiated secre-
 tion from the surface of the  alimentary canal.  I was intimate-
 ly acquainted with a  patient  who suffered repeated and increas-
 ing attacks of constitutional irritation.  When the disorder was
 wrought  up, as it were, to a crisis, he was forewarned, by a
 sensation, as if his stomach was filling, of the  occurrence that
 was about to take place.  In less than a quarter of an hour he
 would vomit more than two quarts of a  fluid resembling coffee-
 grounds in colour and  consistence.  Shortly afterwards  very
 O
    * In the inquiry into the probable uses of the bile, it ought to be observ-
 ed  that in many persons, in whom that secretion is either for a cons.dera-
 ble time wholl/suppress'ed, very deficient, or much depraved, it does not
  appear that the nutrition of the body is detective. 
142        ON THE CONSTITUTIONAL ORIGIN  AND

copious discharges of a similar darker coloured and  offensive
matter, took  place  from the bowels : but a green viscid  bile,
appearing distinct and uncombin'ed, was intermixed with this.
These evacuations  ceased in a day or two, and the constitu-
tional irritation disappeared with them.
  I examined the bodies of several persons,  who  died under
attacks of this nature, and found the villous coat of the alimen-
tary canal highly inflamed, swoln  and pulpy.   Bloody specks
were  observed  in various  parts ; and sphacelation had actually
taken place in one instance.   The liver was  healthy in  some
cases,  and diseased in others.   1  conclude therefore that these
diseases, which were termed heematemesis and melaena,  arose
from a violent disorder, and  consequent  diseased secretion of
the internal coat of the bowels; and that  the blood, discharged
when the  affection was at its height, did not flow  from any sin-
gle vessel, but from the various points of the diseased surface.
  Indeed I think it probable, that  the profuse discharges, which
sometimes follow the continued exhibition  of  purgatives, con-
sist of morbid secretions from the  bowels themselves, and not
of the residue of alimentary matter detained in those organs.
Such evacuations, either  occurring spontaneously, or excited
by medicine, frequently relieve  irritation of the  chylopoietic
viscera.
  It seems probable that the stools which  resemble pitch are
principally composed of diseased  secretions from the internal
surface of the intestines, since they do not seem either like the
residue of the food or discharges from the liver.   Can we sup-
pose that all the black and  fetid .matter which was  discharged
from the bowels in the first case, was poured forth solely  from
the liver ?
  The subject of morbid secretions is however particularly illus-
trated by that well-known alvine discharge, which so much re-
sembles yeast in colour  and consistence that it  cannot be  con-
founded  with faeces, with blood,  or with  a vitiated secretion
from  the liver.   A medical man of my acquaintance  took, for
some disorder in his stomach and  bowels, an aperient medicine,
which  apparently emptied  those organs.   He ate nothing  but
a little  bread in  broth  for his dinner, and a small  quantity
with  his  tea  in  the evening.   He experienced an unea-
siness in his bowels, and an inclination  to evacuate  them af-
ter he  had gone to bed;  but he  resisted  this desire  till four
o'clock in the morning,  when its urgency forced him to rise.
He then  discharged, what he supposed to amount in quantity 
TREATMENT OF  LOCAL  DISEASES.
143
to a gallon, of a matter exactly like yeast, unmixed with any
bile or faeces.   When  he arose in the morning, he had a simi-
lar  evacuation of about  a quart; and on  the succeeding day
there was a solid stool, apparently of the same  substance, col-
oured of a light green from  an admixture of bile.   He had a
natural stool the next day : his appetite returned, and the uneasy
sensation subsided.
   An unhealthy colour of the  faeces may further be attributed
to some degeneracy in the  quality of the  alimentary  matter;
such as may be supposed to take place when the digestive organs
fail in the  performance of their offices, and different alimenta-
ry  substances  are  in  consequence detained in the  bowels,
where they may pass through chemical  decompositions and
re-combinations.  But, though I  am inclined to  allow the full
operation of these causes, the following reasons lead me to be-
lieve that  the  colour  of the faeces  generally depends on  the
kind and quantity of the bile.  In the  natural  state of the  di-
gestive organs, when there  is no  peculiarity of  diet,  and  no
medicine is taken,  the bile  alone  colours the  residue of the
 food.   The faeces voided during a state of disorder of the  di-
 gestive organs  are  sometimes partially coloured ;  which cir-
 cumstance cannot be well accounted for upon any  other sup-
 position than that of an irregular  secretion  of the bile.   Fluids
 secreted from the intestines  do not usually enter  into combina-
 tion with the faecal matter, but appear distinctly when excreted.
 Thus we find  mucus  and jelly  discharged  from the bowels,
 unmixed with  the  faeces.   Medicines  which  affect the liver
 produce a very sudden  change  in the colour  of  the faeces.
 Small  doses of mercury, without any alteration  of diet, some-
 times change the stools  immediately from a blackish to a light
 yellow colour,  which indicates a healthy  but  deficient secre-
 tion of bile.
    The appearance of healthy bile in the human subject is that
 of a  deep brown, resembling a mass of powdered  rhubarb
 when just moistened with water.   Yet if bile be dropped into
 water, a single drop will dye a large quantity of water of a bright
 yellow, so that the  deep brown appearance is the effect of  the
 intensity of the yellow colour.   In  health there ought to be so
 much bile poured into the bowels, as when commixed with the
 residue of the food, to dye it of the peculiar colour of bile.   It
 is right,  however,  to say that the colour of the bile may vary
 considerably without any apparent disorder of the organ which
 prepares it, or of the health in general.   Sometimes, indeed, we 
 144       ON THE CONSTITUTIONAL ORIGIN  AND

 find green bile in the gallbladder, when the liver is not diseased.
 I cannot, however, but think that the natural colour is a yel-
 low,  so  intense  as to appear brown.   Green bile is usually
 poured out in circumstances where  there is  evident disorder
 of the digestive organs ;  and we cannot well suppose that there
 are two kinds of healthy bile.  The quantity of this fluid should
 be such as completely to tinge the excrement of  its peculiar
 colour.  By attending, therefore, to the colour of the  faeces,
 the kind  and quantity of bile, which  the  liver excretes, may in
 general be ascertained.
  The colour of the alvine   excretions in disordered  states  of
 the viscera is various.   Sometimes they appear  to consist  of
 the residue of the  food, untinged by bile.   Sometimes they
 are of a light yellow colour,  which  denotes  a very  deficient
 quantity of healthy biliary  secretion; they  may  also be  of a,
 deep  olive, of a clay  brown, and of a  blackish brown ;  all
 which show a vitiated state of the biliary secretion.
  Any kind of brown, which  dilution will not convert into yel-
low, I should consider as unhealthy,  since the colour  of  heal-
thy bile is a  bright  yellow,  which by concentration appears
brown.
  Such are the circumstances which I have collected  from my
own observation, and the reports of others, relative to the  al-
vine excretions, in the  disorders which  have been described.
  I have dwelt thus particularly upon the subject of the biliary
secretion, from a belief that its quantity and quality can, in gen-
eral, be ascertained by inspection, and will  therefore  serve to
indicate the presence of disorder.  Whether the foregoing opin-
ions be correct or  not, it will, I think, be generally granted that
the excretions from the bowels commonly indicate the healthy
or disordered  state of the digestive organs.   By the state of
the faeces we may judge how far digestion has been  effected ;
and gelatinous, mucous, and other matters being mixed with
them, denote irritation or disease of the bowels.
  The effects, which medicine or diet may have upon the col-
our of the faeces, ought, however, to  be considered.   When
the food is coloured, and this colour is not altered by digestion,
it will, of course, appear in the faeces; hence, if  it should  be
thought desirable to know accurately the state of the biliary se-
cretion, it would be right to restrict patients to a  diet that  is
not likely to colour the faeces.  The  green  colour  of vegeta-
bles tinges the faecal residue of the food.  Steel also is known
to blacken the faeces.  It should also  be  remarked that the ex-
 posure of the faeces to air after their expulsion, will,  in some 
              TREATMENT OF  LOCAL  DISEASES.          145

 instances, cause a considerable alteration in their colour.   In
 our endeavours, therefore, to ascertain whether the liver is per-
 forming its office rightly, by observing the colour of the  faeces,
 attention should be paid to these circumstances.
   I conclude this review of the opinions entertained respecting
 chylification,  by observing that if the succus intestinalis  be an
 agent in this function, disorder of the intestines is likely to af-
 fect its secretion, and thus impede this second important part of
 the process of assimilation.
   The residue  of the alimentary matter, mixed with  the  bile,
 passes from the small into the large intestines, and there under-
 goes a sudden change; it acquires a peculiar fcetor,  and  be-
 comes what we denominate faeces.   This change is so sudden,
 that it cannot be ascribed to spontaneous chemical alterations,
 (which would be gradual)  but to  some  new  animal  agency.
 If the contents of the small  intestines at their termination,  and
 of the large at their commencement, be examined, they will be
 found totally different, even within a  line of  each other; the
 former being without fcetor, and the latter being in all  respects
 what is  denominated faeces.    Though chemists then  might
 speak of the feculent matter of chyle as faeces, yet physiologists
 would rather apply that term to the  change in  the residue of
 the food, which takes place  in the large intestines, and which
 seems to be effected by  the  animal powers of  those  organs.
 The faeces quickly suffer  chemical decomposition out of  the
 body, although they often remain in the bowels without under-
 going the same kind of change.  Their  chemical decomposi-
 tion is attended  with the sudden formation of ammonia ; yet if
 they be examined when recent, they are found to contain acids
 which ammonia would neutralize.  The inference,  therefore,
 naturally arises, that this third process, I mean the conversion
of the residue of the aliment into faeces,  may, amongst  other
 purposes, be designed so to  modify that residue,  as to  prevent
 it  from  undergoing  those  various chemical  changes, which
 might be stimulating to' the containing organs, as well as injuri-
ous to the general health.
  In a perfectly healthy state of the digestive organs, probably
no chemical decomposition,  even of the faeces,  takes  place;
yet such changes happen, in some degree,  without  apparently
producing any injurious consequences.  To chemical changes
we may  probably  attribute the extrication of inflammable  air,
19 
146        ON THE CONSTITUTIONAL  ORIGIN AND

and the various and unnatural odours of the faecal matter, which
are observable in disordered states of the digestive viscera.
   The means by which this modification of the  residue of the
food, which takes place in the large intestines, is effected, are
but little known.   Analogy leads us to refer it to the effects of
a secretion from the lining of those intestines in which it occurs.
Now if this secretion deviates from  the healthy state, in conse-
quence of an irritated or disordered  state of those organs, we
may reasonably  expect a corresponding derangement of the
process, by which the residue of the  food  is converted  into
faeces.
FURTHER  INQUIRY  INTO  THE  NATURE  AND  EFFECTS  OF
   THAT  DISORDER OF  THE DIGESTIVE  ORGANS,  THE SYMP-
   TOMS OF  WHICH HAVE BEEN  RECITED AT  PAGE  136.

   Having taken this general view of the functions of the chy-
lopoietic viscera, in order to facilitate the forming  a  judgment
relative to those circumstances which  indicate  their derange-
ment, I return to speak more fully of  that affection  of them,
which I have described, as arising from causes recited at page
136.   This subject, it must be acknowledged, is very important,
if it can be shown  that disorders of the digestive organs are the
cause of a great  number of other  diseases.  The inquiry would
then not only lead us to discover the source of many disturbances
of the constitution, which originate in those of the digestive or-
gans (for patients  have no suspicion of any disorder existing
in them), but would also lead  to  the prevention and cure of
many secondary diseases of a more vexatious  and sometimes
of a more  fatal nature,  than those  from which they  orig-
inated.
   If the  tongue  be furred at its back part in the morning, when
there is no fever,  it is  reasonable to infer in  general that the
state of the tongue is owing to  its participating in the irritation
of the stomach.   Such  participation produces an alteration in
the secretions of the tongue : they are  either deficient in quan-
tity, or vitiated in quality.   A  state of irritation in any secre-
ting surface is, indeed, likely to be attended with the same con-
sequences.  It is, therefore, fair  to infer  that, when  a  general
disorder  of the digestive organs takes place, those fluids, which
produce the changes that the food undergoes in them,  are de-
ficient  or depraved, and consequently  that  digestion and the 
               TREATMENT OF  LOCAL  DISEASES.          147

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

 digestion is imperfectly performed, the functions of the intesti-
 nal canal will soon participate in the disorder of the stomach.
 Under these  circumstances,  the  secretion of  bile will also
 probably become irregular.   Should disease commence in the
 large  intestines, as about the rectum, it disturbs the functions of
 the stomach, and secretion of the liver, and becomes augment-
 ed  in its turn by its sympathy with  these parts.  Should  the
 liver be disordered in the first instance,  the stomach and bow-
 els  may not immediately sympathize, although they will proba-
 bly soon become affected.
  1 feel further warranted in considering the symptoms, which
 have been  recited in  the former part of this  paper, as  arising
 from a general disturbance of the functions of the digestive or-
 gans,  from contemplating the effects of blows on different parts
 of  the belly, which do not seem to have injured the structure
 of any single  abdominal viscus, but  yet produce effects deno-
 ting a general di-order of these  organs.   The symptoms have
 varied in severity in proportion to the violence of the blow re-
 ceived.  In the cases which were the consequence of the more
 forcible injuries, the  symptoms were, a furred  tongue; great
 vomiting, so that the  stomach could  retain no food; difficulty
 of  affecting the  bowels by  medicine : great fever ; and even
 delirium.   Indeed, all those  effects were produced, which I
 have represented  as arising  from vehement local  irritation  of
 remote parts of the body.   The disorder  has generally termi-
 nated by a profuse discharge  of  black  and fetid  stools, after
 which the patient  has  perfectly recovered.  On the contrary,
 where the  symptoms  consequent on the blow have been less
 violent, so as not  to claim  such  strict  attention, the  disorder
 has continued.  Persons  who had been  previously in perfect
 health, have become hypochondriacal, and have had all those
 symptoms of disorder of the digestive organs, which have been
 already enumerated as arising from a less degree of local irri-
 tation, with such consequent diseases as originate from such dis-
 order, and which will be mentioned  in  the subsequent part of
 this paper.
  In order to  inquire  more  particularly into the nature of this
 disorder of the  digestive  organs, I have examined the bodies
 of a considerable number of persons who have died of diseased
joints, lumbar abscesses, and other great local diseases.  I knew
 that these patients  had their digestive organs disordered in the
 manner that I have described, and that in many of them the 
           TREATMENT  OF LOCAL DISEASES.            14lJ

secretion of bile had been suppressed for a great length of lime,
and, when it was renewed,  that it was very deficient in quantity,
and faulty in quality : yet,  on dissection, no alteration was dis-
covered in the" structure of the chylopoietic viscera, which could
be decidedly pronounced to be the effect of disease.  It natu-
rally excites surprise, that such a state of irritation, and imperfect
performance of the natural functions of these parts, should ex-
ist for so long a time, as in  many cases it is known to do, with-
out  producing organic disease; still I believe it may be set
down as a truth, (which  has been  verified  by  every  observa-
tion I have made,) that a state  of irritation leads to  those dis-
eased vascular actions, which produce  an alteration of structure
in the irritated parts.
   However, where the disordered state of the bowels had been
of longer duration, 1 have found the villous coat of the intestines
swoln, pulpy, turgid with blood, and apparently inflamed,  and
sometimes ulcerated ;  and these appearances  have been  most
manifest in the large intestines.   Having observed repeatedly
in dissections of these cases, that the large intestines were more
diseased than the small  ones, it occurred to me,  that the fact
might be accounted for in  the  following manner:  If digestion
is incomplete, the undigested  food must be liable to chemical
changes, and the products resulting from this cause  are likely
to be most stimulating to the large intestines._  Indeed, in ad-
vanced stages of this  disorder, mucus and jelly tinged  with
blood are  discharged, and it seems  probable  that  a kind ol
chronic  dysentery  may be thus induced.
   In some instances, where the disorder had existed for many
years, the bowels  had been diseased throughout their substance;
the internal coat being ulcerated,  and  the peritoneal  covering
inflamed, so that the convolutions of the intestines were agglu-
tinated to  each other.   In these cases the liver, and sometimes
the spleen also, were much  diseased,  being  tuberculated  in
 every part.   Such is the result of the information which I have
 obtained by  dissection.
   Accurate attention to the subject, especially  in  medical cases,
 may lead to important subdivisions, which I have not yet been
 able to make.  But when 1 find  that irritation ol the  nervous
 system, however  it may originate, deranges the chylopoietic or-
 gans, and affects  the stomach,  bowels, and liver, apparently at
 The same time, I  think  it  fair  to  infer, that these organs are
 equally operated  on  by  the same cause.  Disorders of the 
150         ON THE CONSTITUTIONAL ORIGIN  AND

brain may affect the chylopoietic organs; and it  is well known
that this influence is reciprocal.  The  stomach  is said to be
chiefly concerned in producing these eflects; but the causes of
the sympathetic affection are probably more general.   A fit of
passion has produced jaundice ; and the irritation of teething in
children frequently suspends the secretion of bile; so  that the
stools are not in the least degree tinged with that fluid.  If the
head can thus affect the liver, it is reasonable to infer,  that the
liver may reciprocally affect the  head.  It  is very difficult to
form an opinion relative to this subject; for. in  the  instances
which have been mentioned, the affection of the liver may take
place, only because it forms a part of the digestive organs, and
not from a direct sympathy existing between it  and the head.
Still, however,  I do not think it unreasonable to  conclude  that
irritation of the other chylopoietic  organs may, as well  as  that
of the stomach, disorder the source of sensation.
   To display how much hepatic irritation may affect the senso-
rium, and consequently the  whole  nervous system, I insert the
following case :

                          CASK II.
   A gentleman applied to  me with a  thickened and tender
state of the periosteum of his tibia.  This disease had troub-
led him for more than a year, but became at last so extremely
painful that he  declared he  had not slept for three months, and
that Ins life was so intolerable  that he  resolved  to undergo a
course of mercury,  even though, in the opinion  of those  sur-
geons whom he had  consulted, his  disease  was  not venereal.
The duration of the disease,  as it had made no greater  pro-
gress, induced me to coincide in the opinion which  had been
given him.   His tongue was  much  furred, his appetite  was
moderate, and he was not conscious that his digestion was other-
wise than good.  His bowels were perfectly regular.    I  de-
sired him to take five grains of the  pilul. hydrarg. every second
night; but, before he took  them, to remark  the colour of the
discharges from his bowels, and to observe whether the  medi-
cine produced any change of it.   In a week's  lime he  called
upon me, and said,  I come to tell you the strangest thing  that
perhaps you ever heard, which is, that I actually do not know
the precise spot where the  lump on my shin was situated,  and
doubtless these pills which you directed are  a most wonderful
compound of opium.  The first gave me sleep,  which I  had 
TREATMENT OF  LOCAL DISEASES.
151
not  had  for  three months.    After taking  a second,  I have
slept soundly all night, and feel myself alert in the day.   Every
other preparation of opium, which I have taken, failed in produ-
cing sleep, and made me ill during the succeeding day.  After
all, continued he,  it cannot be the pills that have made me well,
for they have had no perceptible  effect on me.   I asked him,
had he, as I requested him, remarked the colour of  the  alvine
discharges?    He replied, he  had, and that before he took  the
medicine they were (to use the patient's own words) as black as
his hat, and now they were of a colour of a ripe Seville oranges.
The great relief arising from the correction of the biliary secre-
tion was not to me so strange  as the  patient expected.   It is
doubtless such remarks that have impressed some medical men
with the opinion, that the liver was  the root  of the evil  in all
disorders of the digestive organs.
   Cases like the present, (and several similar ones will be found
recorded in  this work,) appear to me highly valuable on many
accounts.   They  show  that  hepatic  disorder may disturb the
sensorium, either immediately or  intermediately,  by disordering
other organs concerned  in digestion ; they show how disorders
of  the abdominal  viscera may  become the cause  of various
other diseases, by disturbing the source of sensation and nerv-
pus energy ;  and they further show that unirritating  and unde-
bilitating doses of mercury have,  probably by their local action
in the bowels, a great influence in  correcting the  secretion of
bile, and by this means of relieving  hepatic irritation.*

  * To show how stomachic irritation may induce or maintain a general
disturbed state of the nervous system, 1  shall briefly relate the chief cir-
cumstances of a disorder which occurred  in  my own person.   Having, in
consequence of dissection, had some morbific animal matter imbibed from
a cut on my finger, 1 suffered at first from severe fever, which subsiding,
left me much  indisposed. 1 then became subject, occasionally, to consid-
erable and painful ulcerations of ray throat, and to severe rheumatic pains,
which almost prevented me from  going about.  These symptoms left me
in the summer, and returned in the winter, during three succeeding years.
In the second winter, when their recurrence seemed to have arisen in con-
sequence of catching cold, the rheumatic  symptoms rendered me almost a
cripple for three months; ncr were they mitigated by any medicine which
I took.   Exercise on  horseback relieved them in a very  great degree.  I
could not exercise on foot, for the plantar fascias were affected, as were
my ancles, knees, elbows, and the muscles of my back.  During the whole
of this illness I had no appetite, yet I ate  food when it was put on the ta-
ble.  The want of appetite excited no surprise; for 1 thought it was  a
natural consequence of general indisposition.  At the end of three months,
I one day felt sick at stomach, for about an hour, but not to that degree as
to induce  vomiting,  and whilst this sensation continued I had not the
slightest rheumatic pain about me.   I now resolved not to eat till my appe- 
 152          ON THE CONSTITUTIONAL  ORIGIN AND

   Nothing  in pathology is  more  generally admitted, than the
 reciprocal operation of disorders of the head and of the digest-
 ive organs on each other ;  yet the exceptions  to  this general
 rule deserve to be remarked in a  comprehensive  examination
 of the subject.  Some persons have great disorder of the di-
 gestive organs, without any apparent affection  of  the  nervous
 system ; and even diseases of a fatal nature may take place in
 the former organs, without affecting the latter.   Indeed,  if we
 examine any of the most evidently sympathetic affections, we
 shall find the same exceptions.  The stomach generally sympa-
 thizes with disorder of the uterus,  but it  does not  invariably
 do so.
   Many of the symptoms recorded in the description of the
 state of health of those persons who are  affected  by  disorder
 in the digestive organs, denote  a disturbance  of  the  nervous
 and muscular powers.   When we observe this compound dis-
 order, we can seldom determine which were the primarily af-
 fected organs.  General nervous irritation may have preceded
 the disorder of the stomach  and  bowels,  or may have  been
 caused by it.   The history will generally  show, that  the de-
 rangement  of the  digestive  organs is  secondary.   When  it
 arises from local irritation, it can be produced  only through the
 medium of the sensorium.  When it is idiopathic,  it  frequently
 originates in  causes which affect the nervous system primarily ;
 such as anxiety, too great exertion of mind or body, and im-
 pure air.  Sedentary habits and irregularities of diet are causes
 which may be  supposed to  act  locally  on the organs them-
 selves.   Nervous irritability  and  weakness are  not  perhaps
 susceptible of a direct cure  by medicine;  but the  disorders  of
 the digestive organs are  more corrigible  by medical  remedies.
 In practice, these require our chief attention ;  and  if their dis-
 orders be corrected,  all   nervous  irritation frequently ceases,
 and health is restored.   In many instances the  nervous irrita-
tion, which has induced the disease, is trivial, and  would  soon
 cease, were it not kept up  by the  reaction of its secondary
 symptoms.

tite returned, and even then I gratified it very sparingly, eating only veg-
etable food, and drinking  only water.  In one week my appetite became
keen, my digestion easy, my stomach  tranquil, and 1 was as  free from
rheumatism, (a disorder to which I never had been subject,) as at any pe-
riod of my life.  It is also sufficiently manifest how much uncomfortable
feelings of the bowels affect  the nervous system, and how immediately
and completely the general disorder is relieved by an alvine  evacuation. 
TREATMENT OF  LOCAL DISEASES.
153
   Whether this disorder of the digestive organs be primary or
secondary, it generally produces irritation  in  the brain;  and
thus may cause in many instances actual disease of that organ,
as will be  stated in the conclusion of this paper.  But derange-
ment of the digestive organs arises, in  many  cases, from  es-
tablished nervous disorder : indeed there is often reason to sup-
pose  that it is dependent on, or connected  with, actual disease
of the brain.   In such cases, the correction of the  disordered
functions of the digestive organs cannot be accomplished ;  and
even  if it were  practicable, it would not cure the nervous  dis-
ease.   It  is however highly necessary and advantageous to at-
tend to the disorder of the digestive organs, where it is  only  a
symptom of nervous disease.   The relief  of  the  former  will
often  mitigate, though it cannot cure the latter.*
  The connexion of local disease  with general  disorder  has
been  often remarked ; it has been formerly attributed to impu-
rity of the fluids ;  a theory which is not irrational.   Imperfect
digestion must influence the qualities of the blood, and all parts
of the body may be  affected from this source.   But in account-
ing for the reciprocal influence of disorders of the head and the
digestive organs on each other, the modern explanation of these
phenomena, by means of sympathies, is  perhaps preferable.
Afflicting intelligence will  destroy  the appetite and produce a
white tongue in a healthy person; and  a blow  on the stomach
disorders the head.   These  phenomena take  place indepen-
dently of the blood, and can only be  explained  by admitting
that disturbance of one organ immediately affects another.

  * The ingenious Mr. John Bell has of late published an opinion,  that
all nervous disorders depend on the  circulation of blood in the brain.   The
opinion is founded on this dogma; the brain being insensible, there can be
no such thing  as nervous  irritation.   Believing similar  opinions to be
prevalent in the profession, I think it worth inquiring,  whether, if the
motion of a worm  in the stomach produces temporary blindness or convul-
sions there ba not some nervous irritation?  If a man has his leg amputa-
ted on account of a compound fracture, and afterwards  becomes delirious
and dies,__I grant that fulness of the vessels of the head will be found on
dissection ; but was not the vascular action caused by preceding nervous
irritation ? The same fulness of vessels and signs of inflammation are found
in those who die of fevers ; but do not the miasmata  which cause them
affect the brain, and suddenly impair and disturb its energy, and is  not
then  the vascular action a consequence ?  I would ask too,  practically,
does blood-letting cure disorders in which there is a fulness of the vessels
of the head?  It must be granted, that in many instances it temporarily
alleviates them, but in others it fails to relieve and even aggravates them.
20 
154          ON  THE  CONSTITUTIONAL  ORIGIN AND

  The writings of the ancients abound with passages, in which
local  diseases are  attributed to affections of the abdominal
viscera, and the  same fact  has been noticed by several of the
moderns.   The French  surgeons appear to be very solicitous
to keep the bowels in a cool and tranquil state;  and Dessault
ascribes the origin of erysipelas to a bilious cause.   The Ger-
man surgeons, Richter and Schmucker, attribute many local
diseases to gastric affections; and  in Italy, Scarpa  views  the
subject in the  same light.   The  English  practitioners seem to
have been less attentive to  this class of disorders; insomuch
that Fischer, a German, who published an account of the state
of medicine  in this  country, expresses  his  surprise that  the
English should be so little acquainted with gastric diseases.   I
know not  exactly what ideas these gentlemen may annex to
the terms gastric  and bilious disorders, since they do not par-
ticularly describe them.  I have represented the subject in the
foregoing  pages, as it has appeared to me on the most attentive
examination.
  There is also  an  excellent dissertation, in which the effects
and treatment of disorders of the digestive organs are particu-
larly described, inserted in the eighth volume of the Memoires
de la Societe Royale de Medicine of Paris for the year 1806,
at page 310, entitled Reflections sur le Traitment de la Manie
atrabilaire compare acelui de plusieurs autres Maladies chron-
iques, et sur les  Avantages de la  Methode  evacuante, par M.
Halle.  After describing the discharges from the  bowels in
atrabiliary mania, he observes, that a similar state of those or-
gans is found in other diseases, namely, dropsy, hypocondriasis,
accompanied with difficulty of breathing and palpitation, obsti-
nate coughs, and a great number of very different diseases; to
all of which  the same treatment is  applicable.   That the ex-
tremely  prejudical  consequences of disorders of the stomach
and bowels have been noticed at  all times by persons of obser-
vation, and particularly by those who are in the habit of judging
of their state by their excretions, is  sufficiently evident.   The
ancients sought to correct the error by purging with  hellebore,
and the moderns by more compound purges, to use the words
of M.  Halle, par le melange de purgatifs resineux et des mer-
curiaux.   I have not, however, met with any physiological in-
vestigation of the nature of these diseases, nor of the rational
objects of cure.  It is to promote such an investigation, that I
have laid before the public  the facts  which have come under 
TREATMENT OF  LOCAL  DISEASES.
155
my observation, and the reflections to which they have given
rise.
   In  investigating the connexion  between local diseases and
disorder of  the  health in  general, I can  perceive, that failure
in the functions  and irritation of the digestive organs may act
prejudicially on the system in general in various ways.  They
may produce weakness, for strength and  vigour seem  to arise
from the conversion of our food into perfect blood.  They may
produce an impure  state of that fluid,  and they may produce
great irritation of  the brain,  and thus influence  the whole
body.   However, what I have to observe respecting the causes
and cure of local diseas.es will be most properly introduced and
best understood after the cases have been recorded, upon which
the opinions have been founded.
   The result of all  these observations, which I have been  able
to make,  relative to this subject,  has induced me  to believe
that the disorder of the digestive organs, caused by the various
circumstances which have been recited, consists in a weakness
and irritability of the affected parts, accompanied by a deficien-
cy or depravity of the fluids  secreted by them, and upon the
healthy qualities of which the  due performance of their functions
seems to depend.   This opinion is deduced immediately from
the consideration of the symptoms, and  confirmed by all the
collateral  evidence, which  we  can collect.    The duration  of
the affection, without fatal consequences,  shows that it is a dis-
order of functions, and not  a disease of •structure.  Dissections
confirm the opinion.   Blows which excite general irritation  of
the digestive organs, produce also the symptoms which charac-
terize the like disorder, when it arises  from nervous irritation,
or is excited by intemperance.  I doubt not but every one  will,
on reflection, consider the  disorders of the digestive organs  to
be of the first importance, and will perceive the propriety  of
diligently  inquiring  into their nature, that we  may know them
when they exist,  and  that  our  attempts to remedy them  may
be conducted on rational principles.  This consideration will, I
trust, vindicate me for employing so much time in an investiga-
tion which, perhaps, some  may consider as tedious and unpro-
fitable. 
156         ON THE CONSTITUTIONAL ORIGIN  AND
OCCASIONAL  EFFECTS  OF  DISORDER  OF  THE  DIGESTIVE
                          ORGANS.
  It is generally  admitted, that  disorders of the  chylopoietic
viscera will affect the source of sensation, and consequently the
whole body ; but the variety  of diseases, which may  result
from this cause,  has not been duly weighed and reflected on.
  It may produce in the  nervous  system a diminution  of the
functions of the brain, or a state of excitation, causing delirium ;
partial nervous inactivity and insensibility, or the opposite state
of irritation and pain.   It may produce in the muscular system,
weakness,  tremors, and palsy;  or the contrary affections of
spasm and convulsions.  It may excite fever by disturbing the
actions of the sanguiferous system; and cause various local
diseases by the nervous irritation which it produces, and  by the
weakness which is consequent on nervous disorder or imper-
fect chylification.  Or if  local diseases  occur in a constitution
deranged in the manner which I have described, they will be-
come peculiar in  their nature and progress, and difficult of cure.
Affections of all those parts which have a continuity of surface
with the  stomach; as the throat,  mouth, lips, skin, eyes, nose,
and ears, may be originally caused or aggravated by this com-
plaint.   I  must  observe, before I proceed to  the  relation of
cases,  that such  a disqrder of the  digestive  organs as  I have
described existed in  every instance.  I do not take upon my-
self to say that it was the  primary cause of the general derange-
ment of the constitution, with  which the local disease  appeared
to be connected ; it  might have  been the  consequence, as in-
deed has been stated in these preliminary observations.

                        TREATMENT.
   I shall now  proceed to mention the plan which I have pur-
sued in the treatment of these disorders, when they have been
connected with surgical diseases:  with what degree of success,
the following cases will demonstrate.  1 do not feel altogether
competent to give full  directions relative to this subject; be-
cause I have never attended  to medical cases with that  degree
of observation which would lead me properly to appreciate the
efficacy  of different  medicines,  when administered either  in
their simple or compounded forms.   The subject is so  impor- 
TREATMENT  OF LOCAL DISEASES.
157
rant, that the public would be highly indebted to any practition-
er, who would point out the varieties of these diseases, and the
appropriate modes of cure.  The  method of treatment, which
I have adopted, is simple, and  founded on the  opinions I  have
formed of the nature of the  disease, and on physiological views
of the  functions of the affected organs.   Believing the disorder-
ed  parts to be in  a state of weakness  and  of irritability, my
object has been^ to diminish the  former and  allay the latter.
Believing also that the secretions into the stomach and bowels,
upon the healthy state of which the due performance of their
functions  depends, were,  in  consequence of  such  disorder,
either  deficient in  quantity  or depraved in  quality ; I have en-
deavoured to excite, by means  of medicine, a more copious and
healthy secretion.
  It is a principal object of medicine to give strength  and  tran-
quillity to the system at large, which must have  a beneficial in-
fluence on all its parts, and greatly promote the well-doing of
every  local disease.  We cannot  reasonably expect tranquilli-
ty of the nervous system whilst there  is disorder of the diges-
tive organs.   As  we  can  perceive no permanent source of
strength but from the digestion of our food, it becomes impor-
tant on this account that we should attend to its quantity,  qual-
ity,  and the periods of  taking  it, with a view to ensure its per-
fect digestion.
   First, With respect to quantity :  There can be no advantage
in putting more food into the stomach  than  it is competent to
digest, for the surplus can never afford nourishment to the bo-
dy ; on the contrary,  it will  be productive of various  evils.
Being in a warm and moist place, the  undigested food will un-
dergo  those chemical changes  natural to dead vegetable and
animal matter : The vegetable food will ferment and become
acid, the animal will grow rancid and  putrid ;  this  is only ren-
dered evident occasionally,  when a disordered  stomach rejects
some of its contents; then the  teeth are roughened and set on
edge by the  corrosive qualities of the acid, and  the throat feels
burnt  by the acrimony of the rancid oil.  These effectst, hough
occasionally made apparent, must constantly take place, unless
by the digestive powers of  the stomach the food is converted
into a new  substance which is not liable to  these  chemical
changes.   Such new and irritating compounds may not indeed
materially injure  a healthy stomach, but cannot fail  to be detri-
mental to one that is weak  and irritable, as well as to the whole 
 158        ON THE CONSTITUTIONAL ORIGIN AND

 tract of the alimentary canal, and thus maintain and aggravate
 its disorder.  Part of the food thus changed  will be  imbibed
 from the bowels, and render the blood impure,  from which there
 is no outlet for various kinds of matter but through the kid-
 neys ; and thus may prove a cause of foul urine,  as well as of
 the presence of  many substances in that fluid not natural to it,
 and be productive  of  serious diseases in the  urinary organs.
 Observing the evils resulting from undigested aliment, we sure-
 ly ought cautiously to guard against them by proportioning the
 quantity of our food to the digestive powers.  Nature seems
 to have formed animals to live and  enjoy health upon a scanty
 and precarious supply of  food ;  but man in  civilized  society,
 having food always at  command, and finding gratification from
 its taste, and a temporary hilarity and energy  result  from the
 excitement of his stomach, which he can at pleasure produce,
 eats and drinks  an  enormous deal  more than is necessary for
 his wants or welfare ;  he  fills his stomach and  bowels with food
 which actually putrifies in those  organs ; he fills also his blood
 vessels till he oppresses them, and induces diseases in them as
 well as in his heart.   If his digestion be imperfect, he fills them
 with unassimilated substances, from which nutriment cannot be
 drawn,  and  which must  be injurious.  In proportion as the
 powers of the stomach are weak, so ought we to  diminish the
 quantity of our food, and take care  that it should be as nutritive
 and easy of  digestion  as  possible.   By adopting an abstinent
 plan of diet even to a degree that produces a sensation of want
 in the system, we do that  which  is most  likely to create appe-
 tite and increase  the powers of digestion.   In how great a  de-
 gree want effects these objects,  is evident in  those who have
 been  obliged to  fast from necessity, or  have been  much re-
 duced by haemorrhage.
  Secondly, As  to quality: It is not  my intention to discuss
 the question as to the nature of the food proper for  mankind.
 When the stomach  is.weak,  it seems particularly necessary
 that it should be  nutritive  and easy of digestion.  I may fur-
 ther observe, that its qualities should be adapted to the feelings
 of the stomach.   In proof of this  proposition, numerous instan-
 ces might be mentioned of apparently unfit substances agreeing
 with the stomach, being digested and even quieting an irritable
 state of stomach,  merely because they were suitable to its feel-
ings.  Instances  might also be  mentioned of changes in diet
producing a tranquil and  healthy state of stomach in cases 
             TREATMENT  OF LOCAL DISEASES.          159

where  medicines had  been tried  in vain.  Neither can such
occurrences excite surprise, for as digestion and the consequent
tranquillity of the stomach depends on a proper quantity  of
healthy juices being  secreted  and commixed with  the  food,
such secretions are likely to be produced by whatever  agree-
ably excites it,  and obstructed by whatever has a contrary ten-
dency.
   Thirdly,  As to the times of taking food : It is evidently the
intention of nature that we should  put into the  stomach a cer-
tain portion of food, the excitement of which inducing a secre-
tion of gastric fluid, by its  action becomes digested.   This of-
fice of the stomach  being  effected, it should be left in  a state
of repose till its powers are restored and accumulated, and  this
return of energy  would in health be denoted by a return of ap-
petite.   It is probable that three hours  may elapse in health
before the digestion of a moderate meal is effected,  so that the
stomach is empty and in a state of repose.  It is therefore rea-
sonable to allot the same portion of time  for the same purpose
when the organ is disordered,  whilst we have  diminished the
quantity of our food in order to proportion it to  the diminished
powers of the organ ;  yet instead  of pursuing this rational plan
of diet, many persons  are taking food every third or fourth hour,
pleading in  excuse for such conduct that they cannot do with-
out it.   The truth is, that  when the stomach is disordered, the
exertion of digesting a single  meal after its  excitement and ef-
forts have ceased, is productive of sensations of languor, sink-
ing and inquietude, which  ought to be calmed or  counteracted
by medicines, and not  by food, for a second meal cannot be di-
gested in this state of the  stomach.   Wo also often teaze and
disorder our stomachs by  fasting for too long a period;  and
when we have thus  brought on what I may call a discontented
state of  the organ, unfitting it for its office, we sit to a meal,
and fill it to its utmost, regardless  of its powers or its feelings.
The rules  then  for diet  may be thus  summarily expressed:
We should proportion the  quantity of food to the powers of the
stomach, adapt its quality to the feelings of the organ, and take
it at regular intervals  of six or seven  hours thrice  during  the
day.  It would be well if  the  public would  follow  the advice
of Mr. Addison, given in the  Spectator, of reading the writings
of 1 j- Cdrnaro, who, having naturally a weak constitution, which
 he seemed to have ruined by intemperance, so that he was ex-
 pected to die at the age of thirty-five, did at that period adopt 
 160       ON THE CONSTITUTIONAL ORIGIN  AND

 a strict regimen, allowing  himself only  twelve  ounces of food
 daily.  By this plan of diet he lived to more than one hundred
years; and it is delightful to observe the tranquil, cheerful and
energetic state of mind accompanying his bodily health, and in a
great degree induced by it.   Cornaro found that as the powers
of his stomach declined  with the powers of life in general, that
it was necessary he should diminish the quantity of his food,
and by so doing he retained to the last the feelings of health.
   Every thing which we take into  the stomach, except food,
may be considered in two  points of view; either as a diluent or
a  medicine.  Water is  the  only diluent, and  we  are in  the
habit of mixing alimentary matter and stimulants with it.  Di-
luents probably ought not  to  be  taken during  or immediately
after our meals, since they would be likely to render the juices
of the stomach less efficacious in  the digestion of our food.
Hunger and  thirst  seem  to  be incompatible   sensations:  an
hungry animal would eat to satiety,  and the stimulus of the food
would bring on a discharge of the juices of the stomach, which
have the power  of digesting the food;  and it is not probable
that the sensation of thirst would  be experienced till this ope-
ration of the stomach is effected.  If the sensation of thirst then
occurred, water would appease it, without frustrating the diges-
tive functions, and being absorbed;  from the alimentary canal
a certain portion of it would be furnished to the blood, and the
surplus would pass off from the skin, lungs and kidneys.  All
stimulants must be  regarded  as medicines ;  vinous  liquors are
of this class, and being suitable  to the feelings of the stomach,
are in many cases very  efficacious,  yet  they  are  very liable
quickly to pass into a state of acetous fermentation,  and to pro-
mote that change in the remaining quantity of the vegetable
matter contained in a disordered stomach, and  thus produce a
strong and injurious acid.  The rule for taking vinous liquors in
persons to whom habit has rendered them necessary, may be thus
briefly stated.   They should  not take them during their meals,
lest the temporary excitement they produce should induce them
to take more food than the powers of the stomach are capable
of digesting, but afterwards  they may be allowed so  much of
them as may be required-to  induce agreeable  feelings, or to
express the fact more  clearly, as is  necessary to prevent those
uncomfortable sensations which the want of them may occasion ;
and  it  may be added,  the less they take the better.   People
deceive themselves on this point.    A disordered stomach will 
TREATMENT OF  LOCAL  DISEASES.
161
 feel uncomfortable after eating ;  fermented liquors remove for
 a time the unpleasant sensations.  Potion after potion is swal-
 lowed on this account, often without producing permanent tran-
 quillity, and  much to the injury of the stomach.   Wine drink-
 ers do not drink wine after every meal, which proves that wine
 is not necessary to their digestion ; and many who confided in
 this belief have been convinced of their error, by leaving it off
 and finding that they digested their food as well when deprived
 of it, and that such privation greatly contributed  to their even-
 tual restoration to health.   When stimulants seem requisite, and
 fermented liquors  run into  the acetous fermentation in the  sto-
 mach, spicy and aromatic vegetables should be substituted, such
 as ginger, pepper, mustard, he.
  Stomachic medicines are given to strengthen a weak stomach,
 to tranquillize an irritable one,  or to  counteract  some morbid
 peculiarity in the feelings and actions of that organ.   There is
 a time when stomachic  medicines seem to be particularly  re-
 quired.  About three hours after a meal, when the stomach is
 exhausted by the labour of digestion, when its morbid propen-
 sities are  increased by the  languor  consequent to  fatigue; at
 this period, when persons are in the habit,  through ignorance,
 of taking food to appease their distress, they ought, as has been
 said, to take these kinds of medicines.
   Even our  food must be  considered as exerting a medicinal
 influence in disorders of the stomach, when that organ is irrita-
 ble.  A vegetable diet and abstinence from fermented liquors
 may tend to tranquillize  it.   On the contrary, when it is weak
 as well as irritable, that  aliment which is most readily digested
 is to be preferred, and cordials are sometimes beneficial.  The
effects of food and medicine can never be considered as result-
ing from their operation on the stomach solely, but from their
conjoint influence upon the nervous system in general.  Irrita-
bility of the stomach  may arise from that of the brain,  and un-
 stimulating diet may tend to tranquillize the latter organ, and
 thereby alleviate the  disorder of the former.   On the contrary,
a more generous diet may, by exciting the  nervous system,
produce that degree  of energy in its actions, which invigorates
the stomach, and tranquillizes its disorder. It may further be  ob-
served in some cases, that the kind of medicines or diet which is
serviceable to the stomach, may aggravate the nervous disorder;
and on the contrary, that those means which seem to tranquil-
lize nervous irritation tend to diminish the powers of the stomach.
               21 
162         ON THE CONSTITUTIONAL ORIGIN  AND
   Bark and steel are not uncommonly  given in these diseases
to increase the powers of the stomach : they ought, I think, to
be  administered in  small  doses, and never when the tongue is
dry ;  as they seem  to suppress  those secretions, which in many
cases are  already deficient;  and the increase of which would
tend to relieve irritation in the affected organs.   I mention this
opinion, however,  rather to account to the  reader  for these
medicines not having been prescribed in the  subsequent cases,
than from any other motive ; as I do not feel perfectly compe-
tent to decide upon their degree or kind of utility.
  Vegetable diet-drinks  appear to  me very useful  in tranquil-
lizing and correcting  disorders of the stomach and bowels, for
this is the manner in which they  seem to be  efficacious in the
cure of local diseases.   The vegetables prescribed  in the  dif-
ferent formulae are  so dissimilar, that we can  scarcely suppose
that they act  specifically upon the local  disease.   Even sweet-
wort has obtained  considerable celebrity.   When diet-drinks
fail to  correct the disorders of  the digestive organs, they also
fail to produce any  amendment  on  local  diseases.   Such  ob-
servations have induced me to believe that they have the utility
which I have ascribed to them, of tranquillizing and correcting
disorders of the stomach and bowels.  It is  allowable to form
an opinion from such  observations, though  I am  sensible of
their invalidity  as argnments to prove its truth.
  Whilst thus on the one hand, by  endeavouring  exactly to
proportion the quantity of food to the powers  of digestion, by
adopting  an abstinent  system  of diet,  and  taking  medicines
suitable to the condition of the stomach, we endeavour to foster
the powers and ensure the tranquillity of this  important organ,
we ought on the other most carefully to attend to  the regulation
of the action of the  bowels, with a view  to insure their tranquil-
lity ; for the state of one part of the canal will be regulated by
the state of health or disease in the  other.  To produce tran-
quillity of the bowels when they are in a disordered state, it is
necessary that the  residue of the food  be daily carried down
and discharged from those organs;  this is their  natural func-
tion, and if they fail in its performance, they  should be excited
by  appropriate medicines, yet  without  teazing  them so as to
induce what is ordinarily called  purging.   Purging, occurring
spontaneously,  shows that the bowels  are irritable,  and  the
aqueous and other discharges which take  place  from them  in
that condition  often relieves  their irritability.  When purging
occurs in consequence of taking  medicine, it shows  that the 
TREATMENT OF  LOCAL  DISEASES.
163
bowels have been irritated and have relieved themselves in th* ir
usual manner.   Persons may be  purged without having their
bowels cleared of the fcecal matter which may be detained m
them : we should therefore endeavour to ascertain what kind
or combination of purgative medicines will  excite a healthy ac-
tion  of the bowels, without teazing them or producing discharges
from the organs themselves.  The  best mode of  proportioning
the degree of excitement to the end designed is to take a dose
of a suitable medicine at night, but short  of  that which may
prove irritating ; if it fails  sufficiently to excite  the organs, a
similar dose may be taken in the morning  ; which also failing,
it may be repeated at an advanced period  of the  day.
   Purging medicines sometimes relieve unpleasant sensations ;
but they do not in general produce even this effect;  and all ac-
tive  purges seem to  me to increase the disorder.   It is natural
to suppose that strong sVimuli will aggravate the unhealthy con-
dition of weak and  irritable  parts.
   I  have  already expressed my opinion of the manner in which
the continuance of purgative medicines, in such  doses as  do
not  immediately purge, relieve disorders  of  the digestive or-
gans, by producing morbid secretions which afford considerable
relief, either  when  they occur spontaneously or  are  thus in-
duced.   This plan of practice  is what Dr. Hamilton has sug-
gested,  and the utility of which he has  so successfully  eluci-
dated.  I am aware that laxative medicines  may relieve irri-
tation merely by augmenting  the natural secretions of  the vis-
cera, and thus unloading their vessels ; and also by determining
the fluids from  the  head, when  the nervous symptoms  are
aggravated by a plenitude of the vessels of the  brain.  As I
have found the lenient plan of  treatment, (that of exciting the
peristaltic  action of the bowels, so as to induce them  to clear
out  the whole of the residue  of  the  food, without  irritating
them, so as to produce what  is ordinarily called purging,) par-
ticularly successful,  I have rarely deviated from it.   I  am not,
therefore,  warranted from experience  in  speaking decisively
respecting the more free use of purgative medicines.
   It is difficult, in many cases, to regulate the actions of the
bowels either by diet or medicine.   They are costive for a time,
and  then fits of purging come on.   The former state must  be
obviated,  in order to prevent  the latter.  Medicines which ex-
cite a healthy action of the bowels in one person,  are either in-
ert or too active in another.   Doses, which  would have no
effect in a state of health, become  purgative in this  disorder; 
164        ON THE  CONSTITUTIONAL ORIGIN AND

a circumstance  which shows that the  bowels  are  irritable.
There are some rare  instances of the  contrary, in which it is
exceedingly  difficult to excite the actions  and  secretions  of
these viscera.
  1  have  found  in some cases,  that  purgative  medicines
and spices dissolved in spirit  and water, have  answered bet-
ter than  any  thing  else,  in  producing  a  sufficient, but  not
too copious  a discharge  from the bowels.  Equal parts of
compound tincture  of rhubarb and senna  is the formula  to
which I allude.   When irritation  in the large intestines  has
been  denoted by  the   mixture of mucus and  jelly  with  the
faeces, and sudden and  urgent calls to void  them, I  have ad-
vised  oily and mucilaginous medicines  as aperients: as castor
oil, mixed with a large proportion of mucilage.  My sole object,
however,  has been  to regulate the state of the  bowels ; and
when they have been  regular  without medicine, I have rarely
recommended any.
  At the  same time,  I have not  been  inattentive to the error
in the biliary secretion, which exists in the  greater number of
these cases.   I have endeavoured to correct this error by the
administration of such small doses  of mercury  as  do  not
irritate the bowels, and are not likely to affect the constitution,
even  though persevered in for a considerable time.   In this
state  of  the  digestive organs, calomel, in  small quantities,
sometimes proves irritating.   I have combined it, as  in Plum-
mer's pill, and have  given one grain every other night.   Where
this dose  produced uneasy sensations, or acted  as an aperient,
five  grains of the pil. hydrarg. were substituted in its place;
and   even this quantity has  been  diminished  in some cases.
When the bowels are  very irritable, the hydrarg. cum creta has
been  given.*  When  it appeared necessary,  on  account of
the biliary secretion, and when the calomel did not irritate the
bowels, 1 have increased  the  dose.  The relief, which arises
from  the increase or correction of the  biliary  secretion, in a
great number of  these cases,  shows how much the liver is con-
cerned in causing  or aggravating the symptoms in these diseases.

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

induced by  the  absorption of  morbific animal  poisons;  and
thus  mercury may relieve disorders of the digestive organs by
relieving the nervous disorder which caused them.  But when
mercury is given in still larger doses, as it  is  for the cure of
syphilis, it never fails to irritate and weaken the constitution,
and thus to disorder the digestive  organs.   Persons who  are
salivated have, as far as I  have  remarked, the  functions  of the
liver and digestive organs  constantly disturbed  by that process.
I cannot, therefore, but think that it is  wrong to use  mercury
in hepatic affections to that extent,  which  would  disorder  the
functions of the liver, if they were previously healthy.   In  the
majority of cases the disorder has existed for a long time, and
has become habitual; therefore it is not likely to be cured sud-
denly.  For this reason, we should adapt our  treatment to the
more rational expectation  of effecting a gradual  recovery than
a sudden cure.  The most judicious treatment will not remedy
the disease, if the exciting causes  continue to operate ;  such
as improprieties of diet, agitation of mind, sedentary habits, or
impure air.
   Although experience has made me think very highly  of the
efficacy of small doses of  mercury,  in exciting and correcting
the biliary secretion ;  yet  it ought  to  be mentioned,  that in
some few cases, this medicine fails to produce  its usual  effects,
and  that the biliary secretion becomes healthy  without  its  ad-
ministration.   Nor is  this  surprising, for in general disorders of
the  digestive  organs, one organ is more disordered than  the
rest, and appears to have  been  the cause of the whole affection.
Thus the liver may disturb the functions  of the stomach and
bowels, or it may  be disturbed  by  them.
   The following cases  will afford sufficient testimony  of the
efficacy of such simple treatment as lhave recommended,  and
which appears to be well adapted  to gradually restoring  the
healthy actions of the digestive organs in cases of chronic dis-
order  and  disease.  The treatment must be  considered very
deficient, as a general account of what can be  effected by med-
icine.   In acute disorders of the digestive organs, we know that
nauseating medicines  by exciting the secretions,  often  relieve
stomachic irritation, and that emetics and other remedies which
suddenly and  powerfully affect the stomach, produce great
changes in the state of that organ and  of the  nervous system,
as well  as  correspondent alterations  in local  diseases.  In
some  inveterate cases, apparently depending on  established
nervous  disorder, this simple  treatment has been  ineffectual. 
TREATMENT OF  LOCAL DISEASES.          167
Under such circumstances, the nervous affection appears to re-
quire the principal attention.
  In investigating the treatment of these disorders, it is neces-
sary to ascertain, not only what  medicine is beneficial,  but also
what change it produces in the circumstances of the disorder.
The administration of a medicine may in one case be succeed-
ed by a discharge of bile, and a  striking relief from  long  con-
tinued and distressful feelings; yet the same medicine  may be
given in many other  instances without the  same consequence.
Was the change, then, in this instance accidental ? or  must it
be attributed to some unnoticed peculiarity in  the disease or
constitution ?
  I have generally explained to the patients the objects which
I had in view, in correcting disorders of the digestive  organs,
by saying that there  are three things which 1 consider  as right
and necessary to the cure of disorder.   First, that the  stomach
should thoroughly digest all the  food that is  put into it.  The
patient, perceiving the necessity of obtaining this end, becomes
attentive to  his diet,  and observes the effect which the  quantity
and  quality of his food  and  medicines have upon  his  feelings,
and the apparent powers of his  stomach.  Secondly,  that  the
residue of the food should  be daily discharged  from the bow-
els : here too, the patient,  apprized of the design, notes  what
kind and dose of purgative medicine best effects the intention ;
and  whether it answers better if taken at once, or  at intervals.
Thirdly, that the secretion of bile should be right, both with
respect to quantity and quality.   In cases  wherein the secre-
tion of bile has been for a long time deficient or faulty, I  re-
commend, as  I have said, unirritating and  undebilitating doses
of mercury to be taken  every second or third night, till the stools
become of the wet-rhubarb colour.  This  mode of exhibiting
the medicine has at  least the advantage of being innocent,  and
if months elapse before the object is accomplished, we cannot
wonder at the tardiness of the cure, when we  consider  the
probable duration of the disorder, prior to  our attempts to  cor-
rect it.  The patient is relieved in proportion as the end is ac-
complished, which feelingly induces him to persevere  in  such
innocent measures.   By thus engaging the co-operation of the
patient, the practitioner will, in my opinion, derive considerable
advantage in the treatment of the case.
   Whenever circumstances would permit, I have recommended
the patients to take as much exercise as they could, short of pro-
 ducing fatigue ; to live much in the open air;  and,  if possible, 
 168        ON THE CONSTITUTIONAL ORIGIN  AND

 not to suffer their minds to be agitated by anxiety, or fatigued by
 exertion. The advantages of exercise in nervous disorders, upon
 which those of the digestive organs in general so greatly depend,
 appear to me  very striking.  It were to be wished that we had
 some index to denote the strength and irritability of the ner-
 vous system, serving as the pulse does with regard to the san-
 guiferous organs.  Perhaps the strength, agility,  and indefatiga-
 bility of the muscles may  be regarded  as the surest evidence of
 energy of nervous  power and  bodily vigour.   If  this  were
 granted,  however, it would follow that many persons, possess-
 ing great nervous power, have nevertheless great nervous irrita-
 bility.  Many people, who are extremely  irritable and hypo-
 condriacal, and are constantly obliged to take medicines to regu-
 late their bowels whilst they live an inactive life, no longer suffer
 from  nervous  irritation, or require  aperient medicines, when
 they use  exercise to a degree that would be excessive in  ordi-
 nary constitutions.  The inference which I draw from cases of
 this description is, that nervous  tranquillity is restored in con-
 sequence of the superfluous  energy  being  exhausted by its
 proper channels, the muscles.  When, on the contrary, the
 nervous system is weak and irritable,  exercise seems  equally
 beneficial; but caution is  here requisite as to the degree in
 which  it should be taken.   A weak and irritable patient may
 not be able to walk more  than half a mile without nearly faint-
 ing with fatigue  on  the first day  of the experiment;  but  by
 persevering in the effort, he will be able to  undergo consider-
 able muscular exertion without weariness.  Does not this  im-
ply a considerable increase of bodily strength ?  and is  not the
 acquisition of strength the chief desideratum in the cure of many
 disorders?   The nervous  irritability also, when dependent  on
Weakness alone, will proportionably diminish with its cause.
In the  latter case, the nervous energy seems to be augmented
in consequence of our increasing the demand for it.  I  am in-
 duced  to make these observations,  from a belief that exercise is
 not employed, as a medical agent, to  the extent that its efficacy
 seems  to  deserve :  of its  medical  effects  I entertain  a  high
opinion.  It is however right to direct patients with regard to its
 use, not to exert themselves for some time previous to a meal,
nor for three  hours after.   I would prescribe to my  patients
the following rules : They should rise early, when their powers
have been refreshed by sleep, and actively exercise themselves
in the open air  till they feel a slight degree of fatigue; they
should rest one hour, then breakfast,  and  rest three hours, in 
               TREATMENT OF  LOCAL  DISEASES.          169

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

  * After I had written the above account of the  treatment, which I had
 found the most succcessful in the correction of disordered states of the di-
 gestive organs, I was much gratified by the perusal of  Dr. Hamilton's
 publication on the Effects of Purgative Medicines.  I think there is a great
coincidence in the mode of treatment which  I  have  described, and that
 which is  sanctioned by  his more extensive experience.  He prescribes
 purgative medicines to act as eccoprotics, to excite but not to stimulate the
 bowels; and he combines with them generally unirritating doses  of mer-
cury.  Dr. Hamilton's plan of treating these diseases also accords very
 much with  that of Mr. Halle, to whose Memoir I have referred the reader
               22 
170       ON THE CONSTITUTIONAL  ORIGIN AND
CASES.
                     SECTION  1.

          ON NERVOUS AND MUSCULAR DISORDERS.

  Long before my attention was excited to disorders of the di-
gestive organs, I had remarked that there was a paralytic affec-
tion of the lower extremities, resembling that which is produced
by a  disorder of the medulla spinalis,  in consequence of dis-
ease of the bodies  of the vertebrae.   This paralytic  affection
also appeared to me to vary with the state of the patient's health.
  These observations led me to propose a method of treatment,
which proved successful in  the cases of two young ladies, who
were  affected in this manner.  The issues,  which had been
ineffectually kept open in the back, were healed ;  and the state
of the health in general was amended by country air,  exercise,
attention to diet, and a few simple medicines.  The. use  of the
limbs returned  in  proportion as  the health  became established.
Such were  the  observations which I had made relative to  this
subject, when I  met with the following cases.

                          CASE III.
   A  young lady, whose stomach and bowels were disordered
in the manner  already  described,  became  gradually affected
with  weakness of the lower extremities, and  pain  in the loins.
The  pain became  at length very severe, and  was aggravated in
a manner almost insupportable  by  the  agitation of a carriage.
This lady could scarcely walk, and gave a description  of the
state of her limbs, so exactly resembling that which  is  some-
times consequent to diseases of the  vertebrae, that I thought  it
right to examine the spine.   I struck with my finger the spinous
 process of each lumbar vertebra, and  upon touching  one in
 particular, the patient complained of great pain ; but pressure
 on the contiguous  vertebrae also caused much uneasiness.   Un-
 der these circumstances I  placed a blister on each side of the
 spine, and kept up a discharge from the surface  by dressing it
 with savine cerate.   These means, with rest, relieved her suf- 
               TREATMENT  OF LOCAL DISEASES.         171

tarings ; but, as her health declined, she went into the country,
where  she soon became much better.  The blisters were now
suffered to heal, and she shortly afterwards  had recovered so
much,  as to  take long  rides on a rough-going horse.   She re-
turned from  the country in good health,  and was  both muscu-
lar and fat.   About  a year  afterwards she  was so ill,  in the
same way, that she wished to have  issues made in the  back:
but I would  not consent  to this, from  knowing that  the bone
could not be diseased.  Of this return of pain in the back, and
weakness in  the lower extremities,  she  again  got well, upon
amendment  of her health in general.   Since that period, now
five years  ago,  she has been, sometimes, very well, at others,
pale and  emaciated ;  and these changes have corresponded
with the natural or deranged state of her bowels.

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

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

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

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

bladder were completely restored ; * his speech became articu-
late ;  and his general health, in every respect, much improved.
He remained in  the  hospital about  two months, but with very
little amendment in the state of the lower extremities, when his
friends suddenly removed him, on  account of some disagree-
ment  with the nurses,  and I  was unable to learn whither they
had conveyed him.
  The history of the preceding  case was taken by Mr. Crutt-
vvell, now practising  as a  surgeon in Bath, who had  been for
several years a most industrious student at the hospital, and
whose accurate observation and extensive information  induce
me to place entire confidence in  any statement of a case which
I received from  him.  To that gentleman I am also indebted
for the following particulars, relating to a patient who died some
little time ago in the hospital, and whose body was examined.
The dissection serves still further to elucidate my present subject.

                         CASE VII.
  Elizabeth Griffin,  twenty years of age, was admitted  into St.
Bartholomew's hospital in August,  1785, on account of an in-
ability to  move her lower limbs; which was supposed to origi-
nate from a disease of the spine.   On examination, however,
there were no appearances, which  indicated caries of the ver-
tebrae.  Her voice was,  at times,  considerably affected : and
she was  subject to occasional attacks, resembling, in  some de-
gree,  epileptic paroxysms.  The affection of the limbs  was lia-
ble to considerable  variations.   At times, as she assured me,
she could walk  across the ward  with very little difficulty ; at
others, she could not  even  stand without assistance.  Her tongue
was extremely, and, I believe, constantly white; her pulse
natural.   Her bowels were generally costive, and it was  ne-
cessary to employ active  medicines in order to procure stools,
which were always of a dark colour.  A slight temporary diar-
rhoea sometimes happened, and she invariably remarked, that the
ease  or difficulty with which  she  could walk, and the pain in
her head, with which she  was troubled, were in exact conform-
ity to the state of the bowels ; all the  symptoms being  relieved
by the diarrhoea, and returning as the bowels became again cos-

  * I have seen several cases which induce me to believe that the weak-
ness of the sphincter vesica?, which occasions young persons to void their
urine during sleep, very frequently arises from the same cause. 
TREATMENT OF LOCAL DISEASES.
175
live.  There was an appearance of irritability and languor in the
eye, which 1 have before observed in these cases, and the pu-
pils  were generally much dilated.  After the patient had con-
tinued in the hospital about seven  weeks, she was attacked with
fever, and died.  To this brief account of the symptoms, I now
subjoin the dissection.
   No diseased appearances were observed in the brain, though
it was examined  with the  most  particular  attention : neither
was there any disease of the vertebrae.   No disease, in short,
was observed except in the abdominal viscera.  The chief mor-
bid appearance, in them, consisted in an ulcerated state of the
villous coat of the ilium near to its  termination in the coscum.
The  ulcers were numerous, and  situated where the  mucous
glands are chiefly found.  The internal coat of the large intes-
tines, also, appeared inflamed.
   The liver was healthy in  its structure.   In the gall bladder
about one ounce  and a half of a light green serous fluid was
found, which had not in the least degree  the soapy, or muci-
laginous feeling of bile.
   Cases, like those which have been related, are not, if I may
judge from my own experience, at all uncommon.  They suf-
ficiently prove, in my opinion, that local nervous disorders and
muscular debility may  arise  from a  general  disorder  of the
health, in which the digestive organs are chiefly affected.  This
disorder, as has  been stated  in  the  preliminary observations,
may, sometimes, be the cause, and sometimes the effect, of the
nervous affection.  In either case,  however, its correction is
of high importance in the medical treatment of the disease.   In
the fifth  and sixth  cases;  a  disorder of the digestive  organs
must, I think, be allowed to be the cause of the nervous affec-
tion, from  the sudden and  complete  cessation of the latter,
when the cure of the former was accomplished.   Decisive in-
stances like these are particularly valuable ; they show what
great nervous disorder may be produced  by that of the diges-
tive organs, and consequently how  much the latter disorder is
likely to aggravate the former, when it occurs even secondarily
as its effect.   I have  seen a considerable number of such cases,
which I cannot relate with precision, because I had not sufficient
opportunities of observing the patients, to enable me to note
the progress of the disease with accuracy.
   Of these I can only observe,  in general terms, that I have
seen several instances of pain, imbecility, and wasting of the 
176         ON THE CONSTITUTIONAL  ORIGIN AND

muscles in one of the lower extremities, which were considered
as the effect of disease about the hip joint; yet the event proved
that there was no organic affection of that part.   The complaint
was connected with that state of constitution which I have de-
scribed, and was amended as the health in general improved. I
have also  seen several instances of wasting of the muscles of
one of the upper extremities in children ;  so much indeed were
the muscles shrunk, that the bones and joints could be as dis-
tinctly examined as in a skeleton.   The local affection in these
cases came on suddenly.  I lately saw a little boy, who had
an  attack of this kind in his left arm several  years ago, and
on whose  case I was at that time consulted.   The bowels had
been violently disordered  previous to the paralytic affection, and
were, at the time I saw him, in an extremely  unhealthy  state.
I recommended  that the chief attention should be paid to cor-
rect the disorder of these organs,  and  that the arm should be
supported by a  sling.  The limb gradually recovered,  and
though it is not at present quite so  large and strong as the oth-
er, yet the difference is so slight, that  it would not attract the
attention of a common observer.  About six months ago I saw
a little boy in very similar circumstances, and  in his case, the
arm quickly recovered its powers of motion, as the state of the
digestive organs  became healthy.
  I have also seen cases in children, in whom,  after some gen-
eral disorder of  the  health, accompanied  by derangement of
the stomach and bowels, an affection of the muscles of the ex-
tremities has taken place, like  that which produces the varus
and valgus: I mean a predominance of the actions  of some
muscles over others, producing distortion of the limb.   I have
seen this  happen sometimes  in one,  sometimes in  both the
lower extremities.   I have also seen the  arm similarly affect-
ed.
  That the local symptoms in these cases, as well as in those
which have been more fully detailed, arise from  a nervous affec-
tion of the brain, and not from any cause  acting locally on the
nerves  of the affected part, will,  I believe, on due consideration
be granted.   I suspect however that some persons may hesitate
to admit such an opinion, from the belief that  disorder of the
brain must operate generally, and  not  partially, on the  ner-
vous system.  Perhaps the contemplation of the consequences
of slight apoplectic effusions in the brain, may assist us in form-
ing just notions on this subject.  Such slight effusions of blood, 
TREATMENT OF  LOCAL DISEASES.           177
occurring in various parts of the brain, have been known to par-
alyze one leg or one arm,  or the muscles of the tongue,  or of
one half of the  face,  without affecting the  rest of the nervous
or muscular system.
   Another opinion which I wish to be considered  is, whether,
when there is considerable and continued paralysis, there  must
necessarily exist some pressure  or organic disease  in the brain.
That  this exists  in many instances is undoubted ; but the num-
ber of cases  in which  the paralytic  affection  is  merely  ner-
vous,  and independent of visible disease, is in my opinion  very
considerable.  The instances  which  have been related  war-
rant this conclusion, and show such cases to be more frequent
than is generally  supposed.   When  there is organic disease
of the brain, the case is very hopeless ; and probably no  con-
siderable alleviation  of the symptoms will  take place, by that
attention to the state of the digestive organs  which I have re-
commended.  In  dubious cases, (and such, on the first exami-
nation of them, the majority of these instances will probably be,)
it  seems  right to try  the  effect of correcting disorder of the
digestive organs, with a view to alleviate nervous irritation, be-
fore we proceed to those severer methods, which the  belief of
the existence of organic or vascular disease in the brain would
induce us to institute.  For if blood-letting and counter-irrita-
tion be employed, in order to  diminish  vascular action ;  or if
mercury be employed  to some  extent in order  to  induce the
absorption  of deposited  substance; these measures must ag-
gravate that disorder of the general health, upon which, in many
instances, the nervous affection depends.
   My object, in  the  recital of  the foregoing cases, is to point
out a  cause of paralysis  in particular  muscles, which from its
locality would, I  suspect, be generally attributed to some  local
disorder of the  nerves of  the affected part, and therefore be
treated  erroneously.   If my opinion  of the  nature of these
cases  be correct, they can only be successfully treated by means
which operate upon the constitution in  general.  I  have partic-
ularly recommended that our efforts should be directed to cor-
rect any errors that may exist in the functions of the primae viae,
for reasons that have been stated in the preliminary observa-
tions.    Of the efficacy of such endeavours I have seen many
more  instances than I have brought forward; indeed the  pro-
priety of such attempts seems so obvious, that I  doubt not but
they will be made, and the effect of them will, by that means,
              23 
178       ON THE  CONSTITUTIONAL  ORIGIN AND

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

  * Such cases as I have related, with others that it would  be foreign to my
present purpose to mention, have impressed the opinion on my mind, that
disorders of the digestive organs may originally cause,  or  may secondari-
ly aggravate, a nervous disorder;  and produce, as has been "mention-
ed, in the nervous system, a diminution of the functions of the brain • or a 
TREATMENT  OF LOCAL DISEASES.           179
CASES.
                      SECTION II.

ON THE EFFECTS  OF DISORDERS  OF THE  DIGESTIVE ORGANS
            ATTENDING INJURIES  OF THE  HEAD.

   I  shall next speak of those cases, in which local disorders
of the head,  produced by blows, are kept up  and  aggravated
by affections of the  digestive organs.  After  what has been
observed respecting the reciprocal influence of the  diseases of
the brain, and  the  chylopoietic viscera,  it  will readily be admit-
ted,  that an  injury of the former may  disturb the functions of
the latter.   Thus, concussion of the brain  occasions vomiting
as one of its immediate consequences,  and  will also be  found
to produce, almost constantly, at  a more remote period,  that
disturbance of the  digestive organs, which I have  described in
this  paper.   If the disturbance be only  moderate  in  degree,
but continued, it will often  re-act upon  the head,  so as to occa-
sion  an irritable slate of the  injured parts,   and  impede their
recovery.
   In many cases of blows upon the head, a slow  inflammatory
affection continues in  the parts chiefly injured, and  ultimately
produces destructive diseases.  The bone sometimes becomes
diseased, or  an exostosis grows from its internal table; the du-
ra mater becomes thickened, or  matter  slowly  collects on its
surface.  Such local  disorders produce others of a  more  gen-
eral  nature, and destroy the  patient.   These  occurrences  are
however, in  my  opinion, rare in  comparison  with the  cases
first  described; in which a painful state of the  injured parts is

state of excitation causing delirium, partial nervous inactivity, and insensi-
bility ; or the opposite state of irritation and pain : in the muscular system,
weakness, tremors, and palsy ; or the contrary  affections of spasms and con-
vulsions." Could these circumstances  be proved,  it  would be scarcely
necessary to add, that those painful affections of parts, to which perhaps
some predisposition exists, may be excited in a  similar manner; such as
gout and rheumatism. Indeed rheumatic pains are  very  usually concom-
itant upon that state of constitution, which existed in the  patients, whoso
cases I am relating. 
180        ON THE CONSTITUTIONAL ORIGIN AND

kept up by means of disorder existing in the digestive organs.
The necessity for an  accurate  discrimination  between  these
disorders, must strike us on the  most superficial view of  the
subject;  for the  lowering treatment,  which is necessary in  the
first and rarer case, would be  detrimental in the  second and
more frequent ones.   By  attending to the state of the digestive
organs in these dubious cases, we may be enabled  to form  a
probable opinion of the nature of the local  complaint; for,  if
there be nothing wrong in the general health to excite or  maiiv-
tain it, we may reasonably conclude  that  it was merely  local;
on the other hand, the inefficacy of evacuations  in  curing  the
local disease would naturally  suggest the opinion, that it pro-
ceeds from irritation, and is dependent on a disorder of the
health in general.  It should be  further observed,  that  when
the local disease is of an inflammatory nature, and likely  to in-
duce morbid alterations in the structure of the  affected  parts,
still it may be maintained  and aggravated  by disorder  of the
digestive organs.   I  have  very frequently seen  patients  suffer
so severely as to warrant a suspicion, that local disease  of the
most formidable  nature  existed;  in these the usual methods of
treatment were ineffectual; and  they recovered suddenly  or
slowly, in proportion as the state  of  the  digestive organs was
corrected.   I  shall relate some examples of the  disease  under
consideration, which will enable the reader to identify the case,
when it occurs in practice.

                        CASE VIII.
   A young gentleman, about ten years  of age,  fell out of  a
window, six feet high, and struck the back part of  his  head
against some stones.   He was stunned by the blow,  but per-
fectly recovered from the effects of the  accident  by bleeding,
purging, and a low diet.  He caught the scarlet  fever  about
six weeks  afterwards, and recovered from  that also.    But,
whilst he was  convalescent, the pains returned  in  that part of
the head which had  been struck, with so much violence,  as to
induce the belief that some serious local mischief would ensue.
After they had continued without abatement for a few days, I
was desired to see  him.   He was  lying in  bed, and  could
scarcely be prevailed on to lift his head from the pillow.   The
integuments of the occiput were so tender, that he would hard-
ly allow me to examine the part;  I ascertained, however, that
there was no fluid under the  scalp, nor  any  inequality in  the 
TREATMENT OF  LOCAL  DISEASES.
181
bone.  He dozed a good deal, and lay in a comatose state, but
was occasionally restless.   His  pulse was  very frequent, his
skin hot and dry, and his tongue covered with a thick yellow
fur.   He  breathed almost without moving the diaphragm,  and
complained much if the epigastric region was compressed.  He
loathed food; his  bowels  were costive, and  his  stools  of a
blackish colour.  He was ordered to take small doses of calomel
at night, and draughts with rhubarb and kali vitriolatum in the
morning.  The tongue soon became clean, and the stools  nat-
ural ; his  appetite and spirits returned, and he no longer  com-
plained of any uneasiness in the head.
   This case presents us with a striking example of what I be-
lieve to be a common occurrence; I mean, a disordered state
of the digestive organs taking place subsequently to a consider-
able febrile affection.   Indeed,  when we reflect in how weak
and  irritable a state the brain must be left upon the subsidence
of such a  disorder, and how much the chylopoietic viscera must
suffer from the impaired  and  disordered energy of the brain,
we might naturally expect such a derangement of the functions of
the digestive organs  to ensue.  When such  disorder happens
in this manner, it frequently  produces many local diseases,  to
which  the constitution may perhaps be predisposed;  a circum-
stance I shall speak of in a future part of this paper.  In the
present case, it brought on a painful  state of parts recently  in-
jured,  with a considerable degree of fever.  That  the morbid
state of the stomach  and  bowels was the cause of both, is fairly
to be inferred from their  ceasing  so immediately, when the
disorder of the digestive organs was  corrected.   A case of this
kind, presenting an example of sudden recovery, is particularly
valuable,  because it clearly demonstrates the cause and the ef-
fect in swell diseases.  The  cause can indeed  be seldom  so
suddenly  removed ;  and. the gradual cessation of it under any
plan of treatment leaves  room  for a variety of conjectures,  as
to the  mode of cure or of  recovery from those disorders which
I have considered as effects.  1  could relate many cases of simi-
lar but less severe symptoms,  produced by the same  cause,
which gradually got  well, in proportion as the disorders  of the
digestive  organs  were corrected.   As it does  not, however,
appear to me necessary to accumulate instances  to  prove  so
obvious a fact, I shall content myself with adducing two  more
cases, to exhibit such effects in different points of view. 
182       ON  THE  CONSTITUTIONAL ORIGIN AND
                        CASE IX.
  A lady fell down in frosty weather, in consequence of her
feet slipping from under her, and the occiput struck  against a
smooth stone pavement.  She  was  stunned  by the  fall, but
soon recovered;  nor had she for some weeks the severe symp-
toms, which appeared  in the sequel.   This circumstance shows
that there was nothing produced by  the blow that necessarily
caused the  subsequent symptoms ; which must therefore be at-
tributed to  inflammation  or irritation taking place afterwards.
When some weeks had elapsed from the time of the accident,
the parts which had been struck became  extremely painful;
and the pain extended  forwards over the scalp to the right eye,
the sight of which became imperfect.  The integuments upon
which the blow had been received were extremely tender, and
the patient  became faint when they were examined even slight-
ly.   These circumstances naturally  induced a belief that some
disease was taking place; and  bleeding and purging were  em-
ployed to prevent its progress.   The symptoms were mitigated
for a time by these means, but they  quickly returned with  as
much severity  as before.  After three months the patient came
to London, fully persuaded  that nothing but an operation would
be of permanent benefit.  When I first saw her,  she tottered
in moving from one chair to another, and replied  to  questions
with hesitation and effort.  Her eyesight was  so much  affect-
ed, that she could not  read;  and she entertained an apprehen-
sion that she should lose her  senses.   Her  tongue  was but
slightly furred ; her bowels  were habitually  costive,  and the
stools dark-coloured.  It was  evident where the injury  had
been received  ; for the aponeurosis had been separated from
the pericranium  by an effusion of blood; and, though  this
blood had been absorbed, the detachment of the scalp was dis-
tinguishable by the touch.  No inequality  was perceptible  in
the surface of the bone.  When I mentioned my suspicion that
these symptoms were rather the effect of  irritability  of consti-
tution, dependent on the state of the stomach and bowels, than
of local mischief, she gave not the least credit  to the  opinion ;
but said she was persuaded  that the  bone was starred, and that
three  fissures extended in different directions.   I  ordered her
to take five grains of the pilul.  hydrarg. every second night,
and a draught  twice a  day, containing one ounce of  the  com-
pound infusion of gentian, two drams of the infusion  of  senna,
and one dram of the compound  tincture of cardamoms.   These 
TREATMENT OF  LOCAL DISEASES.
183
medicines produced a considerable purgative effect.  On the
second day there was but little pain  in the  head; the patient
walked about the room very steadily, and had read a newspa-
per in the morning.  When I asked  her  opinion of this  sur-
prising alteration, she imputed it to the evacuations which had
taken place ; but she was still persuaded that the bone was in-
jured, and still apprehensive that, without some operation, she
should ultimately lose her senses.  The  medicines  were  con-
tinued in such quantity as to  procure only one  alvine  evacua-
tion daily.   A fortnight elapsed  under this plan  of treatment,
during which the stools became  nearly of a natural  colour, and
the patient's health was considerably amended.  There  were
times when no uneasiness was felt  in the  head ; and, during
some nights, the pain was so trivial as to give but  little  inter-
ruption to her sleep.   It was, however, occasionally  disturbed
by pains, which were, in  her opinion, as intense as at any for-
mer period of the complaint.  Her  pulse was  good, and the
muscular strength greatly improved.   The  occurrence of the
pain in paroxysms strongly impressed me with the belief that
it was nervous, rather than depending upon local disease.  Un-
 der these circumstances all ideas of an operation were dismis-
 sed from my mind, but it was far otherwise with respect to the
 patient.  Being obliged to return into the country, she consid-
 ered the possibility of a relapse with horror; and was so con-
 vinced that the bone had been injured, that she earnestly  re-
 quested it might be examined, were it merely to ascertain what
 was the fact.   I  saw no objection to this  examination,  but
 thought, on  the contrary, that advantage might possibly arise
 from an incision, which would loosen the tension of the  scalp,
 and produce a discharge that might relieve the irritation of the
 part.   I accordingly made an incision of a semicircular form,
 extending farther back than the part which had  been  struck,
 and turned  up a portion  of the scalp, so as  to  see  the bone,
 covered by  its pericranium, to  the  extent  of a crown  piece.
 The bone was uninjured, and together  with the  pericranium,
  appeared perfectly  natural.   The scalp being replaced,  the
  wound was dressed superficially,without any attempt to  favour
  the union of the parts.   If they un  ted  under these circumstan-
  ces, there  would be  an additional  reason  for believing  that
  neither the bone nor the  subjacent  parts were diseased.   The
  pain was as severe for the first two  days  and nights  after  this
  examination as it had  been at any former period: it abated 
184       ON THE CONSTITUTIONAL  ORIGIN AND

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

                          case x.
   May  29, 1805, a labouring man, aged forty-five, fell from a
considerable height upon his head, and was  immediately brought
to St. Bartholomew's hospital.  No fracture of the skull could
be  discerned; and  the patient seemed to  labour under the ef-
fects of violent concussion of the brain.   By venesection, and
other antiphlogistic means, he soon recovered his senses.   Ev-
ery thing went on very favourably  for three days, when he was
attacked with  shivering,  nausea, pain  in the head, impatience
of light, and other symptoms, which usually are considered as de-
noting inflammation of  the membranes of the brain.  He  was
consequently  bled, and had a blister applied on the head.  He
was suddenly seized in the evening with a more excruciating
pain in the head, which, after lasting half an hour, was succeed-
ed by convulsions, so violent that three  men could scarcely hold
him.  When  the  fit abated,  he  expressed himself much re-
lieved, and said that he was  easier than before its  accession.
Some calomel and rhubarb were given to obviate a costive state
of his bowels.  On the next morning (June 2d) he had  a re-
turn of the. pain and convulsions ;  and  the symptoms were so
violent, that he was bled four times in  the course of the day.
This treatment, however, had no effect in diminishing the pain
and other  symptoms, and another fit of convulsions took place
in the evening.  The purgative  operated  on  the  succeeding
night, and brought away a large quantity of highly offensive fe-
culent matter of a light greenish-yellow colour.  On the 3d
of June his breath was extremely offensive ; his skin hot and
dry ;  his  pulse quick ; his tongue  thickly  furred ;  and he had
great tenderness in  the epigastric region, and right hypochon-
drium.  He was ordered to take two grains of calomel imme- 
TREATMENT OF  LOCAL DISEASES.
185
dintely, and a saline medicine at intervals ; this produced two
motions in the course of the day.   By pursuing this plan for a
few days, the state of his bowels  was rendered more regular,
and the discharges acquired a  healthy colour ;  in  proportion
as  this was effected, the tenderness of the abdomen  was  re-
moved, and the tongue  became clean.   He had no  return of
convulsions, the pain and other symptoms subsided, and in a
short time, when the digestive organs had  been restored to a
natural state, he went out of the hospital perfectly well.
   Cases of this description  have  been noted from the earliest
ages.  Many  passages in the  works of Galen show that he
was well acquainted  with the  circumstances that have been
stated  in this  section.   Bertrandi*  has related  instances of
abscesses taking place in the  liver, consequent to injuries of
the  head.   Andouille j- relates additional cases,  and  makes
further observations on  the same subject.  Of  late, Richter J
has  delivered  similar opinions,  and has directed  the  practice
which  should be pursued, when the head is  disordered  by the
re-action of affections of the digestive organs.   Still, however,
these circumstances seem to me to be stated rather as occasion-
al, than as occurrences which are common and naturally to be
expected ; and I therefore think myself warranted in supposing,
that they have not made a sufficient impression on the  minds of
surgeons, in this country at least.§
  I  beg leave, in the conclusion  of  this section, to repeat what
was said in the former one, viz. that I consider the disease as
depending on  nervous  irritation in the parts affected, which is
either  caused,  maintained, or aggravated by disorders  of  the
digestive organs.  Yet as the local disease  must be regarded
as chiefly nervous, it might, in  some rare instances, exist  in-
dependently of any manifest disorder of those organs.   I may
furl her add, that much nervous irritation in any part generally
excites vascular action.   It becomes  therefore highly impor-
tant to attend  to the nature and cure  of such disorder, as it
might  ultimately lead to the production of organic disease,
which  would destroy the patient.

  *  Mrmoiresdel'Academie de Chirurgie, torn. iii. p. 484.
  +  Ibid. p. 506.
  t  Chirurg. Biblioth. b. viii. p. 538.
  §In Dr. Cheston's Pathological Observations, however,  cases of this de-
scription are noticed.
24 
186       ON  THE CONSTITUTIONAL  ORIGIN AND
                    SECTION  HI.

  ON  UNDEFINED  AND  UNDENOMINATED DISEASES ARISING
          FROM DISORDER OF THE CONSTITUTION.

  The next class of cases, to which I shall call the reader's at-
tention, is that of unhealthy indurations, abscesses, and sores.
Sometimes but one local disease of this description exists, but
in general they break out in succession in different parts of the
body.   The circumstance of their  successive  formation is,
I think, a  proof that they depend  upon some  error  in the
health in  general;  and I have accordingly observed that  they
are seldom, if ever, unattended with  disorder of the digestive
organs.  The imperfect history which  the patients  generally
give of their previous state of health, will not enable us  to de-
termine with certainty  that the disorder of the bowels was the
cause of their ill  health, and subsequent local  diseases ;  but I
can confidently affirm,  that those diseases in general become
tractable,  in proportion as the disorder of the viscera is correct-
ed ; and that frequently no new local symptoms occur, after  some
attention has been  paid to the state of the digestive organs.  The
diseases to which  I allude, have  not been described in books
of surgery ; and indeed it is scarcely possible to  delineate with
precision  their various appearances.   It would be quite imprac-
ticable to  describe  all the diseases, which make the subject of
the present section; namely, unhealthy  indurations,  abscesses,
and sores.  They may be compared, not improperly, in varie-
ty and number, with the infinitely diversified combinations and
shades of colour.   Yet a brief and general description of them
will assist to recall them to the remembrance of the experienced
surgeon ; and to enable the inexperienced practitioner to re-
cognize them, when they occur.
   Some  of these  affections  are  quite  superficial,  occupying
merely the skin.   The first that I shall  describe is,  I believe,
well  known to surgeons,  as  a disease, which is frequently,
though not constantly, cured by giving mercury to such an ex-
 tent as slightly to  affect the constitution.  A  small  induration
or tubercle takes place in the skin, and  this is followed by the
successive formation of others at small distances from the  origi-
nal one.  The skin between these tubercles becomes thickened. 
               TREATMENT OF LOCAL DISEASES.         187

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

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

But, since I have found that these diseases indicate some dis-
order of the health in  general, the correction of which is the
great object in their  cure  and  prevention, I have perceived
that there is less necessity for  undertaking this most arduous
investigation ;  which,  indeed,  could never be accomplished
without very extensive opportunities  and  indefatigable  dili-
gence.
   It will be found in  the majority of  these peculiar diseases,
that the patient had been indisposed for some time before the
occurrence of the complaint,  and  that afterwards the  health
had become more evidently deranged.   The digestive organs
are  disordered.  The  tongue is  furred  at  the  back  part,
chiefly  in the  morning; and the biliary secretion is deficient
or depraved.   My attention has been directed to the correction
of this disorder;  and  the most beneficial  effects have result-
ed  from this  attention.  The  sores  have healed readily  in
some instances ; and, in those cases where many had previous-
ly formed in  succession, no  new disease has in general taken
place.  In some  few instances, new sores have  formed after
the medical treatment of the disorder had commenced, and
even after it had been for  some time continued.  This proba-
bly arises from the difficulty which is  experienced in correct-
ing an  habitual and long-continued constitutional disorder.   In
some still rarer cases I have found similar but much milder dis-
eases arise, after the disorder of the digestive organs had been
in a great degree corrected.
   Whilst I am  writing this, there are four patients, whom I
have  attended in St.  Bartholomew's hospital,  with these  dis-
eases ;  which  I mention,  to show the  younger  part  of the
profession how  frequent they are.   The health of these pa-
tients has been surprisingly amended  in a very short period,
by employing  the means  which I  have described ; and the
sores have healed  rapidly, although nothing but simple dress-
ings have been applied to them.
  It is not meant by these  observations to depreciate the utility
of topical applications to unhealthy ulcers,  but  merely  to show
how mueh they depend on the state of the health in general;
for some of them, which have remained uncorrected by a great
variety of local  applications, will get well under simple dress-
ings, when the  state of the constitution is amended.   It is not,
however, to be expected that this will generally  happen ; for
local diseasedaction having been  excited, becomes established, 
1 90       ON THE CONSTITUTIONAL ORIGIN  AND

and may continue, independently of the cause which produced
it.  Topical remedies will, under these circumstances, be  em-
ployed  with  the greatest advantage.   Again,  topical  applica-
tions  are of the highest utility in general practice, because an
irritable sore affects the whole constitution, and aggravates and
maintains that disorder by which it might have been originally
caused.  The disorder of the digestive organs cannot in many
instances be corrected,  till the  fretful state of the local disease
is diminished.   I may  further  mention, with  relation to this
subject, that I have seen patients, who scarcely ever slept from
the pain of the local disease, whose stomachs were greatly dis-
ordered, and who had  a distressing purging, which could only
be  controlled by opium, sleep without interruption during the
night,  regain  their appetite, and  have  their bowels  become
tranquil and regular, when, after various trials, a dressing has
at last  been applied, which quieted  the irritable state of the
sore.   It is right, however,  to mention, that the effects of such
an application are not, in general,  permanent;  but after a time
the sore becomes again fretful, and requires some new dressing
to soothe or control its irritability.
   I have  seen some cases of such diseased sores as I have
described,  in  consultation  with  other  surgeons, who have be-
come convinced  that my opinions are well founded.   Others
have occurred, even in the persons of medical men, whose feel-
ings co-operated to render their conviction more strong.
   Having thus, from general observation, acquired the opinion
that the  peculiarities  of local disease depend  chiefly  on the
state of the constitution, I shall  relate  some cases, which  were
treated  in conformity with the principles  which  such  an opinion
would naturally suggest.  I  must,  however, previously caution
the reader against inferring, that I attribute all local diseases to
some  general error in the state of the health.  1 have seen local
diseases, which  could not be deduced  from any general indis-
position, nor  corrected  by remedies which  act  simply on the
constitution at large.  I  wish to guard against the suspicion of
being inclined to make general assertions; while I avow, at the
same  time, that my observations induce me to believe,* that the
peculiarities of local disease generally  depend  upon constitu-
tional causes.  Reason also suggests  the same opinion; for  if
sores  of the same character break out in succession in  different
parts of the body, can we doubt that they arise from the state of
the health in general ? 
TREATMENT OF LOCAL DISEASES.          191
  There appears  to  me  a combination of nervous irritability
and weakness, and to such a combination I am inclined to attri-
bute the peculiarities of these variable  and  unclassed  local
diseases.  Perhaps I may explain my meaning further, by ad-
verting to what happens not unfrequently in cases of venereal
and other buboes.   The  part and  the constitution  have been
both weakened  by the disease that  has occurred ; they have
been further debilitated by the mercury  employed for its cor-
rection.  The disease subsides,  but a new disease and  action
commences; a trivial wound frets out into a  phagedaenic  sore,
which is very difficult of cure.  The sores, in different  cases,
are nearly as various in  appearance, as those of which I have
been speaking.   To what are we to attribute these  dissimilar,
perplexing,  peculiar sores, if not to irritation  occurring in weak
and irritable parts ?   As the peculiar  diseased actions of these
sores originate chiefly from the weakness and irritability of the
parts, induced  by  the previous disorder which they have un-
dergone ; so in their  advanced  stages they frequently  present
the  best instance that  can perhaps  be adduced, of a peculiar
local  disease existing independently  of constitutional disorder.
It is true they affect the health in general; but it may, by atten-
tion, be kept in  a moderately  right  state,  and yet the sore
remains  unamended.  The  diseased  actions of these  sores
sometimes  gradually,  and  sometimes  suddenly  cease; when
healthy  actions  succeeding,  the  sore  heals.  I remember a
sore of  this description,  to which  almost every variety of
dressing had been tried without benefit.  It was very extensive,
and had burrowed in various directions beneath the skin.  The
ulceration at length became stationary ; but  after  nine  months
the sore still remained as foul and fretful as  it had  been for a
considerable time ; when  in the course of one week  it perfectly
cicatrized,   leaving the hollows  which I have described ;  for it
had thrown out no granulations to fill these chasms.
   Having thus stated the  opinions, which I have  formed, rela-
tive to these kinds of local diseases, and which have been de-
duced from cases too  numerous  to  record, of  which I have
preserved no accurate accounts,—I proceed to relate some cases
treated  in conformity to these opinions, which will, I trust, be
sufficient to exemplify and illustrate the present subject.

                          CASE  XI.
   A gentleman's servant, between  thirty and forty years of age,
was sent to  me with a bad ulcer in his cheek, situated between 
192       ON THE  CONSTITUTIONAL ORIGIN  AND

the nose and  under eyelid.  The surrounding parts were in-
flamed, swoln, and  indurated, so as to rise  fully  half an  inch
above  their natural level.  The sore was of  an  oval  figure ;
measuring  about an inch and a half in length,  and half an  inch
in breadth  and depth; indeed I could scarcely see its  bottom.
The surface was covered by adhering matter of a greenish  hue.
The cuticle round the margin was thickened, and had in some
parts scaled off.   The patient had been rubbing  in  the mer-
curial  ointment for  this complaint.   He declared that he  had
had  no chancre for many  years,   but had contracted a gonor-
rhoea about a year before his present disorder.   His health was
much  disturbed ; he  had  no appetite ;  his tongue  was much
furred   and tremulous ;  his bowels alternately costive and lax ;
his faeces blackish.   1 advised him  to take five grains of  rhu-
barb about an hour before  dinner, and  five  grains of the  pil.
hydrarg. every second  night, with castor oil or senna  tea oc-
casionally,  so as  to  procure a motion daily.   The  sore  was
dressed with spermaceti cerate.  I  saw him again in three days ;
when he said that he felt himself under the greatest obligations
to me.   He had been entirely free from pain and distressful
sensations,  since he began  to take the medicines;  although he
declared, that before that time, he  should have been thankful to
any one who would have destroyed him.  I mention this, because
I have  often remarked in these cases, the surprisingly great re-
lief and comfort which  have arisen  from a change,  produced
by means apparently insignificant and inadequate.  The bowels
now acted  regularly, and the stools were more copious and of
a more natural colour ; and  to this correction of the biliary
secretion I  am inclined to impute that relief, which he so forci-
bly depicted.  The  sore had discharged profusely ; the  sur-
rounding swelling and inflammation were much lessened.  He
pursued the same plan of treatment for a month, during which
time he recovered  his appetite ; his tongue became  clean ; his
bowels regular, and  the biliary  secretion natural.   The  sore
had  contracted into  a small  compass, but without the  appear-
ance of granulations ;  and the surrounding parts were not swoln,
though still red.   His health  became at  this time again much
disordered, in consequence of his catching cold, from exposure
to rain.  He  had pain in his bowels, with a slight  purging ; his
appetite failed; his tongue  was furred;  and he had a  severe
cough, attended with  copious expectoration.  The sore on the
cheek  also  enlarged to about one  half of its former size :  and 
TREATMENT OF  LOCAL  DISEASES.          193
the surrounding parts became tumid.   I had the patient admit-
ted into St. Bartholomew's Hospital, where he took the decoc-
tion of cascarilla with squills.  His  cough  became  materially
better  in a short time: the state of his  stomach and bowels
also greatly  improved.   The  sore again  diminished  in  size.
About a fortnight after his admission into the hospital, an erup-
tion came out  over  his  whole  body.  The spots were of a
copperish  hue,  but  rather  smaller and  more  elevated  than
venereal  eruptions generally  are.*   Some  of the eruptions
gradually disappeared ; and, in about a fortnight, it was cer-
tain that many  were entirely gone.   About this time he began
to complain of  his throat;  and an ulcer, of the size of a  shil-
ling, formed  in each  tonsil.  The edges  of these  sores were
elevated and uneven, without any appearance of granulations ;
the surface was covered with  yellow  adhering  matter.   The
patient now again caught cold : he was attacked with pain in
the bowels, and purging, which obliged him to get up frequent-
ly in the night,  and to remain for some time out  of bed.   The
cough  and expectoration returned : he lost his appetite;  and
he  had a  furred  tongue.   Dr. Roberts,  whom I  met at the
hospital, did me the favour to prescribe for him.   In a day or
two afterwards, an erysipelatous inflammation appeared on the
right side of his face, opposite to the situation of the sore.   The
eyelids  were so tumid that he could not open them: the ery-
sipelas spread to the other side of the  face; and the other eye
was equally closed.   The  fever  also  ran  very  high,  and the
patient  became delirious; so that  he was obliged, for  many
days, to be confined  by a strait  waistcoat.   These  symptoms
gradually abated, and he recovered, so as to be in better health
than I had ever seen him.  He was discharged in about six
weeks, in a state of convalescence; and attended Dr.  Roberts
as an out-patient.  The eruption and sore throat had entirely
disappeared ; the  original  ulcer  was  firmly healed ;  and the
contiguous skin had become  soft and natural, though it was still
discoloured.  A  year has since  elapsed, and he has had no
return of his complaints.
   It is, I  think, sufficiently  evident,  in  the  present instance,
that the peculiarities of the local diseases had their origin in the
state of the constitution.

  * Many persons who saw the patient, did npt entertain a doubt but that all the
symptoms arose from syphilis; it was their progress alone which evinced the
contrary.
               25 
194       ON THE CONSTITUTIONAL  ORIGIN AND
                        CASE XII.
   I was consulted, by a medical gentlemen in my neighbour-
hood, on the case of a lady about forty years of age, who  had
been long subject to  dyspepsia, and severe headaches.  Her
present and chief complaint had been of about three months'
duration.   It began with weakness, and an apparent irregular-
ity in the motions of the lower extremities, attended with  con-
siderable  pains  resembling  rheumatism,  and  rigidity of the
calves  of the legs.    These  symptoms  increasing,  she  was
unable in the course of a month to move about at all; but was
obliged to be lifted  in and out of bed.   At this time an indu-
ration of the muscles of the calf of each leg  had taken  place.
The indurated substance was about three inches in length, and
between two and three in breadth.   It was severely painful  at
times, and the integuments covering it  were  occasionally in-
flamed.  There was also  some pain and swelling in the ham.
Leeches, sedative lotions, and  mercurial  ointment had  been
applied ;  cicuta and tonics had been given, but without  allevi-
ating the symptoms.   I first saw the patient  about  six  weeks
after she had been obliged to keep her bed  entirely ; and the
peculiarities of the present case  led  me  at  once  to  refer its
origin to the state of the health in general.  The  appetite and
digestion were impaired,  the tongue was much furred, and the
faeces blackish.   I merely recommended  fomentations to the
indurated parts, considering it  the  primary  object  to correct
the morbid state of the digestive organs.   With this  view the
compound infusion of  gentian with  the  infusion of senna  and
tincture of cardamoms was given, in such  doses as to procure
an adequate evacuation daily, and five  grains  of  the  pil.  hy-
drarg.  were  taken every  second night.   These simple medi-
cines were  completely successful:  after taking them a short
time, the discharges from  the bowels were natural,  and  prop-
erly coloured with bile.   The appetite  returned ; the tongue
became clean, and the pains almost immediately ceased.  No
cutaneous inflammation, indicating  a disposition to suppuration,
appeared again over the indurated  parts,  which gradually  re-
covered their natural state.  In a fortnightthe patient could go
about with a stick, and in two months could  walk as well  as
before  her  complaint.  She has enjoyed  better  health, since
this time, than for many years before.*

  * The state of the indurated muscles, in  this case, was  such as would
lead to the belief that suppuration would take place  in different parts of 
TREATMENT OF  LOCAL DISEASES.          195
                        CASE XIII.
   A gentleman, thirty-two years of age, who had been  subject
for several years to occasional attacks of severe  pain in the
bowels, was seized, about the end  of August,  with  a  violent
purging, which  continued  for  a fortnight, and was attended
with fever.   About a month afterwards, he felt pain in his leg
at night, which gradually became continued even  during the
day, and obliged him to confine himself to bed.  In the begin-
ning of October a swelling was perceived near  the inner ankle,
which  suppurated, and  was  opened  on the twentieth  of the
same month.   Two large  tea cups full of dark brown matter
were evacuated.   The  discharge continued profuse for some
time, and afterwards diminished.  Four other  small gatherings
then took place in succession, and, bursting, continued  to dis-
charge ; each aperture  fretting  out  into  a full sore.  About
the beginning of February I first  saw  this case,  which  was
considered as a disease of  the bone.   The five sores had aper-
tures in them leading to   sinuses, which communicated  with
each other.  A probe introduced into one of these,  near the
bottom of the tibia, could be moved  upwards  and  downwards
along the surface of the bone, which  was not, however, denu-
ded.   From an upper ulcer  the probe could be passed  behind
the bone, and under the muscles of the calf; this indeed seem-
ed to be the original seat of the abscess, from which the  sinu-
ses  proceeded  to  their different outlets.   The  integuments
were oedematous and firm  to the touch,  so  that I  could not
distinctly feel the outline of the tibia;  but  1 thought that the
bone was not  altered either in form  or  size.   The firmness
with which the patient stood  upon the limb,  and the want of
aching pain in the bone, contributed also  to  make  me  believe
that it  was not diseased, and that the  whole disorder  consisted
in an unhealthy  abscess, the  discharge from which issued  from
the various sinuses in the manner already described.  I could
not but attribute such a disease to a  general  disorder  of the
health, and indeed the patient's countenance  and appearance
indicated a constitution much weakened and harassed by illness.
His tongue was  furred, and  the discharges from  the  bowels
were irregular, deficient in quantity, and of a blackish  colour.

the hardness; indeed, I have seen many cases less formidable in appear-
ance terminate  in that manner.  Seeing how much  the  irritability of
muscles is disordered by that state of constitution which I have been de-
scribing, I think it is allowable  to conclude that most of the organic disea-
ses of muscles originate from this  cause. 
196       ON THE CONSTITUTIONAL ORIGIN AND

With a view to the correction of these symptoms, I directed
the patient to take  five grains of the pil. hydrarg. every second
night, and the infusion of gentian with senna, so as to  procure
one motion daily.  But little benefit  was  obtained  by these
measures;  and  in about a fortnight afterwards a thickening of
the integuments took  place over the  fibula; a  considerable
swelling gradually  arose, and another abscess formed,  which
burst  in  about three weeks, and  discharged a  considerable
quantity of brownish  matter  mixed with blood.   During  this
time the limb was merely poulticed, and the patient could  not
leave his bed.  His pain was extreme, and he had no  rest at
night.  The use of opium was necessary to alleviate  his  suf-
ferings, and opening  medicines  occasionally to procure stools.
He took  but little nourishment, and his health greatly declined.
The disordered state of the stomach and  bowels was much
aggravated by this  local  irritation.   Indeed, the situation of my
patient was now particularly perplexing.   The  local  disease
made the general health worse ; and  the  aggravation  of this
general disorder, which appeared to have  been  the cause of
the local  disease and of its continuance, proportionately increa-
sed the latter malady.   The confinement  to bed  afforded an
additional obstacle to recovery ; yet it was impossible  to  re-
move him in  his present state, on account  of  the  pain  which
motion occasioned.  The  leg was insupportably  painful in a
dependent posture.  As change  of air and exercise seemed
essential  to his recovery, I was induced to try if Mr. Baynton's
excellent bandage, by supporting the weakened vessels, would
prevent their distention, and the consequent pain.  The  sores
were dressed, after as much matter had been expressed from
the sinuses as could be  done without occasioning pain.   Strips
of sticking-plaster were  applied  after  the  manner of a many-
tailed bandage;  and  the limb was afterwards rolled with a cal-
ico roller.  The patient felt comfortable, and found his limb
strengthened.   He was directed to wet the roller, if the parts
became heated.  The effect of this treatment was surprising
both to the patient and myself.   The  pain, which had been
constant  before pressure had been employed, ceased from  the
time of dressing till five o'clock on the following morning ;  but
from that time it gradually increased till noon, when the  dres-
sings were renewed.  The cause of this  occurrence now  be-
came manifest; for, upon opening the  bandage,  more  than a
teacupful of matter was discharged from the different  sinuses. 
TREATMENT OF  LOCAL  DISEASES.
197
I dressed the limb as before, cutting holes for  the escape of
the matter opposite to two of the chief sinuses.   I  desired the
patient to put his leg to the ground, in order to ascertain the
effect of the perpendicular position when the vessels were sup-
ported ;  and he experienced no  inconvenience.  The  second
day passed as the former, without  pain; and  as  the  matter
poured into the  sinuses readily escaped, he had no uneasiness
from its detention.   I  recommended  him to sit up, and put
his leg to the ground several times in  the day, in order to ac-
custom it to that position.   After I had dressed  it on the  third
morning, the patient stood  up,  and took two or  three  steps
very feebly;  but this was rather the effect of general weakness
than of particular infirmity in the  diseased limb.   I now ad-
vised him to go a little way  out of town  in  a  carriage.  The
air and exercise, together with the freedom from pain, produced
a very beneficial effect.   He began to recover his  appetite, to
sleep at night, and acquired so much  strength, that he was able
in a week to go about  his house, and  to  resume his attention
to business.  The discharge from the sinuses was very trifling,
and the sores looked much  better.  The patient  now under-
took to dress his leg himself, and hired a lodging out of town,
so that I only saw him occasionally.   His limb was so much
amended in the course of a fortnight,  that it caused no  more
trouble than that of daily  dressing.   But his  health was not
good.   His countenance had the same expression  of illness as
when  I  first saw him; his  tongue was  white  and dry; his
bowels costive  ; and  the  stools of an  unhealthy colour.  I
therefore recommended him to take again the same medicines
which I  had formerly ordered him.   His health now improv-
ed ; his  tongue became moister, and  less furred;  the bowels
more regular;  and the faeces coloured  with a  more  healthy
bile.   He  continued recovering till the middle of April,  when
he began to complain of the trouble of applying the sticking-plas-
ter, and  used the calico roller alone.  I did not see him for three
weeks, and then found  him in a very desponding state. He com-
plained of the tediousness of his  confinement, which had lasted
more than half a year, and said that he would willingly submit
to have the sinuses laid open, if that would make him well.   I
found his leg well, excepting two orifices near the  tibia;  three
ulcers which formed  the apertures of as many sinuses, had
healed ; the outline of the bone could  be  distinctly felt; and
there was no alteration of it in form or size.  I  was unable  at 
 198       ON THE CONSTITUTIONAL ORIGIN AND

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

ON  MORE DEFINED DISEASES, AS  CARBUNCLE  AND  SCROFU-
  LA,  ARISING FROM DISORDER OF  THE  CONSTITUTION.

  If, upon an extensive and accurate examination of the sub-
ject, it were to appear, that many very peculiar and  very  dis-
similar local diseases originate from a common  cause,  namely
from weakness and irritability of the system in general, our in-
quiry would be further extended, and we  should  feel  anxious
to know whether similar causes may not operate in the produc-
tion of more common and more frequent local  disorders.   As
far  as my late observations have  enabled me to  determine, that
state of the digestive organs, which  I consider  as causing or
denoting constitutional disorder, exists prior to the formation of
a carbuncle; and is exacerbated  during the  progress  of  that
disease.   This opinion indeed will appear probable, if we con- 
TREATMENT OF  LOCAL DISEASES.
199
sider the kind of persons who are attacked with carbuncles, and
the considerable  derangement of health,  which  even a  trivial
local disease of this nature occasions.  I shall mention but one
case in support of this opinion, though  I have  made  similar
remarks in several other instances.

                         CASE  xiv.
   I  attended a gentleman,  who was afflicted with carbuncles,
during three successive attacks, at the interval of about a year
between each.   I made an incision through the indurated skin,
down to the subjacent sloughy cellular  substance,  and thus
brought the local disease to  a crisis.   This treatment was suffi-
cient in the two first attacks ; the extension of the disease was
prevented ; the sloughs separated, and the wound healed.   The
patient, whose mode of life  was intemperate,  had cough ;  diffi-
cult  respiration ; fullness and tenderness of  the parts situated
in the epigastric region ;  unhealthy  secretion of bile;  and in
short, all those symptoms which denote a very considerable de-
gree of disorder of the digestive organs : it is probable  indeed
that  some organic disease of the chylopoietic viscera existed.
After he had recovered from the carbuncle, I told him that the
most important disease still existed ;  and urged him to be atten-
tive to his diet, and to the directions of his medical attendants.
He still however continued to live intemperately, and his disor-
der  increased.   He was indeed nearly  dying  from diseased
viscera, when he was attacked with carbuncle for the third time.
The division of the parts produced a  temporary cessation of the
disease ; but it began  again to spread in  every  direction from
its circumference, and he died.
   It will not, I  believe, be  doubted,  that biles are a slighter
degree, with some variation, of the same  disease, which causes
anthrax and carbuncle ; and it is almost unnecessary to remark,
that  some persons are  subject to a successive formation of very
large and troublesome biles  from the least irritation of the skin.
I have seen many persons thus affected ; and there has  been,
in every instance, disorder of the digestive organs, the correction
of which has prevented the  return of these vexatious local dis-
eases.  One gentleman, who had been   tormented for  many
years by the quick successive formation of biles as large as eggs,
has been free from  them for some years ; though he has had
other disorders, which  denote such a condition of the constitu-
tion, as it has been my object to describe in this paper. 
200        ON  THE  CONSTITUTIONAL ORIGIN AND

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

                         CASE XV.
  A child of two years old had  the smallpox, from  which he
did not seem to recover,  but, on the contrary, fell into a very
bad state of health.  The absorbent glands on the right side  of
the neck became  enlarged in succession, so as  to form alto-
gether a very considerable tumor, which extended down to the
collar bone.  The axillary glands then became affected in the
same manner;  the swelling was  unusually great, and  seemed
to extend under the pectoral muscle,  elevating it, and forming
by this means a continuation of tumor  with the glands of the
neck.   These  swellings  had partially  suppurated,  and had
broken in two places, viz. in the neck, and about the margin of
the pectoral muscle : but no relief followed ; on the contrary,
the  mass of  disease seemed to  be rapidly increasing.   The
child was bowed forwards, so that the spine was much curved
in the loins; the left leg appeared paralytic, and a swelling was 
             TREATMENT OF  LOCAL DISEASES.           201

perceived in the abdomen, which I could not but ascribe to an
enlargement of the external iliac  glands.  The child  was ex-
tremely emaciated ; his skin felt hot and dry ; his tongue was
covered with a brown fur ; and the stools were black and high-
ly offensive.   As there  was no expectation  that he could sur-
vive this desperate state, those medicines only were prescribed
that seemed likely to  correct the  state  of the digestive organs ;
such  as occasional doses of calomel,  and rhubarb.   A strict
attention to diet was also recommended.  Under this treatment
the stools gradually  became  natural,  and  the  tongue  clean.
The disease seemed to  stop immediately.   As the  health was
restored, the swellings rapidly  subsided ; and the child became
one of the healthiest and stoutest  of the family.

                         CASE XVI.
   A female child, after having had the small pox, got into bad
health  from  disorder of the digestive organs.   She  was then
suddenly  attacked with a scrofulous affection of the knee and
elbow of the opposite  sides of the body.   Two  collections of
fluid had  taken place beneath the fascia of the leg and thigh.
The joints were greatly enlarged, and  the swelling was appar-
ently caused by an increase in the size of the  bones.  Had I
seen either joint, as a single case  of disease, I should  have said
that it would leave the child a cripple.   It was manifest, in the
present instance, that these local diseases were the consequence
of general ill health; and that the first object  was to  correct
the disorder of the system.  The functions  of the digestive or-
gans, which had been deranged,  were restored to their  natural
state  by  employing  the  same diet  and medicines which had
been so signally successful in  the preceding case.   By these
means  the  health was re-established,  and   the local diseases
gradually disappeared.
   I have heard it remarked  by surgeons of great experience,
that patients often recover when  many scrofulous  diseases ap-
pear at the same time ;  although  some of them may be  so con-
siderable, that they would seem to warrant amputation,  had they
appeared  singly.  The cases which  I have related afford a
most clear and satisfactory account of the  mode of recovery.
General irritation and  weakness  bring on  diseases,  to  which
perhaps a predisposition may exist, in several parts of the body ;
these cease when their exciting cause is removed.
26 
202        ON THE CONSTITUTIONAL ORIGIN  AND

  Of late indeed I have been equally surprised and rejoiced to
see swellings of the absorbent glands in children  readily dis-
persed by that medical attention to correct errors in the functions
of the digestive organs, which I have described.   Some of these
swellings came on rapidly, and some slowly, but these were so
large and so much  inflamed, that if any person had formerly
told me  they might be dispersed by  such measures, I should
have thought the assertion an absolute absurdity from its direct
contradiction to  my former experience.   From amongst a con-
siderable number of cases, I shall relate the following.

                         CASE XVII.
   The son  of  one  of my friends had gradually fallen into a
very bad state of health.   The child was about six years of age,
and had been unwell for  several months ; when, in  conclusion,
two glands in the neck became gradually enlarged, till  each
had attained the size of a large walnut.  The child's tongue was
much furred,  his appetite very deficient  and capricious; his
bowels had a costive tendency ; his stools were never of a pro-
per colour.  His flesh was wasted and flabby, his countenance
pale, his pulse feeble and frequent; and his general demeanor
languid  and irritable.   I told his father, that  I  could advise
nothing as a local application better than bread and water poul-
tice ;  and that the chief object of attention was  the  correction
of that disorder under which he had long laboured, so that his
constitution  might regain its  natural  tranquillity and strength.
Upon this subject I promised to speak to  the  gentleman who
had hitherto attended the child.  In about two days a deep red-
ness came over the  most prominent part of each  gland, de-
noting,  as  I concluded, a  disposition in the internal  parts  to
suppurate.   The child took half a grain of calomel with five  of
rhubarb every second night, and ten drops of the acid, vitriol.
dilut.  three  times a day.   In about a week, an evident amend-
ment was observed in the appetite,  spirits, and colour of the
excretions from the bowels.   In a fortnight, the spirits of the
child  became, to use the  words of the parents, ungovernable;
and an evident amendment of the health in general took place.
[n a month,  the child might be said to be well; though he still
remained thin.   After another  fortnight, he  discontinued  all
medicine, except the occasional use of the  powders, for at this
time all vestiges of enlargement  in the glands had disappeared.
I do not relate this case as extraordinary  for I have seen seve- 
TREATMENT OF  LOCAL DISEASES.
203
rai worse cases cured by the same means;  and as I have said,
some of the swellings have come on tardily and others rapidly.
It is related merely, because in the same family another  child
had  suppuration of the glands, which  left a  sore that healed
slowly.
  It cannot indeed be proved that these cases would have been
strumous ;  it can only be said, that to all appearance they were
the same as others which I have  formerly seen suppurate, and
form sores slow in healing, and such as  are generally denomina-
ted scrofulous.

                        CASE  XVIII.
  A slender child, about  five years of age, had five swollen
glands on the right side of the neck,  and three on  the left.
Their  magnitude was considerable, and  the child's  appearance
sickly  ; and  the disorder  had so  threatening an appearance,
that the  gentleman who attended  the family requested the pa-
rents to take some additional  opinion on the case.  The tongue
was furred, and the bowels so habitually costive, that sometimes
a week elapsed without any alvine  evacuation.  As the child
was feverish, he took at first some saline medicines in a state
of effervescence, which was afterwards changed for the diluted
vitriolic  acid.   He also  took half  a grain  of calomel, every
second night, which gradually  brought  about a  regular  secre-
tion of healthy bile, and  in about  three weeks the  child might
be said to be well, for his bowels acted  regularly when no med-
icine was taken, and the discharges from them  were  properly
tinctured with bile.  The use of calomel was now only recom-
mended, if the appearance of the  stools varied  from the rhubarb
colour.  The swollen  glands disappeared, nothing  but a  bread
and water  poultice having been applied to  them.  The bodily
powers of  the child were considerably augmented, and his as-
pect became healthy.

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

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

                         CASE XX.
   A child about five years of age, after having had the measles,
got into a bad state of health, and had  several scrofulous ab-
scesses form on the fore-arm.   They became sores of various
sizes, but in  general about that of a shilling ; the  surrounding
skin was thickened and of a purplish  hue. The sores were foul
and without granulations.  In this state they were  when I first 
              TREATMENT OF LOCAL DISEASES.          205

«aw the patient, and had continued with occasional amendment
and deterioration for two years.   Being consulted on the case,
and perceiving the child appeared out of health, I examined his
tongue, which  was  furred ;  inquired respecting his appetite,
which was deficient, and  the state of his bowels, which were
costive.   The same medicines were prescribed as in the former
cases.  In about six weeks the child got into remarkably good
health, which it had not enjoyed from the time of its  first indis-
position, and the sores rapidly and soundly healed.
   My observations have led me to  believe, that most local dis-
eases are preceded by general indisposition, of which the disor-
dered state of the digestive organs is an evidence,  and may have
been  a cause.   The relief arising from the correction of this
disorder is indeed surprising, and the general knowledge of this
fact I have  deemed my duty to promote to the utmost of my
power.  When the appetite  has been  deficient, 1 have been
accustomed to recommend acids as medicines;  when, on  the
contrary, it has been good, and the digestion difficult and imper-
fect, I have recommended bitters and alkalies.
   I mention  this to  account  for my giving the vitriolic acid in
these cases.   It is in addition to its medical properties, so plea-
sant, that even spoiled children will take it  without agitating
themselves, and distressing their parents.   It pleases me to be
able to give proofs of its utility ; because, I think, they will be
allowed  to  disprove that any  specific good arises  from  the
administration of alkalies.   Alkalies may be  useful  occasion-
ally in dyspeptic  cases ; but that they have no specific action in
the cure of scrofula, I have long thought from some experiments
which I made on this subject at the  hospital.  In cases of scrof-
ulous glands, I  gave soda in doses which were gradually  in-
creased till they affected the qualities of the urine, without per-
ceiving any benefit to accrue to the local disease from  their use.
The pleasure which I feel in  thus endeavoring to disprove the
specific virtues  of alkalies arises from this circumstance : That
if 1 am right in my notion, that they are chiefly useful by their
operation in the stomach and bowels, it shows how much bet-
ter it is to be informed of what  ought to  be done for the cure
of diseases, than of the means by which it may occasionally be
accomplished ; or, in other words, it shows how much superior
the rational is to the empirical practice of medicine.
   After having attempted  to show that many non-descript disea-
ses arise apparently from  the state of the  constitution, and that 
206       ON  THE CONSTITUTIONAL ORIGIN AND

carbuncle and scrofula are sometimes consequences of the same
cause ; it may be inquired, whether, if the same general distur-
bance of the health can produce so many varieties of local dis-
ease, it may produce many  others, and  even  every variety.
Even in  cancer, disorder of the digestive organs appears to  be
antecedent to the local disease, and aggravated by its existence ;
but whether this disorder be the effect or cause of the constitu-
tional diathesis, cannot, 1 think, be at present determined.
CASES.
                     SECTION  V.

   ON DISEASES  OF VARIOUS GLANDS, ARISING FROM  DISOR-
                DER OF THE CONSTITUTION.

   I have also observed that diseases of particular organs seem
to originate, in  many instances, from disorder of the system in
general.   The testis of the male subject, and  breast of the fe-
male have furnished me with examples of this observation.   In
the cases to which I allude, the testes were alternately affected,
enlarging considerably, and then subsiding.*   I have met with
numerous and interesting  cases of such diseases of the breast;
however, the relation of  a few will be sufficient  to inform the
reader of all that I  know concerning this subject.

                         CASE XXI.
   A lady came to  London, to  submit to the removal of a dis-
eased breast, if it  should be judged  necessary.   The  disease
had existed for more than two years.  The  breast of the affect-
ed side was one third larger than the other ;  indurated in seve-
ral parts; and so much enlarged and hardened in  one place,

  * The cause which excites and maintains alternate irritation and disease
of the testes, generally resides in the urethra; but there was no disease of
that part,  in the cases  which I now mention.  The patients first became
unhealthy, and disorder of the testes followed.  Similar affections are not
uncommon in pseudo-syphilis. 
            TREATMENT  OF LOCAL DISEASES.            207

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

                         CASE  xxif,
   A lady consulted me on  account of a considerable swelling
of the  breast,  attended with much pain.  It had come on sud-
denly, and had been painfu! about  a week; but she thought
that a  lump had existed previous to this time.  The  principal
tumor was on the side next the  sternum, and was  as large as an
hen's egg; it seemed  to  be distinct, yet  there was  a general
swelling, with partial induration of the substance  of the gland.
The tongue was furred,  the bowels  costive,  and the  pulse fre-
quent ; and she was, to use  her own expression, very  nervous.

  * It may not be improper  to  observe here, for the instruction of the
younger part of the profession, that if a breast containing a portion which
is  particularly indurated be examined with the points of the fingers placed
circularly, the disease will feel like a separate tumor ; but if the flat sur-
face of the fingers be moved over it, its true nature will become manifest. 
208        ON THE CONSTITUTIONAL ORIGIN AND

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

                       CASE XXIII.
   A medical man, who resides in the country,brought his daugh-
ter to town for  advice.  She  had  apparently a tumor in her
left breast, between the nipple and the axilla ; in which part she
had felt a good deal of pain.  The swelling was  of very con-
siderable size, and the  breast so tender, that I could not exactly
make out whether it arose from  distinct tumour, cr from a par-
tial enlargement of the mammary  gland. Want of time prevented
the patient's father from showing the case to  another  surgecn.
I could only give him this opinion; that in the present circum-
stances, no one would think  of an operation.   1 recommended
the  application of the  lotio  ammon. acetat. when the part felt
heated ; and as the patient had  disorder of the stomach and
bowels to a great degree, that the chief attention should be paid
to the state of these organs.   A  grain of calomel was  directed
to be taken every  second night; rhubarb before dinner, and
infus. gentian and senna, if necessary.
   About two  months afterwards, having occasion to be in that
part of the country where the patient resided, 1 called on her.
Her father then told me  that the swelling  had subsided con-
siderably, after his  daughter's return into the country ; and that
of late he had not examined the complaint, as she told him she
felt no uneasiness from it.
   When I now  examined the breast, I could not  perceive any
difference between  it and the other.   No vestige was left of a
disorder, which had been of such a magnitude, as to occasion
considerable alarm; a circumstance that excited the  greatest 
TREATMENT OF LOCAL DISEASES.
209
surprise  in  the nrnd of her father, who was a practitioner  of
much experience.*
  Before I  had paid attention to those complaints which arise
from, or are aggravated by,  constitutional causes, I could not
have believed that such considerable local diseases, after resist-
ing various topical  and general means, should  give way  so
readily and  completely to small  doses of medicine.   It is only
by considering the manner in which this  effect is  produced,
that the subject can be placed in a proper point of view.
  An attention to the state of  the bowels is indispensably neces-
sary, even in the common practice of surgery.  A simple cut
of the finger frets  into a bad phagedaenic sore,  which resists
every local remedy so long, that amputation is at last proposed.
This is  the  consequence  of  bad health,  which  in its turn  is
aggravated by the  irritation of the  sore.  The patient has a
furred tongue, with  other symptoms of disordered digestive or-
gans.   An attention to this disorder corrects the painful slate
of the sore,  which now heals rapidly under simple dressings.
   A patient has a disorder in the urethra, almost too  trivial for
surgical  attention ;  yet  producing much inconvenience.  The
functions of the digestive organs are  impaired, and he  is hypo-
chondriacal.  He consults a  physician, under whose care his
general health is amended, and  he no longer feels or thinks of
the local disease.
   An erysipelatous inflammation of the leg is imputed to some
trivial cause ; as for instance a  gnat-bite.   It becomes worse
under the common  remedies.  The health  has been long de-
clining,  and the  chylopoietic  viscera  are obviously deranged.
The erysipelas is quickly cured by medicines prescribed  for
that disorder.
   A patient has  a trivial  sore on his leg,  which the surgeon
finds a difficulty in  curing by  the usual methods.  The patient
feels  indisposed, and has a manifest  disorder of his digestive
organs.    The sore begins to slough, and becomes very painful
The  disorder  of the stomach  and bowels  is  augmented;  so
great is  the indigestion,  that the small quantity of food which
the patient thinks it necessary to swallow for sustenance, feels
weighty  and uncomfortable in the stomach ; and the vegetable
food becomes almost corrosively acid.  Opium fails to procure

  ♦ I have  also known cases of induration  and suppuration of  the salivary
glands, apparently caused by the same general disorder, and cured by the same
treatment.
               27 
210         ON THE CONSTITUTIONAL ORIGIN  AND

sleep, or even to give ease.  When the mortification has spread
so as to occupy almost  one fourth of the integuments of the
leg, several very copious pultaceous stools of a greenish brown
colour are discharged from the bowels in the course of the night,
and the patient's feelings undergo an entire revolution.  Before
this, the stools  procured by medicine  were watery and dark-
coloured.   The patient now sleeps like  one long harassed by
pain and watching ;  his stomach is tranquil and willingly receives
aliment, which now produces no uneasy sensations.   The skin
which had been hot and dry, becomes moistened with a gentle
perspiration,  and the pulse beats with its natural frequency, and
in a  tranquil manner.  The  effects of  this  favourable  crisis
being maintained by medical treatment, the sloughs  are thrown
off and the sore heals with a rapidity indicative of considerable
vigour of constitution, and further demonstrative of the slough-
ing not having been the  effect of vascular weakness, but of ner-
vous irritation.   I could relate numerous cases of erysipelatous
inflammation terminating in sloughing, in which the disease arose
from  a similar  constitutional cause.
   In  order  further to  elucidate  this subject,  I subjoin  the
chief circumstances of a case which occurred  since the  pub-
lication of the second edition of this book.
   A gentleman who once had a  pimple  on  his  leg  spread by
sloughing, so as to  produce a considerable chasm both in cir-
cumference  and depth,  was  much alarmed   when  another
equally trivial complaint  manifested the same disposition.   He
was at  this  time in London on a visit, and desired  me to at-
tend him.   The patient was about 50 years of  age, and a ro-
bust healthy looking man  ; his pulse was remarkably vigorous,
and in all  respects right;  his tongue but slightly furred, and
his bowels regular.   To me his apprehensions seemed unfound-
ed : he was, however, confined to a sofa, and a linseed poul-
tice applied for nearly three weeks, without any augmentation
of the disease, or  any separation in the circumference of the
eschar.  The  slough had split into portions, and a fetid matter
oozed from it: at that  time the poultice was changed to one
made with stale beer, with a view to excite a little action in the
indolent parts.  It  produced, however, irritation,  and in one
night the sloughing  of the integuments increased to  one  third
more  than  its former extent-   The linseed poultice was again
employed, and after some weeks were  elapsed, as no separa-
tion had occurred in the circumference of the slough, and it ap- 
              TREATMENT  OF LOCAL DISEASES.         211

pearing penetrable by  medical applications, weak acids, infu-
sions of bark, dilute spirits, and resinous tinctures were tried, to
learn the effect upon the slough and contiguous parts ; some of
the slough had by this time  separated, and new flesh of no un-
healthy appearance presented itself beneath the  sloughing part
which  extended  no deeper than the skin.   None of the appli-
cations seemed  of any material  benefit, and any  thing of an
irritating nature  appeared to produce  irritation, with a slight in-
crease in the circumference of the slough.  As the sloughing
of the skin  seemed to  be the effect of disease extending in it
while the cuticle was entire, and when consequently no appli-
cation  could have any peculiar effect,  but would act as a simple
stimulus; and as all stimulants appeared injurious, 1 contented
myself in future  with the application of the linseed poultice and
simple  dressings.  Under their use the sloughing  of the skin
continued to spread during  a  period of about six months, when
the patient died.
   The disease began about the middle of the tibial side of the
leg, and extended towards the. front and outside, till it occupied
about  three-fourths of its circumference : it extended  also to-
wards the  ankle, and to within about two inches of the upper
end of the tibia.   At one  time it spread  by  a dusky coloured
inflammation, suddenly occupying a considerable extent  of skin ;
yet in this district there were parts more discoloured, and pre-
senting an appearance similar to  that arising from the transuda-
tion of blood from the veins in dead bodies.   The parts so dis-
coloured first sloughed, leaving  several insular portions of skin
still preserving its vitality.  Some of these portions slowly per-
ished, others never completely mortified.  At  other times the
mortifications spread slowly, and  merely from the circumference
without any previous disease  in the skin being apparent :  every
new  extension  was  preceded by constitutional  disturbance ;
and when  the  patient felt  well and  was  tranquil, the  disease
continued stationary at times for  a fortnight or three weeks. As
the sloughs successively separated in the order  in which  they
 took place, a healthy granulated surface appeared beneath them,
 which cicatrized ;  and cicatrization also taking place from those
 portions of skin which did  not completely perish, the sore heal-
 ed  with more than usual celerity, so that a  short time before
 the patient's death tbere was much less slough and appearance
 of disease than at former periods.
    Having described the local treatment of this unfortunate case, 
212       ON THE CONSTITUTIONAL ORIGIN AND

I have only to relate the circumstances observed relative to the
system at large, and the medical treatment which was instituted.
The patient had been accustomed to eat a well-cooked dinner,
and to drink a liberal quantity of wine afterwards.  .About four
months preceding  this attack, be had  very  much  diminished
his quantity of wine ; and  from this time he thought  that he be-
came nervous and  uncomfortable.   His nervous feelings were
manifested by anxious looks  and inquiries, and  by impatience
to have things done at  the moment and in the manner  he wish-
ed : he was also  apprehensive and  solicitous about others,  in
cases which warranted no such feelings.  He was thirsty, and
generally  had a tumbler of water on the  table, which he  sipped
occasionally,  though he did not indulge himself in drinking  it.
He ate his breakfast and  dinner with appetite, and in moderate
quantity.   His bowels were regular ; and the  biliary dischar-
ges, although not right, were not materially otherwise.   The first
attentions  were paid to the digestive organs,in the manner descri-
bed in the introductory remarks;  but when the mortification was
extending, nitric acid and bark, were exhibited.  When the bark
was increased to a moderately large dose, in order to  ascertain
whether it was likely to be of service to the local  disease,  it
rendered the patient slightly feverish, increased his  thirst, and
caused the tongue to become dry and brown.   These medicines
were  changed for cordials,  as  camphor julep,  with  aromatic
confection,—which seemed to answer better.   Opium was tried,
and seemed  to be  beneficial in  moderate doses, administered
at regular  intervals; but  in larger doses it seemed injurious.
The patient throughout suffered very little pain, and  slept well,
except  at  those times when  a  temporary disturbance  of his
health, that has been mentioned, occurred.  At those times, al-
so,  the  white  part of  the eye  assumed a yellowish  tint, and
there was an  expression of languor  and disquiet in his counte-
nance.  As cordials agreed with him, a liberal quantity of wine
was permitted ; nevertheless, he gradually became feebler, and
his  flesh wasted, whilst his belly enlarged. Of this enlargement
he took notice himself: it first appeared to be merely  tympan-
itic, but subsequently water was evidently effused.   The right
foot and ankle became considerably  oedematous ; of the  left  or
diseased limb they were but slightly so.  He had but little pain,
and talked of returning into the country.  He was good-humour-
ed and  cheerful almost to the last.   A short time before his
death his  memory failed, and he  thought but little even  on his 
TREATMENT OF LOCAL DISEASES.         213
own case.  At last he was se'zed with profuse diarrhoea, con-
sisting of watery  discharges; and, being exhausted,  he slept
during the last 24  hours of his life.
   Now,  that the   slouahing was  not  in this case the effect of
vascular  debility, I infer not only from the  state of the pulse,
but  from the  rapid healing of the sore : that  his nervous sys-
tem was  merely disordered and not diseased, was to me suffi-
ciently evident.  Although I  was extremely desirous of exam-
ining the  body, I was not permitted to do so.
   A patient  supposes that his knee is  strained; for pain and
inflammation of the joint suddenly come on, with deposition of
fluid into  the articular cavity ; this attack is attended  with fever,
furred  tongue, and  unnatural  discharges  from the  bowels.
Leeches,  cooling washes,  and  poultices; in short,  all topical
applications are unavailing.  It is a case of rheumatic inflamma-
tion, for  which a physician is  consulted.   Five or six weeks
elapse without any abatement of the disease, the patient being
almost unable to stir in bed.  An alteration  in the health sud-
denly  takes place; the tongue becomes clean, the bowels reg-
ular, and  biliary secretion healthy ; and there is no longer any
pain in the knee.   All the fluid  is absorbed from  the joint in
two days, and  the  patient walks about his chamber.   Or there
may actually have been some local injury ; but the consequences
are very considerable and violent, and quite  incommensurate to
the cause.  Such occurrences can only be explained by impu-
ting the effects to the state of the health in general.*
   A case like that described in  the preceding  sketch would,
I believe, be acknowledged by every one to be dependent on
the state of the constitution in general ; but  I could bring for-
ward  a great number of instances  of chronic  affections of joints,
incurable  by local  measures, which were evidently cured  by
correcting those errors in  the state  of  the  digestive organs,
which were the cause or  effect of general disorder  of  constitu-
tion.   In  diseases  of joints,  we find  three distinct kinds of
cases.   First  a scrofulous disease of the bones, which ultimate-
ly affects their articular  surfaces;  secondly,  an inflammatory
affection of the joint, producing effusion of fluids into its cavity,
and ulceration  of the cartilages and ligaments; and in this case,

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


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

  * As I know of no treatise on diseases of the hip in which the distinction
of cases is made; and as,  from what I have seen, I cannot but consider
(he subject to be very important; so I think 1 should do wrong to forego
the present opportunity of relating as succinctly as  possible two of a con-
siderable number that have come under my observation, in order to excite
attention to this subject.

                             case r.
  A boy about twelve years old was sent from school to London, being sup-
posed to have  a lumbar abscess.  There was a considerable  collection of
fluid beneath the fascia of the thigh ; but it received no impulse when  the
patient coughed.  The boy limped in walking, as if he had a diseased hip,
scarcely bearing on the affected joint.  When pressure  was made on  the
front of the orbicular ligament, it gave him acute  and considerable pain.
He was kept perfectly quiet in bed, blood was taken by leeches repeatedly
from the integuments opposite to the inflamed joint, and linen  wet with
diluted aq.  ammon. acet. constantly applied,  till pressure no longer occa-
sioned pain.  A blister was then applied over the joint, and the cuticle
being removed, the sore surface was dressed with savine cerate.  This
dressing produced considerable inflammation and  ulceration beyond the
blistered part, and caused the surface of the skin which had been deprived
of its cuticle to mortify.   Near a month elasped before the sore healed.
At this time no fluid  was discoverable  beneath the fascia; no uneasiness
was felt when the joint was compressed ; and the  boy could not be prevent-
ed from getting up, because he felt as competent to walk about, as before
the occurrence of his disease. He went to school again in the country, and
after two years was put into a merchant's employ ;  in which  situation, he
was obliged to be constantly walking about the town.  He  then again be-
came lame in the same manner, but not to the same degree.  There was,
however, no effusion  of fluid beneath the fascia of the thigh.  A month's
rest with similar treatment seemed to have cured this relapse ; and 1 then
told his father that he must change the employment of his son—observing,
that though the joint might recover sufficiently to endure common exercise,
without injury, it was not to be expected that it would ever be able to sus-
tain violent exertions with impunity.  I urged him, also, to let me  know 
TREATMENT  OF LOCAL DISEASES.            215
CASES.
                      SECTION   VI.


DISORDERS OF PARTS WHICH HAVE A CONTINUITY OF SURFACE
                WITH THE ALIMENTARY CANAL.


   I  had formerly observed spasmodic strictures of the oesopha-
gus  to  disappear under various modes of treatment, in a man-
ner  which I did  not understand.   Mercury seemed to  effect
the cure in three instances.   Many cases have occurred to me
lately,  in which  the irritation in  the oesophagus seemed to be
first excited and afterwards  maintained by disorder of the di-
gestive  organs.   It will be  readily  allowed,  that  spasmodic


immediately if there was  any return of lameness. About three months
afterwards, I met the father and his son in the street, and observed that
the youth limped in walking very  much.  I asked why I had not been
informed immediately, as I had requested, of return of lameness ; and fur-
ther inquired, whether the boy still continued in the same situation.  Being
told  that he did so, I felt so much hurt at the cruel and absurd conduct of
his father, that I declared I would no  longer interfere in their concerns,
nor was 1 asked to do so.
  All that lean further relate of this case is, that a  large abscess formed
and broke behind the trochanter, and that I  once  afterwards saw the  poor
lad lying in St. Bartholomew's hospital with his thigh bone dislocated, in
consequence of the destruction of the ligaments of the joint.

                             CASE II.
  A  young lady of a delicate and susceptible  constitution, who had suffer-
ed much uneasiness of mind on account of some of her friends, became so
excessively lame in the. left hip that she could not move a few  steps with-
out support.  Pressure on the  front of the  joint occasioned  considerable
pain.  Her tongue was much furred, and her  bowels greatly  disordered,
and she had fits of agitated and difficult respiration.  I recommended noth-
ing but tepid fomentations to the hip, and explained to her physician what
I thought would be right to be done with regard to the state of the diges-
tive  organs
  As she became better in health, her power of moving  about  increased,
and  she went to the seaside.  After two years, there still remained some
tenderness, when the hip-joint was compressed and some thickening of the
parts which covered it.  She, however, eventually got well, though no  local
applications of any moment were made to the diseased parts.  I need scirce-
ly add, that the means employed in the first case, with such striking success
would have been prejudicial in the latter,  whilst those  which were  ser-
viceable in  the last case,  would  have  been futile and  nugatory in the
former. 
216        ON THE CONSTITUTIONAL ORIGIN  AND

strictures  of the oesophagus, when long continued, may cause
a thickening in the affected part of the tube, and thus the stric-
ture may become permanent.   One instance will be sufficient
to illustrate and verify this view of the subject.

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

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

the operation of this cause has been so little adverted to in books
of surgery ; since the phenomena which prove the fact are so
well  known.  Are  the monstrous noses, caused by excessive
drinking of vinous and spirituous liquors, to be  otherwise ac-
counted  for, than by irritation arising from the stomach?  And
do not worms in children cause a teazing sensation in the ex-
tremity of the  nose ?  1 had seen in  private practice,  several
cases of irritation and swelling of the end of the nose, in  some
instances accompanied  with small ulcerations of the pituitary
membrane.   In these cases, the skin over the nose, which was
tumid, became rough and discoloured : the middle of the discol-
oured part became sound ; whilst the circumference retained its
morbid actions, the disease there  spread  in a small degree.
In these cases the tongue was furred ; and there were evident in-
dications of disorder in the stomach and bowels.  The disease
was checked, and cured, by attention to  this disorder.   1 was
strongly impressed  with the opinion, that if these cases had
been neglected, they would have terminated in that herpetic
ulceration, which so often affects the end of the nose.  I have
also seen several instances of that herpetic ulceration in its con-
firmed state more materially benefited by medical attention to
correct the disorder of the  digestive organs than by any  local
application: and I feel confident that  it may  be frequently
cured by such endeavours.
  I have observed,  in all the cases of that noisome and intract-
able disease, ozaena, which have come under  my  care lately,
that the stomach and bowels have been disordered;  and  more
benefit has been obtained by endeavouring to bring these organs
into a healthy state, than by all the local applications which had
been  previously tried.  I stated to a  medical friend my  opin-
ions respecting one  patient, who came from the  country, and
begged to know the effect of the treatment which I  had pro-
posed.   He informed me, after some  months, that he had not
been able to succeed in correcting the visceral disorder;  and
after relating the means which had been used, he adds, " The
patient was now attacked with a bilious disorder, to which she
had formerly been subject, and for which I gave her six grains
of calomel in a bolus, which soon relieved  her.  During this
attack  the nose seemed  well;  there was no fetor in the  dis-
charge, and  she recovered  her sense of smelling." However,
the disease returned afterwards as before.
28 
218       ON THE CONSTITUTIONAL ORIGIN AND
  I have known several instances of persons who have  for a
long time been subject to polypi of the  nose, in which the  poly-
pi ceased to grow after some attention had been paid  to correct
a disorder of the digestive organs.
  In farther confirmation of the opinion,  that diseases of the
nose depend much upon the state of the stomach, I shall  men-
tion the case of a woman,  who had a disease of the nose, which
I expected would, at least, prove very tedious and very trouble-
some, but which got well  speedily  under simple dressings, in
consequence, as appeared, from the effect of internal medicines.

                        case  xxv.
  This patient was  between  thirty  and  forty  years of age;
had  a  furred  tongue,  bowels alternately  costive and lax, and
the discharges  discoloured.  An enlargement of  the left ala
nasi, caused  by a great thickening of  the parts covering and
lining the cartilage, had gradually taken place.   The skin was
discoloured, and an  ulcer, about the size of a sixpence, had
formed on the under surface of the  ala.  The sore was  deep,
with a  sloughing surface,  and uneven and  spreading edges.
Spermaceti  cerate was employed as a  dressing; and the ex-
ternal  skin was frequently bathed with Goulard's  wash.   She
was ordered to take internally five grains of rhubarb an hour be-
fore  dinner, five grains of the pil. hydrarg. every second  night,
and the infusion of gentian with senna occasionally.  The sore
ceased  to spread, the swelling gradually subsided, and all dis-
eased appearances were removed in the  course  of a month.
The patient also found her health considerably amended.
  In most cases of deafness, there is probably a state of  irrita-
tion, and a tendency to inflammation,  throughout the passages
of the  ear.   The external meatus  may be unusually sensible,
the secretions being  either suppressed,  or  discharged in an un-
natural quantity.  The lining  of  the   Eustachian  trumpet is
thickened;  and  hence it becomes partially obstructed.   It
must be admitted that such a state of the organ  is likely  to be
aggravated by a cause, which maintains or produces irritation
in the  nose.   When dullness of hearing also depends on  a tor-
pid state of the nerves, it  may  be caused by  the same circum-
stance, which is known to affect the sensibility of other nerves.
   Indeed, I  have remarked  that the hearing of many persons
has considerably varied with the state of their health in general; 
TREATMENT of local diseases.         219
so that  I felt no  surprise from  the occurrence  related  in
the following case.
   A  gentleman applied to me on account of some pseudo-
syphilitic symptoms, which I told him  would gradually become
well.  I advised him, at the same time, to be particularly attentive
to the  state of the digestive organs,  which were generally disor-
dered by the effects of the poison.   He took five  grains of the
pil. hydrarg. every second  or  third night.  The disorders for
which he had consulted  me were all removed in the  course  of
two months  ;  when I received a letter from him,  saying, that
he thought it a duty he  owed to me and to the public to inform
me, that the lenient course  of  mercury, which  I had  recom-
mended, had cured him of a considerable degree of habitual
deafness.
   It is well  known that ophthalmy frequently arises  from con-
stitutional causes;  and  in  such cases the digestive organs are
generally  deranged.  The  health will be most speedily restor-
ed, and the local disease most effectually diminished, by correct-
ing the disordered state of the  abdominal viscera.  There is
no necessity for  enlarging upon  this  subject; yet  it  may be
useful to  state what I have observed respecting those ophthal-
mies,  which  take  place  subsequently to  gonorrhoea, and
which have  generally been ascribed  to  a retropulsion of that
disorder, or to the accidental application of the discharge to
the surface  of the  eye. In the worst  of the  cases,  which I
have seen lately,  there  was considerable redness and irritability
of the eye, lasting nearly a fortnight.   The  digestive organs
were deranged in all the  instances, to which I  allude ;  and I
attribute the comparative well-doing of these patients to the
attention  which  was   paid to their correction.   In  other
cases, which I had formerly been witness to, where  evacua-
tions by bleeding and purging, &c. were employed, the  disor-
der  was  extremely obstinate ;  nay, several  patients lost their
sight.
   The cases of ophthalmy  connected with gonorrhoea appear
to be of two kinds.  In the worst case,  and that which I have
happened to meet with most rarely, there is,  I think, reason to
suppose that  some of the discharge from the urethra has been
accidentally applied to  the surface of the eye.  This  circum-
stance may  be inferred  from the copious and puriform discharge
which takes place from the conjunctiva  which is continued for
about three weeks, and from the  disease not yielding to any 
220       ON THE CONSTITUTIONAL ORIGIN AND

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

                       CASE  XXVI.
  A gentleman, having a gonorrhoea  and  being in a remote
part of Scotland, felt himself obliged to go to the  west of Eng-
land with the greatest expedition.   He came to London by the
mail coach,  and during the journey his eyes became greatly
inflamed, and he was much tormented with dysury ; he  was
indeed so ill, upon his arrival in town, as to  be unable to pro-
ceed on  his journey.  His  eyes were exceedingly red  and
painful,  and  the lids tumid.   He had frequent and  urgent de-
sire to void his urine.
  The discharge from the  urethra was very copious.   His
tongue was much furred ; his bowels had a costive tendency ;
the  stools were blackish and offensive.;  his pulse  frequent,  and
neither full nor strong ; his skin hot and rather dry.  He said
that formerly having a gonorrhoea,  he  had  been  affected with
ophthalmy in the same manner.  He was directed frequently
to bathe  his  eyes with a lukewarm  decoction of  poppies ; but
the  chief attention  was paid to the state  of his stomach  and
bowels.   He took five grains of the pilul. hydrarg. every night,
and other medicines to procure a  sufficient alvine evacuation
daily.  On the third day he had severe rheumatic pains in his
shoulder.  On the fourth, his knee became affected with rheu-
matism, and  so  much swollen that he  was incapable of mov-
ing  about, though his eyes were much  better, so that he  was
able to sit up and bear the window-shutters  of his chamber to
be left open, which he could  not before have permitted.  On
the fifth day, though better, his eyes were still much inflamed, his
dysury troublesome, and he was unable to walk from the rheu-
matic affection of  his knee.  The discharges from the bowels
had been regularly observed,  and they  still continued of a very
wrong colour, till the evening of this day, when he had a stool 
TREATMENT OF  LOCAL  DISEASES.
221
properly tinctured with healthy bile.   He  now felt a sudden
and surprising amendment, which appeared equally so to others
on the following day ; for I found him walking about with very
little  lameness,  his  eyes requiring  no further attention  than
wearing a green shade, and  he had no dysury.  In  two  days
he pursued his journey, nor  did he experience any relapse.
   There is a chronic ophthalmy, which is, I believe, generally
considered to be venereal, probably from the difficulty of curing
it, and probably from mercury being frequently beneficial to it.
As cases of this description  evince how much ophthalmies are
likely to depend upon constitutional causes, I shall briefly relate
the following, to identify the kind of disease to which I allude.

                        CASE  XXVII.
   A gentleman had  for more than two years been more or less
subject to a chronic  ophthalmy.  When he was very bad, he
had twice used mercury for  its cure, and with temporary suc-
cess.   The last mercurial course was a considerable  one, as
the relapse of his disorder was attributed to  the insufficiency of
the former one.   The ophthalmy, however, returned  with as
much, if not with more severity than formerly.  The eye was
extremely red,  very irritable, and  his vision very imperfect.
I found the patient shut up in a close and dark chamber, from
which he rarely ventured to  stir, lest he  should  catch cold.
His tongue was furred, and  his biliary secretion faulty.  I di-
rected small doses of mercury  every second  night, merely as
probilious medicines, and requested him to  pay  attention  that
his bowels were kept clear without being what  is called purged.
I also urged him to go out into the air, and use active exercise.
By pursuing  these  measures, the ophthalmy was nearly well
in  about three weeks.  He  now either caught cold or  fancied
that he had done so ; his  general health became disturbed, and
his ophthalmy  returned.  It got well, however, as  the distur-
bance of his  constitution  wore off;  and though he had two or
three times, during a year,  some trivial returns of ophthalmy,
yet they were always induced by general disorder, and readily
got well by measures directed to  correct disorders of the ali-
mentary canal.
   That cutaneous diseases * are much connected with the state
of the stomach, is generally known.   Hence various medicines

  * It may perhaps be right to advert to the direct and sudden sympathy
which exists between the skin and the stomach.  In affections of the lat- 
222       ON  THE  CONSTITUTIONAL ORIGIN AND
have been recommended to correct disorders of that  viscus,
with the view of removing the more evident,  but  consequent
disease of the skin.   The account, which I have given of dis-
orders of the digestive organs, may lead to a more rational and
less  empirical  treatment, and to the more just appreciation of
the value and mode  of  action of remedies, which are sanc-
tioned by experience.   It  is almost superfluous to relate any
case to authenticate so well known a fact; the following, how-
ever, may be found interesting and instructive.
   A patient in  St. Bartholomew's hospital had  an herpetic dis-
ease of the skin.  This  had healed in the  middle,  and spread
in the  circumference to  such a degree, that it occupied nearly
the whole length of the leg, and  included two  thirds of its cir-
cumference.    The skin had recovered a moderately sound state
in the  centre.   The  disease  was  propagated  in  the circum-
ference  by  an ulceration,  which threw  out a projecting  and
firm fungus of a tawny colour, of about half an inch in breadth.
A small groove or channel separated this fungus from the  sur-
rounding inflamed skin, which had not yet ulcerated.   A simi-
lar disease occupied  the  back part of the  arm; this was of an
oval figure, and resembled, in every circumstance, that which
I have already described upon the  leg.   These  diseases  had
existed for nearly two years, and continued to  spread in op-
position to every mode of treatment.   Mercury had been  em-
ployed, even to salivation, without any marked  alleviation  of
the local complaint.  I immediately perceived that  the diges-
tive organs were greatly  deranged : upon  correcting  this  dis-
order, the skin surrounding the disease became  pale; and all
disposition to'spread ceased.  The fungus, however, still  pro-
jected, and did not heal; it was therefore dressed with a weak
solution of kali arsenicatum.  This remedy seemed to subvert
the diseased actions, which had produced the fungus; so  that,
in less than two months, the patient was  discharged from  the
hospital, perfectly well.

ter organ, the skin is dry and cold, moist  and cold, hot and dry, or moist
and dry; and  it  suddenly changes from the one to the  other condition,
as the state of the stomach varies.  When the digestive organs are disor-
dered,  the irritable state of the skin is manifested by the effects of blisters
and other irritating applications.  A  blister  produces a  tormenting local
disease, and even a Burgundy pitch plaster causes extensive erythema.
Indeed, when the constitution is irritable, all the modes of counter-irrita-
tion, which surgeons employ under other circumstances  with success  for
the cure of local diseases, are likely to do harm ; and thus these curative
methods obtain discredit in consequence of their ill-timed employment. 
TREATMENT OF  LOCAL  DISEASES,          223
   I have seen similar herpetic diseases, of much  less extent,
succeed to the absorption of matter from sores upon the geni-
tals.  These have got well when the patient has gone into  the
country, and appeared again when  he  has  returned  to  town.
They have healed under a course of mercury, and broken out
again when it was discontinued.
   In this review of disorders, occurring in parts having a con-
tinuity of surface with the digestive organs, I have traced them
from the  stomach.   Another set of diseases  may originate
from the same source.   The large  intestines suffer more in ad-
vanced stages of these disorders than the smaller  ones;  hence
disorders of the rectum, and particularly many irritable  disea-
ses about the orifice  of that  bowel, are deducible  from this
cause.   I shall not, however, prolong the account by the relation
of cases; but content myself with assuring the reader, that the
opinion has been  derived from  facts, and not  from precon-
ceived notions of the operation of such disorders.
   I subjoin to this section a case, to show how irritation in the
vagina and contiguous parts may be connected with disorders
of the digestive organs.   Cases of considerable discharges from
that canal frequently occur in children, and which I believe  to
 depend chiefly on constitutional causes: disorder of the diges-
 tive organs induces dysury, and from  the urinary organs the ir-
 ritation may be communicated to the  vagina.
   Previous to the history of the case, 1 shall add a few obser-
 vations  as to the different meaning of the words disorder and
 disease, which 1 believe have been  generally used indifferently,
 being  considered  as  synonymous.  When I first published
 these observations,  I then wished to have defined these terms,
 and to employ them strictly according to the meaning I ohould
 attach to them; but I forbore  doing it, thinking it  might be
 construed into mere affectation.  Disorder, I should define to
 be  an unhealthy state of the feelings or functions of parts, with-
 out any apparent alteration of structure :—and disease, a visi-
 ble alteration in the  appearance or  structure  of the  affected
 part—Disorder is  nervous; disease  is  the effect of vascular
 actions, excited by nervous disorder.  An organ  may  become
 diseased  to a  certain  degree,  and yet, disorder ceasing, Us
 feelings and functions may be natural and healthy ; yet disease
 must have  a  tendency  to  establish  disorder.   That disorder
 alone will destroy life, is proved by numerous facts : our chief
 attention  should  therefore be  directed to the  tranquillizing of 
224       ON  THE CONSTITUTIONAL ORIGIN AND

the nervous system, with a view  to prevent the occurrence  of
disorder, which  continuing, may lead to the production of dis-
ease.   If, however, disease  be already  established,  the  same
attention must be continued, to prevent its increase, and to relieve
that nervous disorder which has produced it,  and is  attendant
upon it.  Though the facts, proving that disorder alone may be
fatal to  the individual are not uncommon, yet 1 think  it may be
right to relate one case, to show distinctly what kind of eases  I
am alluding to.
   A female child, five years of age, having disorder of the di-
gestive organs, had also discharge from the vagina and dysury :
afterwards several sores formed about the  labia pudendi, which
were foul and fretful, and did not heal under any of the appli-
cations that were tried.   The tediousness  of  the  case induced
the parents and  medical attendant  to wish  for  an  additional
opinion.   Being consulted on the case, I  suggested  some un-
important alteration in the local treatment, and urged  particular
attention to diet, and to the regulation of the  functions of the
bowels  and  biliary secretion, which was  extremely wrong.
The sores after a little time became materially better;  but the
disorder of the digestive organs  rather increased, when, after the
child had for several days discharged  nothing  from the bowels
but a substance resembling clay in consistence, and of a  slate
colour, it died suddenly of nervous disorder.
   The body was very attentively examined ; and though the
alimentary canal was slit open throughout  the greater  part of
its  extent, no  morbid  appearance could be discovered :• the
other abdominal and pelvic viscera were alike sound in structure ;
the gall-bladder was greatly contracted, appearing as  if it had
contained no bile for  a considerable time :  not  the slightest
morbid  appearance could be observed  in the examination of the
brain, which  was made with the greatest attention.
                    SECTION VII.

  In this section I shall mention what information I  have  ob-
tained by dissection, relative to the causation of other diseases
by those of the digestive organs.  The  reciprocal sympathy,
which exists between the brain and  the digestive organs, is 
TREATMENT OF  LOCAL  DISEASES.
225
generally admitted; but the kind and the degree of the  effects
arising from this sympathy, are not, perhaps, in general, suffi-
ciently  understood.   These  organs mutually increase each
other's disorder ; till the affection of the sensorium leads to the
greatest disturbance of the nervous functions, and even those of
the mind.
   All this may happen without any  visible disease of the brain.
Dr.  Kirkland particularly  directed  the  attention  of medical
men to nervous  apoplexy; and the observations which have
been made since his time  have proved, that not only a gene-
al derangement of the functions of the  nervous  system,  produ-
cing apoplexy, but also partial effects of a similar nature, causing
hemiplegia and paralysis, may take  place without any  visible
change of structure in the  brain.  1 have met with  numerous
instances of this  kind ; but could not  determine  whether  the
affections were merely nervous, or whether they were  produ-
ced or aggravated by disorder of the digestive organs.   I  only
know, that the patients died affected by apoplexy, hemiplegia,
or more local paralysis, without any derangement  in the evi-
dent structure of the brain.   I  may also  mention, that" I for-
merly examined the brains of three persons  who died in a  co-
matose state, in  consequence of the metastasis of rheumatism.
In these cases no morbid appearance was observed in the brain,
except some slight marks of inflammation of the pia mater.  It
therefore appears clearly to  me, that disorder and  a consider-
able diminution  of the nervous  functions may take place, with-
out any organic  affection of the brain.  The perfect recovery
of patients,  which sometimes  happens,  after such  disorders,
may also be considered as additional evidence of there  having
been, in such instances, no  organic disease of the brain.
   There can be no doubt but that  epilepsy may in like manner
take place without any morbid alteration of the structure of the
brain, or its membranes.  Some of the  persons whose  heads
were examined, without the discovery of any disease of those
parts, had been  subject to attacks like those of epilepsy.   Dr.
Henry Fraser has, of late,  published a  decisive  instance in
proof of this fact.   A patient died of epilepsy,   and  his brain
was examined with particular attention by  Mr. Cooper, with-
out any morbid  alteration  of structure  being  discovered*   In
general, however, morbid appearances are evident in the brains

                * See Fraser on Epilepsy, page 39.
              29 
 226       ON  THE  CONSTITUTIONAL ORIGIN AND

 of those persons who die of epilepsy.   Tubercles are most
 frequently met with.   There is, however, a disorder of struc-
 ture which I wish briefly to mention, as I  do not find  that it
 has been noticed.  In two persons, who  died of  epilepsy,  I
 found  the medullary substance of each  hemisphere  altered
 from its natural structure;  it had lost its natural  firmness, and
 smoothness of surface, and appeared like thick curdled  cream.
   Now, if disorder of the digestive organs is capable  of caus-
 ing or  aggravating nervous disorder, even  to the production  of
 those effects  which have been  mentioned,  when there is no al-
 teration of structure ; it must be  granted that such a state  of
 irritation of the sensorium may lay the  foundation  of an ex-
 citement of the vascular structure of the brain, and thus very
 frequently produce organic disease.  When this has occurred,
 it will aggravate and establish the nervous  affection, and  thus
 perhaps render it insusceptible of cure.
   Such are the general observations which  I  have  made, by
 means of anatomical inquiry, relative to these  subjects.   With
 respect more especially to the investigation of my present ob-
ject, I  have examined the bodies of six patients,  in  whom dis-
 ease most certainly began in the abdominal viscera,  and was
 continued in  them to  the conclusion of their lives.  Neverthe-
 less, the patients seemed to die rather of nervous disorder, than
 of disease of the parts first  affected.  One of the  patients  died
 affected  with apoplectic symptoms,  and five with hemiplegia.
   In all these cases the  liver  was  greatly  diseased, and  the
 bowels also exhibited  diseased appearances.  In  three  of  the
 cases there was considerable inflammation of the membranes of
 the brain, and  a good deal of water in the ventricles.   In two
 of them no morbid appearance of the brain was discovered.   I
 have also  examined a child, who was supposed to  die  of hy-
 drocephalus,  accompanied  by  great disorder  of  the  stomach
 and bowels.  In this case the  bowels were inflamed, the liver
 sound,  and  the  brain perfectly healthy  in appearance;  yet
 there had  been so great a diminution of sensation  and motion,
 as to leave no doubt of the existence of hydrocephalus.   I  am
 aware, that great opportunities of observation, accurate atten-
 tion to  the history of diseases,  and  anatomical examination  of
 fatal cases, are requisite to  enable us to form just  notions rela-
 tive to  the present subject.   I thought, however, that  it might
 not be  improper to state what  had been the result of my  own
inquiries by dissection, in order to promote a more  general at-
tention to  the subject. 
TREATMENT OF  LOCAL  DISEASES.
227
   When my attention was first directed to the subject of sym-
pathetic affections of other organs, caused by disorder of those
concerned in digestion, my primary object was,  to  endeavour
to ascertain, by dissection, how far pulmonary diseases  origi-
nated from such a source.  I have, in  the  course of  my  in-
quiries, had several opportunities of examining the  bodies  of
patients who apparently died of phthisis, combined with diseases
of the digestive organs.   In these cases, both  the history and
dissection tended to prove, that  the chylopoietic viscera were
the seat of the greatest and most established disease, and that
the pulmonary affection was a secondary disorder.    The liver
was greatly diseased, and the lungs were also beset with tuber-
cles ; yet a considerable  portion  of those organs was sound.
But dissections can  never conclusively  ascertain the truth  of
the opinions which I have stated ;  for the same  disposition  to
disease existing in the constitution  may equally affect both the
pulmonary and digestive  organs.    Nay, observations made  in
dissection in general, would tend to disprove the opinions allu-
ded to; for diseases of the lungs are very commonly met with
in dead bodies, while those of the liver and bowels   are  much
less frequent.  Yet  considerable disorder of the  digestive or-
gans does exist, and may continue  for many years, without any
organic disease being apparent: it is possible, therefore, that such
disorder may excite disease  of the lungs, and thus produce a
worse disease in the latter organs, than what existed in the for-
mer.  In short, the opinions, which I have delivered  cannot be
either ascertained  or refuted by anatomical researches alone.
  Accurate attention to the state of the  digestive organs may
determine this important subject,  and lead to the prevention
and cure of the sympathetic diseases which I have mentioned.
The attention alluded to is not of that general  kind, which ad-
verts only to the quantity of the ingesta, and the periodical ex-
pulsion of the egesta, but one  that more strictly observes wheth-
er the viscera are  free from irritation, and whether their secre-
tions are healthy or  otherwise.  My opportunities of acquiring
practical  information  on this subject  must  necessarily have
been very limited ; yet I have seen many cases which, to me,
appeared to prove,  that pulmonary irritation  sometimes pro-
ceeds from disorder of the digestive organs.   In  cases  of sur-
gical diseases,  accompanied by disorder of the digestive organs,
1  have also occasionally observed a cough  attended  with ex-
pectoration, to cease upon the correction of  the disorder  of
those organs. 
22S        ON  THE  CONSTITUTIONAL ORIGIN AND
   A case, which happened about five years  ago, strongly im-
pressed these opinions on my mind.  A servant  of mine  told
me, that his wife was dying of a consumption, which had been
rapidly increasing for six months, and had baffled all attempts
to relieve it.   Thinking that I could procure her  some  medi-
cal assistance from the hospital, I went  to see her.  The case,
however, seemed past hope.  She was extremely emaciated ;
her pulse beat 140 in a minute ; her face was flushed; she had
a most distressing cough;  and spit  up more than a pint of mu-
cus,  mixed with pus and streaked  with  blood, in  twenty-four
hours.   The circumstance, however, which most disturbed her
was a  continual purging of black and offensive  matter.   She
told me that  her  bowels were first disordered ; that an unheal-
thy state  of those organs  had preceded the  pulmonary  affec-
tion, and was indeed habitual.  I  thought it  unnecessary  to
trouble my medical friends in so hopeless a  case ; and  order-
ed some pills, containing one grain of opium, to  be taken  in
such a quantity as was necessary to stop the purging.  As she
informed me  that the disorder began  in the bowels, I added to
each pill half a grain of calomel.   By  these means the  pur-
ging was so much checked, that she did not  find  it  necessary
to take more than two pills in twenty-four hours; and  when
she had taken twelve, the mercury, very unexpectedly,  affect-
ed the mouth.   From that period,  the stools became of a  nat-
ural colour and consistence;  the cough and expectoration cea-
sed ;  and she was soon sufficiently  recovered  to go into  the
country;  from whence she returned apparently in good health.
   Now if it were to  be ascertained, that pulmonary irritation,
which  might  of course produce pulmonary disease, sometimes
arises  from  disorder of  the digestive  organs;* it would  be
right to inquire  further, whether it produces such effects,  by
the nervous disorder  it occasions, and  by its operation on the
health in genera],  or by means of  a more immediate sympa-
thy existing  between the  pulmonary and  digestive organs.   I
do not mean to insinuate, by  what  has  been said, that  pulmo-

  * In the second part of my surgical and physiological essays, in which
I related experiments, made with a view to ascertain the functions of the
skin, I mentioned that as it was manifest  the skin and lungs were both en-
gaged in the function of throwing forth carbonic acid gas, it followed, that
when from vicissitudes of the atmosphere or weakness of the sanguifer-
ous organs, the circulation and secretion of the skin were much diminish-
ed, the  lungs would be liable to plethora, and  have to perform more than
their ordinary duty, which circumstances were likely to induce irritation,
and perhaps consequent disease of those organs.  Those experiments, as
they are not of practical importance, I shall not reprint. 
              TREATMENT  OF LOCAL DISEASES.          229

 nary diseases do not  arise originally and idiopathically ;  but
 only to suggest that they may arise sympathetically, or in con-
 sequence of  disorder of the digestive organs.   The propor-
 tionate  number of cases, in which they originate in this man-
 ner, can only be determined by very extensive experience.
 That the stomach and bowels are disordered, during the pro-
 gress of phthisis, will, I  conclude, be  readily admitted; and
 that an  attention to correct  such disorder is requisite, must be
 acknowledged, from  what  has been said relative to the influ-
 ence of  such  treatment upon various local  diseases.
   The actions of the heart seem to me also to become  disor-
 dered  from sympathy  with the stomach.   That  palpitations,
 and feeble or  intermitting actions of that organ arise from this
 cause, is proved  by their ceasing, when the state of the stom-
 ach becomes  changed.   The palpitations which  take  place
 after eating, in cases where the heart is irritable, further evince
 the  sympathy which  exists between  these organs.  Surgeons
 are occasionally consulted on cases of palpitations of the heart,
 which the patients mistake for aneurisms ;  and 1 have seen ma-
 ny instances,  where  the great degree of palpitation led to  a
 belief, that  some  organic affection existed.   This has ceased
 on an  amendment of the  general health, apparently  arising
 from an  amelioration of the state of the digestive  organs, and
the patients  have continued in perfect health.  I have not col-
lected  any  accurate narratives of the cases that I  have seen ;
none at least which I  could properly present to the public as  a
proof of  the fact.  There  is nothing, however, of which I am
more perfectly convinced ; for I have felt it to be true in my own
person.   After considerable and unusual fatigue, I was seized
with pain, and  a sensation  of coldness  in the region  of  the
stomach.  1 had  no  appetite, and the biliary secretion was
suppressed.    Whilst  this disorder continued, which was  for
many weeks, my pulse intermitted  very frequently, and  I was
distressed with hypochondriacal sensations.  Upon an  altera-
tion in the  state of the digestive organs, and a renewal  of  the
biliary secretions, which happened very suddenly after taking
five grains of the pil. hydrarg. my  pulse became perfectly reg-
ular, and my mind tranquil.
   The observations, which 1 have made in surgical cases, lead
me also  to attribute many hemorrhages, and particularly those
from the nose, to a sympathetic affection of the heart and  ar-
teries, excited by disorder of the digestive organs.
   If such a  state of the system in general, as I have described, 
230        ON THE CONSTITUTIONAL ORIGIN AND

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

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

only to tranquillize and invigorate the constitution, I become con-
firmed in the opinion that a similar state of health may lead  to
the production of dissimilar local diseases.
   I have further observed  with respect to this subject, that per-
sons who have been out of health, but with no other distinguish-
able errors in their constitutions thA such as I have described,
1 mean nervous weakness and irritation, with a marked disorder
in the functions of the digestive  organs, have  been liable to  a
succession of  dissimilar local diseases.  In  such  instances,  I
have seen in succession enlargements of absorbent glands, biles,
rheumatic affections of joints, and dysury :  yet all local diseases
have ceased as the health became re-established,  by  attention
to correct the  disordered'functions of the digestive  organs.   I
have seen also in the same patient  enlargements  of absorbent
glands,  rheumatic  disease  of a joint, and an eruptive disease  of
the skin, which have all equally got  well as the general health
improved, by similar medical attention.  Nay, the continuance
of local diseases in  some instances, after the disorder  of the
constitution has been relieved or cured, does  not in my opinion
invalidate the foregoing conjectures respecting their origin.  Lo-
cal diseases, however induced, may have  become  established
by habit, or continued from that state of  disorder  into which
they have reduced the part that they have  attacked.   A local
disease, however excited, may,  as we  know  from  experience,
be of such a nature as that its actions never cease, and  as  we
have not succeeded in curing.   I allude  to cancer,  which oc-
curs, in conclusion, in such constitutions as I have endeavoured
to describe.
   It has  been said that I  have been hasty  in drawing these
conclusions.   Yet, as may be  seen in  my first  publication, I
mentioned, in  speaking of disorder of the digestive organs  as
exciting or aggravating nervous  irritation, and thereby causing
local diseases, it followed  that the nervous  irritation might ex-
ist, and produce disease, without this usually exciting cause.   I
then, too, brought forward instances of local diseases produced
by local causes, in order to establish our opinions  of the inde-
pendent nature of  local  diseases.  1  further remarked, that
constitutions disposed to local diseased actions, might naturally
be supposed to be liable at the same time to a manifest disor-
der of  the .nervous system and of the digestive organs; and
from thence, as I observed, might have  arisen that connexion
between local  disease and general  disorder,  which 1 have so 
TREATMENT OF  LOCAL DISEASES.
233
continually remarked.  I likewise added, that though the cases
related naturally suggested an opinion, that there is  some con-
stitutional cause for the production of local diseases, they  ap-
pear to me insufficient to prove it.   After  having, however,
drawn the opinions which I  offered from a  very considerable
number of cases, and having been solicitous to state both sides
of the question as fairly as I  was able, that  the  reader might
judge of it for himself, I trust no imputation of haste can pro-
perly be attached to my conduct.  In  my own opinions I place
very little confidence ; yet it is impossible  to  avoid forming
them, and I think it proper to relate them, for the reasons which
have been stated in the Preface.
   That such opinions as  have been delivered in the four para-
graphs preceding the last, are deduced from a partial, though
most commonly presenting view of the subject, I now readily
repeat;  because I have  seen  instances  of  local  diseases, in
which I could not trace any  disturbance  of the nervous system,
or of the digestive organs, apparently adequate  to their pro-
duction.  With respect to some of the striking cases which I
have  related, wherein the suddenness of the cure  made  it, I
think, evident  that the local disease was the effect of nervous
disorder,  induced by that of the digestive  organs ;  it may be
further inquired,  how is it possible, that  a similar cause should
produce such various effects ?   Is it because a  state of weak-
ness and irritation having occurred, those local diseases ensue,
to which there is  a  predisposition  in  the constitution ?  And
are we to consider the general disorder  of the system, as  the
exciting or predisponent cause of the local disease ?
   Granting it were  ascertained, that  local  diseases generally
arise  from disturbance of the constitution at large, and conse-
quently, (as it has  been my  chief  object  to state,)  may  be
most readily and effectually cured by  measures which tran-
quillize or invigorate the  constitution, still it  would be very im-
probable, and contrary to common observations, to suppose that
local diseases might not arise without any material constitution-
al disturbance.
   Though I am  strongly impressed  with  the opinion, that  the
primary causes of local diseases, are,  in general, such as I have
represented, yet 1 think it probable, that there may be adjunct
circumstances at present but little understood,  which by their
co-operation lead to the  peculiarity of such diseases.  In  our
present state of knowledge,  therefore, I think it better to con-
               30 
234          TREATMENT OF  LOCAL  DISEASES.

sider the disturbance  of the system in general, as merely  the
exciting cause of local diseases.  With this view of the subject,
the cases  recorded show how suddenly local diseases are fre-
quently cured, when  the exciting cause is removed ; how gen-
erally they decline in proportion as the exciting cause is dimin-
ished : and thus they indicate  how they may be  prevented by
a timely attention to mitigate and remove that cause.
   It may  not be improper further to state the opinions which I
have formed respecting the origin of diseases of  particular or-
gans, and  which may be considered as  local  diseases, though
they are not generally alluded to when that term is employed.
If we may be able to trace the origins of diseases of the absor-
bent and salivary glands, of the breast and testes,  to  constitu-
tional causes,  why may we not reasonably expect that similar
circumstances may produce diseases of the  lungs, liver, and
kidney ?   It seems to me improbable that so complex a struc-
ture as the human body, should be so correctly formed, as that
every  part should  possess its  due proportion of vessels and
nerves, endowed with an exact degree of natural  and relative
strength ;  or, in other words, that there should be no such thing
as comparative weakness or irritability  of the different organs
of the body, such as should predispose them  to disease.
   We  may therefore account  rationally, and  in  conformity to
acknowledged  facts, for  the  production of  diseases  in vital
organs, by supposing, that  a  state of general  weakness and
irritability being  induced, the naturally weak  parts suffer in the
greatest degree,  and in consequence they most readily become
the subjects of disease.  But  when  diseases of vital or other
organs occur, it  is probable  that another cause contributes to
their production; that is, the  sympathy  which each organ has
with the disorders of another.   If, then,  the  organ  thus sym-
pathetically affected  be naturally disposed to disease, its struc-
ture may  be irremediably spoiled in  consequence of vascular
actions, excited through the medium of nervous irritation.  If
this opinion be correct, it is highly  important, as the  medical
indication in this case is to remove the exciting cause, and our
attention becomes directed to  an organ in which perhaps there
is  but little manifestation  of disorder ; or if there be,  which is
likely to be overlooked when the attention  is so forcibly at-
tracted to an apparently far  greater evil.*
* See the case beginning at page 228. 
ON   ANEURISMS.
   The exposure of a portion of an artery, and tying it in order
to stop the current of blood into an aneurismal sac, as proposed
by Mr. Hunter,  may be said to have been a new operation, at
least in modern surgery.   It is not therefore surprising that er-
rors were at first  committed in the mode of performing it.   The
hemorrhages,  which  took place after the operation  in the first
cases in which it was  performed, arose from the ulceration of
the artery that  had  been tied.   The  vessel  in these cases
was  laid bare and  detached in some degree  from its surround-
ing connexions,  and  the  middle of the  detached portion
was  tied  by  a single  ligature.   An artery   thus  circum-
stanced must necessarily  inflame: which it   would do  in
different modes and  degrees, accordingly as the state of the
constitution, or of  the part was more or less healthy ; and this
inflammation produced the ulceration of the  vessel.
   The occurrence of hemorrhage led some surgeons to adopt
a practice which cannot but be considered as injurious.  They
applied a second ligature above the other, leaving it loose, but
ready to be  drawn tight  if the first should not  answer.   The
second ligature,  however, must not only keep a certain portion
of the  artery detached from the  surrounding parts, but  must
also give  additional  irritation  to the inflamed vessel; and  on
both these accounts it is more likely to make the inflammation
end in suppuration or ulceration.
   The  mode of performing  the operation  for the aneurism,
which Mr.  Hunter's  judgment and experience taught him to
adopt, was to expose and disturb the artery as little  as possible,
and after having tied it to bring the surrounding parts into con-
tact with it again.  Though an experienced and skilful operator
may accomplish this  object with very little  disturbance of the
artery from  its natural situation and connexions; yet I cannot
but suspect  that surgeons, in  general may not be so successful, 
236
ON  ANEURISMS.
especially in cases where, from the deep situation of the vessel,
the surrounding it with a ligature depends more on feeling than
on sight.*  Also, though when the  artery is  sound  and the
constitution healthy, ulceration may not ensue, even  though the
artery is in some degree separated from its surrounding connex-
ions, and tied  by a single ligature; yet it  is surely  proper  to
guard against  those circumstances  which tend to produce  its
ulceration.  As large arteries do not ulcerate when they are
tied upon the surface of a stump after amputation, it occurred
to me that it would be right  to tie them, in cases of aneurism,
as nearly  as possible in the same  manner and under the same
circumstances.  The large vessels on the surface of the stump
continue to  possess all their  natural  surrounding connexions,
whilst they are left  in a lax state, in consequence of their  di-
vision.
   To accomplish  this object in  cases of aneurism, I propose
that the  operation  should be performed in the following man-
ner :—The operator should divide the immediate coverings of
the artery, till he  has fairly exposed  its  surface.  When he
can touch the  bare vessel, he will  not, I believe, find any dif-
ficulty in separating from it, by means of his finger and thumb,
or the  blunt  edge  of an aneurismal  needle,  the cellular sub-
stance that connects it to the contiguous  parts.  This part of
the operation is not painful  and should be  performed slowly.
The firm sides of  the  vessel enable the surgeon  clearly to dis-
tinguish its surface, and by keeping the finger in exact contact
with it,  a  passage may be made completely round  the artery.
Care should be taken not to elevate  the artery more than can
be possibly avoided, because the artery would be stretched in
its longitudinal direction  by so doing  ;  and  care should also  be
taken not to injure  the contiguous veins or nerves.  When the
operator has thus gently insinuated his finger between the ves-
sel and its surrounding connexions, so that an inch of its surface
is every where exposed, two ligatures may be put under it, one
of which is to  be carried upwards, and the other downwards,
as far as the artery is detached, and  then tied as firmly as pos-

  * It can neither be considered as a  compliment to Mr. Home, nor an af-
front to any other surgeon, to suppose that no one can perform the opera-
tion for an aneurism after Mr. Hunter's method better than he does.  Yet
in a series of cases published in the second  volume of the Transactions of
a Society for the promotion of Medical  and Chirurgical  Knowledge,  he-
morrhage from ulceration of the artery appears to have been a frequent oc-
currence. 
ON  ANEURISMS.
237
sible.   The artery should then be divided by a probe-pointed
bistoury in the inter-space between the two ligatures, but nearer
to the lower ligature than to the  upper one.
   In my opinion, large  arteries  should always  be  tied  with
moderately thick  ligatures,  because  we may  then  draw the
noose as tightly  as possible, without apprehension of cutting
or tearing the coats of the vessel, or  of breaking the ligature.
The latter occurrence would in many cases prove a very  em-
barrassing circumstance, and it might be very  injurious on ac-
count of the jerk communicated  to the artery to a considerable
distance.  Also, when an artery  is tied with a thick ligature, the
compression made by it is not so great as to produce a speedy
mortification  and separation  of the end  of  the  vessel,  so that
the ligature remains, in general,  a fortnight before it is  detach-
ed, and therefore, time is allowed for the consolidation of the sides
of the vessel prior to its separation.*  When an artery is thus tied
incases of aneurism, it possesses its natural surrounding connex-
ions and support, and is left loose, in consequence of its division.
It  appears, indeed, in  most respects, similarly circumstanced
to an  artery tied upon the surface of a  stump ; and  as I never


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

                          CASE I.
   Feb. 1796.—James Lindsey, aged thirty-four, about a year
ago perceived a swelling beneath the calf of his right leg;  and
soon afterwards, whilst walking, he suddenly felt, he said,  " as
if  he had been struck on the part by  a cannon-ball," the pain
being so great  that he could  not move  for  several minutes.
The pain, however, gradually  abated;  but the swelling of the
leg had continued to increase since that time.   The whole calf
was now lifted  up by a quantity of blood effused  beneath it.
The  muscles  appeared  thin,  and were so  extremely tense
as to  occasion great  pain, accompanied with  considerable
erysipelas of the whole leg;  so that a speedy ulceration  and
sloughing, or  sudden rupture of the distended part, was hourly
to be dreaded.   Under these circumstances, tying  the artery
above the aneurism,  was the only means of relieving the patient
from his present suffering, and of preserving him from sudden
death.   But  what was particularly  discouraging, both to  the
patient and surgeon,  was  the  discovery  of another aneurism,
situated in the femoral artery of the  opposite  limb.   No pre-
ternatural pulsation,  however,  could be felt in any  other  part
of his  body.—The operation  was performed by Sir Charles
Blicke in the  following manner :—An incision about three inches
in length was made through  the integuments of the middle of 
ON ANEURISMS.
239
the thigh, so as to expose the inner edge of the sartorius mus-
cle and the fascia covering the artery,  which was divided  to
the extent of somewhat more than an inch.   The artery was
separated from its connexions for one inch of its length.  Two
ligatures were put under it, and firmly tied, and the artery was
divided in the interval between them.   The lips of the wound
were then brought together by slips of sticking-plaster.  This
patient'* limb was for some time much  colder than the other,
and nearly three days elapsed before it had regained its natu-
ral degree of warmth ;  but the tension, pain, and erysipelatous
inflammation   quickly subsided.   The  divided  integuments
united  above  and below the ligatures, but not between them ;
and there was also a large discharge from the wound ; which cir-
cumstance was probably owing to  the state of the patient's con-
stitution, which was much reduced in point of strength.  This
man, however, did not complain of the least throbbing, tension,
or pain in the  wounded part; and this  entire exemption from
the sufferings of other patients, I could not but attribute to the
division of the artery.   The upper ligature came away on the
tenth, and the lower on the fifteenth day ; after which the wound
healed gradually, though very slowly.
   About five weeks after this operation, the  aneurism  in the
opposite thigh was almost ready to burst;  the tumor having ac-
quired a pyramidal form,  and the skin covering the apex hav-
ing yielded so much as to form a kind of  process  from the tu/
mor.   Indeed the integuments  at this part  were so thin, that
we every hour expected  them to give way.  The aneurism
was situated so high, as to make it probable  that  the  disease
extended above the place where the arteria profunda is sent off.
The patient had hitherto refused  to  submit  to the operation;
but on reflecting that if  the tumor should burst in the night,  he
must perish unless the bleeding vessel could be  immediately
secured, he consented to let me tie  the  artery  in the groin,
whilst  we had day-light  and proper assistance.  The tumor ap-
proached so near to the groin, as to prevent us from compres-
sing the artery  against the bone ;  for, in attempting  this, the
compress occupied the  place where the incision ought to  be
made, and our endeavours to make a compression still higher
were ineffectual; they weakened, but did not interrupt the pul-
sation  of the tumor.  As the artery was so imperfectly com-
pressed, hemorrhage took place  during the  operation, which,
though not dangerous to the patient,  proved extremely embar- 
240
ON  ANEURISMS.
rassing to the surgeon; for, in attempting to lay bare the fascia
of the thigh, I divided, by the very first incision, so many small
arteries  supplying the inguinal glands, and also so many veins,
that  the blood which was poured forth, completely filled the
space made by the incision, and overflowed  the  sides  of the
wound.   The application of the sponge, the usual resource on
these occasions, was of no avail; for the wound was  instantly
filled again, so  that the  whole operation  was to  be  done
upon parts  covered  with blood, where the  only  guide in its
performance was  the feeling.   I did indeed see some exposed
inguinal  glands, and  found that I had divided two of them
in trying to get at the fascia of the thigh.   As soon as I could
distinctly feel this part, I  made a small opening through it, and,
introducing my finger, I divided it upwards as far as Poupart's
ligament, and downwards as low as the aneurismal  sac  would
allow me.   The pulsation of the artery now served as my guide.
Laying  aside, therefore,  all surgical  instruments, I  made way
with my finger, in a perpendicular  direction,  till 1 could touch
its coats, and then, with my finger and thumb, separated it from
its connexions,  so as to be able to grasp it alone between them.
I then passed two ligatures under it by means of an eyed probe,
and  drawing one  of  them upwards, and the other downwards,
as far as the space would permit, I tied them  firmly.   The up-
per ligature was about half an inch from  the  os pubis,  and the
lower one the same distance from the arteria profunda, which
vessel I had distinctly felt before I  tied the ligatures.
   There are, perhaps, few situations of aneurism where the ar-
tery can be tied so separately  and  distinctly  as here ; the pul-
sation directs the  surgeon to the precise situation of the vessel;
and  if he only keeps sufficiently close to its  sides when he
passes the ligature round, neither the  vein  nor the  nerve can
be included.  I did not divide the artery between  the two
ligatures: it was  suggested that it were better not to do so;
and  I knew that I could obtain all the advantages of a relaxed
state of the vessel, by merely bending the thigh upon the pel-
vis.   The patient did not, after the operation,  suffer any kind
of pain from the  wounded parts; which, I think, shows, that
the artery did not inflame much in consequence of the ligature.
The suppuration was moderate, and every thing relative to the
wound went on as well as could be expected.  The limb, and
particularly  the foot, was colder than that of the opposite side ;
but in about three days, it gradually  acquired its natural tern- 
ON ANEURISMS.
241
perature ; and it all along retained a perfect state of sensibility,
which I considered as a proof that it was sufficiently nourished.
To prevent the heat from being carried  off faster than it was
generated, the limb was wrapped in flannel; but I  avoided the
application of any artificial warmth, lest its stimulus should prove
injurious,  by exciting action when the powers of life in the part
might have been considerably diminished.
   The  blood  in  the  aneurismal  sac  did not appear to  have
coagulated before the operation; for  the bulk of the tumor
could be greatly  lessened by pressure, whenever  the patient
would  allow  the  attempt to  be  made, so that I conclude the
limb had received a considerable quantity of blood  through the
femoral artery, until that vessel was tied.  The  tumor dimin-
ished greatly after the operation, and the blood contained in it
became coagulated.   This reduction of  the swelling, I think,
was owing to a considerable part of the blood passing onwards
through the femoral artery : and I regretted afterwards, that, at
the time of  the  operation,  I  had  not endeavoured to press all
the blood  from the aneurismal sac; which experiment would
have shown how far it was  fluid or coagulated.
   Every  thing, with respect  both to the state of the limb, and
the patient's  general health, went on well till the fifteenth day,
when the  upper ligature separated, and the blood  gushed in a
full stream from  the open extremity of the vessel.   This for-
tunately happened during the attendance of the surgeons at the
hospital, and  the bleeding was stopped by pressure until  their
arrival.   The stream of blood which flowed upon any remis-
sion or wrong application  of the  pressure was so large that
we did not dare  to remove  the  patient  even from  the bed on
which he  lay.  Mr. Ramsden undertook, in this  situation, to
prevent the further  escape of blood from the  vessel, whilst I
proceeded to tie the artery above Poupart's ligament.  Accord-
ingly, I first  made  an incision,  about  three inches in length,
through the integuments of the  abdomen, in the  direction of
the artery, and thus laid bare the aponeurosis of the external
oblique muscle, which I next divided from its connexion with
Poupart's ligament, in the direction of the external wound, for
the extent of  about two inches.   The  margins of  the internal
oblique and  transversalis muscles being thus exposed, I intro-
duced my finger beneath them for the protection of the  peri-
toneum, and then divided them.  Next, with my hand, I pushed
the peritoneum and its contents upwards and inwards, and took
              31 
242
ON  ANEURISMS.
 hold of the external iliac artery with my finger and thumb, so
 that I  was thus enabled to command the flow of blood from the
 wound.   It now  only remained  that I should pass a ligature
 round the artery,  and tie it; but  this required caution, on ac-
 count  of the contiguity of the vein to the artery.   I could not
 see the vessels; but I made a separation between them  with
 my fingers.   Having, however,  only  a  common  needle  with
 which to pass the  ligature, I several times withdrew the point,
 from the apprehension of wounding the  vein.*  After having
 tied the artery about an inch and a half above Poupart's  liga-
 ment,  I divided that part, and thus laid  the new and the former
 wound into one.   I traced as well  as I could with my finger,
 the continuation of  the artery, from the place where the liga-
 ture was now made, to that where it was formerly  applied.  I
 wished to  have divided the artery, and to have suffered  it to
 retract behind the  peritoneum;  but I found it so attached to
 the surrounding parts, as to render such  division difficult,  and
 perhaps not advisable.
   The lips of  the wound were brought together with sticking-
 plaster, and  one suture only was made opposite to the natural
 situation of Poupart's  ligament.   The  peritoneum was pressed
 back into its place, and the protrusion of it restrained by bring-
 ing together the integuments with straps of sticking-plaster.
   No  perceptible alteration occurred in the state of the limb
 after this second operation;  but the patient's health was con-
 siderably  reduced,  by his having  suffered from the complaint
 nearly twelve months, by having  undergone three operations,
 and by the loss of a considerable quantity of blood.  No adhe-
 sion took  place between  the divided parts; the edges of the
 wound were open and sloughly; the wound was  painful,  dis-
 charged a  great deal of pus, and was so extremely tender, that
 he could not bear it to be touched.   Still no greater mischief
 appeared  till the fifth  day after the operation, when a hemor-

  * It would be, I think, an useful addition to our surgical instruments for
 such purposes, to have  needles made  with handles of pure, and conse-
 quently flexible, silver,  and with steel points that have edges just sharp
 enough to pass through the cellular substance ; but neither so pointed nor
 so sharp, as to endanger the wounding any parts of consequence that may
be contiguous to those round which  they are passed.   When the points of
 these instruments were once passed underneath the vessel, the surgeon
 could bend their handles  so  as to accommodate them to the space  they
 have to turn in, and thus  avoid an  inconvenience which, I believe,  most
 surgeons must have experienced : I mean, the great difficulty of turning
 a common needle in a deep and narrow wound. 
ON  ANEURISMS.
243
rhage of arterial blood took place in such quantity, that there was
no doubt but that it arose from the principal artery; though the
ligature with which it was tied  still  remained firm.   The pa-
tient's health was now so impaired, and his weakness so great,
that an attempt at  tying the artery still higher up would have
appeared like torturing him without  any hopes of ultimate suc-
cess.   The wound was therefore  cleansed and dressed ; some
compresses were applied upon it, and bound down by the spica
bandage.   By  this  treatment  the hemorrhage was stopped;
and the attendants were ordered to make a pressure  on the
bandage if any fresh bleeding should occur.   The compresses
were  renewed  for  three  succeeding days; and though occa-
sionally the wound  bled, yet it was not profusely,  or  in such
quantity as to destroy the patient: his strength  however grad-
ually  declined ; a troublesome cough occasioned extreme pain
in the wound,  and  in the  course of the eighth day after the last
operation, he died.

                        DISSECTION.
  No marks of disease  were discoverable in the aorta, or in
the internal iliac artery.  The external iliac was covered by a
great  number  of lymphatic glands, which prevented  it from
being readily  distinguished;  yet, when separated from these,
it did not appear diseased.   For nearly two  inches above the
part  which  was tied, the lymphatic glands covering the artery
were  considerably  enlarged, having no doubt become addition-
ally swollen from  the irritation excited by the ligature.  The
external surface of one of them next the wound, had  ulcerated ;
and the ulceration  penetrated through the gland, and commu-
nicated with the artery, as was  afterwards made  evident by
slitting open that vessel.   It was through this aperture that the
blood had escaped ;  for the ligature still  remained  firm upon
that part of the  artery which it had inclosed.  From this liga-
ture to the place where the vessel had formerly been tied, the
artery was so closely connected with the surrounding  substance,
that dissection  was  required to separate them.   The parts of
the artery from which the former ligatures  had separated, were
about half an  inch  asunder, and the canal of the  vessel ap-
peared perfectly open.  The  whole of the  vessels from the
bifurcation of the  aorta, to the aperture in the tendon of the
triceps muscle, were now  removed, and  carefully  dissected;
and after being stuffed and hardened by spirits, they were cut 
244
ON ANEURISMS.
open to show the state of them  internally.  A coagulum  of
blood, about two inches long, was found above the part where
the last ligature was made.  At what  time this coagulum had
been formed, is perhaps difficult to ascertain; it did not seem
to have taken place after death, for above it the artery contained
no blood ; and if it had occurred immediately after the opera-
tion, it is probable that it would have prevented the hemorrhage.
I have  already remarked,  that the man did not bleed for some
time previous to his  death;  in  which interval, perhaps, this
coagulum  had been  formed.  The ulcerated  opening from
the  artery  through  the  diseased gland,  admitted the pas-
sage  of  a  moderate-sized  bougie.   The  ligature, which
still firmly inclosed the artery, had brought its sides in contact,
so as to render it probable that they would have united.   All
the other parts of the  femoral artery  were quite open, so that
a large bougie could be passed from the lower end of it, through
the aneurismal sac, to the place where the ligature  now re-
mained.   About half an inch of the artery was wanting, which
had been, as it were, cut out by the ligatures in the first  ope-
ration.  The  sides of the arteries below the  part which was
tied were  thicker than natural, and  their internal  surface was
rough, and of a yellowish  white colour.   The arteria profunda
was filled with coagulated blood, and had become reduced to
less than the natural size.   The sides of the artery of the op-
posite limb had firmly united at the part where it had been tied.
No coagulum was found in it, and it had not diminished in size
in any remarkable degree above the part which was closed.
   It may be inquired  in this case, why the  artery did  not heal,
but upon the separation of the  ligature remained widely open.
That the  ligature was tightly applied is, I think, evident from
its suppressing all hemorrhage till its separation on the 15th day.
I am inclined to attribute  the want of  union in the artery to its
unhealthy state, which opinion  is confirmed by the dissection,
which showed that even the lower orifice of the artery had not
healed, whilst the artery in the other limb which was tied much
further  from  the aneurism, and  where the vessel  was  more
likely to be  sound and healthy, had  become firmly united.
The event of this  case would induce me to tie the  artery as
remotely from the seat of aneurism as could with propriety be
done.
   In this  first operation of tying the external iliac artery, I was
urged  to  perform it by  the impulse of the moment, for the 
ON  ANEURISMS.
245
death of the patient would otherwise have been inevitable.  In
this case I thought, I disturbed  the peritoneum too much, and
tied  the  artery higher than  was necessary.  As  the  limb,
however,  did not appear to suffer  materially, 1 felt it a duty to
perform a similar operation in the  following case.  The vessel
was  tied lower down, so that it was brought  into view at the
time of the operation.  It was tied with two ligatures and divided
in the interval; it afterwards firmly united at each extremity,
and the ligatures  came away at the usual time:  neither  did
there appear any deficiency, in the nutrition of the limb.  These
circumstances afford  reasonable  expectations of  success in
future operations of this kind;  yet in the present instance the
operation  appeared to have been too  long delayed, and  the
patient to have died from an event  which  was not foreseen, but
which might perhaps have been  prevented.

                         CASE II.
   -------Wrungel,  a German, by trade a sugar-baker, of a
sickly aspect  and slender make,  about  5 feet 7 inches  high,
and near 40 years of age, was admitted into St. Bartholomew's
hospital, on account of an aneurism in the femoral artery, close
to Poupart's ligament.   This he imputed  to a strain about three
weeks before.   The  tumour at the time of  admission was of
the size of a small orange, and the blood contained in it was
fluid ; for it could be entirely expressed  from  the aneurismal
sac.   At  a  consultation on the  treatment of this case, I said
that  I did not think a  surgeon  warranted in tying the external
iliac  artery, till he was in some measure compelled to it by the
progress of the disease, for  the following reasons.   1st. An
aneurism, in proportion to its increase and duration, obstructs
the passage of the blood through the  natural  and  principal
channels, and obliges  it to circulate by other courses, which are
enlarged  according to the exigency of  the  case.  It seems
highly probable,  that in proportion to the size of the artery
which is tied,  and the magnitude of the part to be  nourished
after that operation, so will be the degree of previous enlarge-
ment in these  collateral channels,  which  is necessary to ensure
its success.   On  this  account the operation should be delayed
longer in  an inguinal aneurism than in any other.
   2dly. The operation of tying the external iliac  artery  must,
in the  present state of our  knowledge,  be considered as very
serious in its  nature, and  uncertain in its event.  I had  then 
246
ON  ANEURISMS.
only once tied this vessel, when  a man would otherwise have
bled to death from the  femoral  artery; and though the limb
was nourished, the artery ulcerated.   The operation was done
a second time in London, and the limb  mortified ;  but no fair
practical inference can, I am  told, be drawn  from the  latter
case,  as the operation was postponed till mortification was. as it
were  impending.
   3dly. There is some chance in  aneurisms of a cure sponta-
neously occurring from the closure of the artery above by the
coagulation of the blood.   To cite those instances only which
have  come within my own knowledge, and which  it seems right
to mention,  as it  increases the stock of facts before  the public,
I have  known such a spontaneous  cure take place twice in the
popliteal artery, once in the arteria profunda femoris, and once
in the  axiliary artery.   For these  reasons it was agreed to
postpone the  operation in the case of  the present  patient  till
circumstances should  appear to demand its performance.*


  * There was, about twelve  months ago, a  soldier in the York hospital,
who had an aneurism of the femoral artery,  but the external tumor had
so much overlapped Poupart's ligament, and  interposed itself between the
integuments and the fascia of the external oblique muscle, as to render an
operation very difficult, if not impossible. In this case, the integuments
mortifying, occasioned a simultaneous coagulation of the blood in the artery,
for though the coagula came out, yet there was no fresh hemorrhage, and
the patient recovered.
  Since the preceding edition of this book, I  have seen two other cases of
the spontaneous cure of aneurisms: one was in the external iliac artery,
and the aneurismal sac formed a large tumour within the abdomen, extend-
ing as high as the umbilicus, and across the belly as far as  the linea alba.
  In the other case, I conjecture, that the  aneurism was in the common
trunk, which gives rise to the right cephalic and subclavian portion of the
brachial artery.  The pressure of the aneurismal sac had caused the ab-
sorption of the ribs beneath the clavicle, so that the tumour presented
itself so  exactly in the situation of the axillary artery, that I believe most
surgeons would at first sight have supposed th^it the tumour, which was
as large as a large fist, and beat vehemently, to have been an aneurism of
that artery ; yet, when the subclavian artery was pressed  above the clavi-
cle, the pulse at the wrist was stopped, without lessening the pulsations of
the aneurism.  The patient  had come  to London, supposing that some
operation might be undertaken for his relief.   His digestive organs were
disordered, and his heart throbbed violently against his  side.   I recom-
mended him to live on as spare a diet as he  possibly could,  observing to
him that, by keeping his vessels in a state  free from plenitude, he was
most likely to lessen that forcible action of the heart which caused the in-
crease of his disease, whilst at the same time the  same measures would
tend to insure the complete digestion of every portion of aliment he re-
ceived into his stomach,  and thereby improve the state of his digestive
organs.  I urged him also to regulate the functions of the other viscera
concerned in digestion.  I heard that about six months afterwards he was
very well; and lately, upon inquiry, was informed that he was as well as
at any period of his  life. 
ON ANEURISMS.
247
  Our poor  patient therefore lay in  the  hospital  during two
months, in which time his disease gradually increased, and his
health declined.   Towards the latter  part of the time he suf-
fered a great deal of pain in  the  front of his thigh, which de-
prived him of rest, and the whole limb was largely oedematous.
These symptoms would naturally arise from the pressure which
the aneurism must make on the anterior nerves and absorbents
of the thigh.  The tumor had advanced towards the surface,
and the  skin had become slightly  inflamed, yet the protruding
part of the tumor was not of  greater extent than when he was
first admitted into the hospital,  and n6 judgment could be formed
of that part which was more deeply situated,  on account of the
general  swelling of the thigh.  The blood could even now be
expressed from the prominent  part of the  tumor, and I felt
anxious,  less the obstruction  to the  circulation in the main ar-
tery should not have been sufficient to have obliged the  blood
to circulate by other channels.   It deserves  to  be remarked,
that the  aneurism may extend considerably beneath the  fascia
of the thigh, causing pain and oedema by its pressure, and yet
that part which advances towards the surface may be  of no
great magnitude.
  The patient's sufferings increased  considerably  during the
week preceding the operation, so that  he declared  his present
state was almost insupportable,  and solicited that something
might be done to change  it either for the better or  the worse.
He never, however, was  able  to  explain the cause  of  this un-
common degree  of anxiety and inquietude.
  The operation was  undertaken on Saturday, the 24th  of
October.  An  incision of three inches in  length was  made
through  the  integuments of  the  abdomen,  beginning a little
above Poupart's ligament, and being continued upwards; it
was  more than half an  inch on the outside  of the upper part of
the abdominal ring, to avoid the  epigastric  artery.   The  apon-
eurosis of the external  oblique muscle  being thus exposed, was
next divided in  the direction of the  external  wound.  The
lower part of the internal oblique muscle was thus  uncovered,
and the  finger being introduced below the inferior margin  of
it and of the transversalis muscle, they were divided by  the
crooked bistoury for about one inch and a half.   I now  intro-
duced my finger beneath the  bag of the peritoneum, and car-
ried it upwards by the  side of the psoas muscle, so  as to  touch
the artery about an inch above  Poupart's  ligament.   I took 
248
ON  ANEURISMS.
care to disturb the peritoneum as little as possible, detaching it
to no greater extent than would serve to admit my two fingers
to touch the vessel.  The pulsations of the artery made it clear-
ly distinguishable  from the contiguous parts,  but I could not get
my  finger round  it with the  facility  which I expected.   This
was the only circumstance which caused any delay in the per-
formance of the operation.   After ineffectual  trials to pass my
finger beneath the artery, I was obliged  to make a slight inci-
sion on either side of it, in  the same manner as is necessary
when it is taken up in the  thigh, where the fascia which binds
it* down in its situation is strong.  After  this I found no  diffi-
culty in passing my forefinger beneath the artery, which I drew
gently down, so as to see it behind the bag  of the peritoneum.
By  means of an eyed probe two ligatures were conveyed round
the  vessel; one of these was carried upwards as far as the  ar-
tery had been detached, and the other downwards:  they were
firmly  tied,  and the vessel  was divided in the space between
them.   Nothing further remained  than to close  the  external
wound, which was done by one suture, and some strips of stick-
ing-plaster.   The threads of the upper ligature were left out. of
the  wound above  the suture which closed its edges, and those of
the  lower beneath.
  A few remarks on this operation may be permitted.  To di-
vide the parietes of the abdomen, push  aside  the peritoneum,
and tie the external iliac artery by the side of the psoas muscle,
is an operation  more formidable in sound, and on its first pro-
position, than it is in reality.   It is  performed  almost  without
shedding blood, so that  the  principal circumstances  of it  are
very evident.   When I formerly performed  this operation,  I
was urged to it by immediate necessity :  I tied the artery much
higher  than in the present case, disturbed the peritoneum  in a
greater degree, and. contrary to my own principles, I did  not
divide the artery.  In the present case,  having time  to delibe-
rate upon the steps of the operation, I detached merely so much
of the  peritoneum as enabled me to reach the artery, as far as
I conveniently could above Poupart's ligament; but not so far
as to make it difficult to ascertain that I surrounded the artery
only with my finger, without injuring any of the adjacent parts,
nor so  far but that I  could draw down and distinguish the arte-
ry which I included in the ligature.   The remembrance of the
swelling in the external iliac glands, and of the ulceration of the
artery in the former  case, led to this difference of conduct. 
ON ANEURISMS.
249
   The poor man was greatly exhausted by the operation, and
his leg which had been chilled by  exposure during the opera-
tion, continued very cold for a long time  afterwards.  It was
wrapped up in flannels,  to prevent the  dissipation of its own
heat; but 1 would not apply any artificial warmth to restore its
temperature, lest it  should act as a stimulant.
   He could  not compose himself after the operation, nor did
he sleep during the night, so that on the  following day his state
was very unpromising.   His  pulse  beat 160  in a minute; his
tongue was covered by a dark brown fur; he looked agitated,
and a purging took place, which was not restrained till the fol-
lowing night by a cordial and opiate mixture.  Respecting his
pulse, it is proper to mention  that it beat 120 most days in the
week preceding the operation.
   His thigh was as  warm as  that of the sound  side, his  leg
cooler than the opposite one, and his foot many degrees colder.
He had, however, perfect sensation  in  his toes, and  power of
moving  them.   The leg  and foot were rubbed with oil three
or four times a day, in order  to prevent  any  stagnation in the
veins, and  to diminish perspiration.  It was well covered as
before by flannels.
   On Monday, the  2d day (Oct.  26) the pulse was less fre-
quent : he had slept a good deal during  the night, and seemed
stupified  by the opium; but  was on the whole so little better,
that I concluded he would gradually sink  in consequence of
the shock of the  operation.  The temperature of the  limb was
a little increased.  The man however took bread and  milk and
other food in moderate quantities,  whenever it was offered  to
him : the purging having  ceased, the quantity  of the opiate was
diminished.   He rather  improved in the  evening, and rested
well during the night; so that on (Oct. 27) the third day after
that of the operation, every circumstance wore a favourable as-
pect.  His pulse did not  exceed 100, and was moderately firm
and full; his appetite  had increased : the  temperature of the
limb was a good deal augmented, so  that his foot was scarcely
colder than that of the sound side; and the oedema of the limb
was considerably diminished.   I  now dressed his wound,  in
which he had not complained of pain, nor of any tenderness,
when the surrounding parts were compressed.   The incision
appeared but as a line,  except  at the neighbourhood of the liga-
tures, where it was a little open, and from whence there issued
a moderate quantity of as healthy pus as 1 had  ever seen.  The
              32 
250
ON  ANEURISMS.
surrounding parts were perfectly natural, both in appearance
and sensation.   On  the  fourth  day (Oct.  28) he  was still
better : his pulse 90 ; his appetite good ; his sleep sound ; and
his limb lessening in size, and increasing in warmth.   The stu-
dents  at the hospital had dressed the wound before my arrival,
and reported  that the discharge was tinged with blood.
  On the fifth day (Oct. 29) he  was still better, his pulse be-
ing but  80 when I counted it.  The wound  and contiguous
parts  looked  remarkably well, but a bloody  sanies  was dis-
charged, which I felt unable to account for.
  On the sixth day (Oct. 30) the state of his health  and limb
continued as well, if not improving.   The bloody  discharge
however  had  increased in quantity, insomuch that it ran through
the coverings of the wound, and soiled the bed ; it had also be-
come  fetid.   From the first occurrence of this bloody discharge
1 felt considerable uneasiness respecting it.   I could not be-
lieve that a healthy wound  would  secrete such a sanies, and I
felt apprehensive lest the wound should spread from  disease.
Nothing however took  place to confirm this idea.  It seemed
probable also that if  the aneurismal sac were not entire, some
of the blood being  exposed to the air might  tinge the discharge
from the wound, and grow putrid.  I frequently pressed on the
tumor, but could press no blood from the wound.  In  this state
of uncertainty it was,  however,  pleasing to observe, that  the
patient's  health  continued in every respect better than  could
reasonably have been expected.
  The circumstances of the case remained very much the same
during the seventh and eighth days  after the operation.  On the
morning of the ninth, (Nov. 2) when I came to the hospital, I
met Sir Charles Blicke, who told me that the poor German was
dying ; intelligence which equally surprised and shocked me.
  He was indeed in  a  dreadful state, appearing like a man far
advanced in  typhus  fever.   His pulse  was  150; his  tongue
covered with a brown  fur; his intellect wavering, and the ac-
tion of his muscles tremulous.  On  examining the wound with
a view to discover the cause of this great and sudden alteration,
and pressing on the tumor beneath Poupart's ligament, I forced
out a  great quantity of blood, rendered  fluid and highly  fetid
by putrefaction, insomuch that it instantly blackened the probe
with which it accidentally came in contact.
  The cause and circumstances  of the bloody discharge were
now made clear; the surface of the exposed coagulated blood 
ON  ANEURISMS.
251
of the aneurism had at first tinted the discharge from the wound,
and then had, by gradual dissolution, been  more  plentifully
commixed  with  it, and  given it a degree of putridity.   Till,
however, the whole  mass had  become  putrid, and had  been
converted in  consequence  into a fluid, it could  not be forced
out from beneath Poupart's ligament when pressure was made
on the tumor; nor did it till that period excite inflammation in
the surrounding parts by its acrimony, or derange the constitu-
tion by its absorption.
  After entirely  expressing the putrid blood, I washed out the
cyst with warm  water,  till it  returned untinged.  The  relief
which  was by these means afforded to the poor man  was very
striking and considerable.  His pulse became moderate, his in-
tellects clear; he had some refreshing sleep, and again took food
in moderate quantities.  On the following day, when the integu-
ments beneath Poupart's ligament were compressed, a consider-
able quantity of fetid discharge and air were forced out.   It was
not however at all tinged with blood, and appeared to me to be
merely the secretion from the cyst which had contained the blood.
I directed that this discharge should be pressed out, the cavity
syringed, and a poultice applied three times  a day; but finding
a considerable quantity of fetid fluid still lodged in the cyst,  I
thought it right to make  an opening into it beneath Poupart's
ligament, to  afford it a  more  ready exit.   No abatement in
the quantity, or  alteration in the quality  of the discharge, was
however remarked ; it  seemed to  be such as a sloughing sore
commonly furnishes.
   This fever came on in the evening of the eighth day (Nov. 1)
after that of the operation ; and I am convinced it would have
speedily destroyed the  patient, had not the cause been detect-
ed and removed.   The  powers  of his  constitution  rallied
again  ; his  pulse was firm, and often not more than 100 ; he
took sufficient food, and slept moderately well.   But the part,
 as has been said, did not go  on well, and seemed to  prevent
 any  increase of strength.   For  a week  I  was not  without
 hopes that  some favourable change  might  happen, but  after-
 wards I lost all such expectations, as his already much reduced
 powers were still further declining ; nevertheless, he held out
 more  than another week, when he died  on November 16, the
 twenty-third day after the  operation.  A few days before his
 death both ligatures came away with the dressings. 
252                   ON ANEURISMS.
                       DISSECTION.
  A very slight adhesion had taken place between the sigmoid
flexure of the colon and that part of the peritoneum which was
opposite  to the wound ; but there was  no other appearance  of
that  membrane, or of the bowels, having suffered any inflam-
mation in consequence of the operation.   The peritoneum was
separated from the loins, and from the posterior half of the left
side  of the diaphragm, by a considerable collection of blood,
which extended downwards to Poupart's ligament, and com-
municated under that ligament by a  small  aperture  with  the
aneurismal sac.  This opening was situated in the direction of
that  crevice which is found between the internal iliac and psoas
muscles.   The only rational explanation  that can be given  of
the formation  of this collection is, that the blood had burst  its
way from the aneurismal sac in the vacancy between the mus-
cles  just mentioned ; after  which it would readily and exten-
sively separate the peritonium in the manner described.  I am
inclined to  attribute to this circumstance the undefinable dis-
turbance of health which the poor  patient suffered during the
week preceding the operation.  It may, perhaps, excite sur-
prise that this  collection did not become putrid.
  No particular account can be given of the aneurismal sac be-
neath Poupart's ligament, since it and  the contiguous parts had
sloughed in consequence of the irritation of the putrid blood.   A
small aperture had been made by this sloughing in the front of
the orbicular ligament of the hip joint,  and a small extent of the
thigh bone was, by  the same cause, deprived of its periosteum.
  A bougie was passed from the lower end of the femoral  ar-
tery into the sac.
  The extremities of the external iliac artery, which had been
divided in the operation, were united  together by a firm new-
formed substance ;  the sides of each extremity  were perfectly
closed, and a small plug of coagulated blood was found in each.
  Having thus given as brief an account as I am able of  the
circumstances of this case, as they  appeared to me, I cannot
conclude without mentioning the observations of others, partic-
ularly as they may  assist in suggesting rules of conduct for  fu-
ture operations on similar cases.   It has been said that the irri-
tation of the   aneurismal bag was  probably a spontaneous  oc-
currence, and not the effect of the  acrimony  of  the  putrid
blood.   But the suddenness of this attack, the manifest exist-
ence of  a cause sufficient to produce it, and the total absence 
ON ANEURISMS.
253
of such  an occurrence in all other cases of aneurism, render
this supposition highly improbable.
  It has  also been imagined that part of the discharged blood
might have returned from the lower  end of the artery.   This
latter opinion is  very improbable, since, after the complete re-
moval of the blood, none returned by that channel:  and in the
first  case which  I have related, none returned  by the inferior
part  of the artery, though the area of it was still of its natural
dimensions, and  unobstructed.  This latter observation had
tended to diminish my confidence in the powers of the com-
municating channels, and made me wish to  defer the perform-
ance of the operation as long  as  possible.   It seems evident
that  in the present instance it was too long delayed.
  It would be desirable in future to  perform the  operation be-
fore  an extensive diffusion of blood  had taken place; indeed,
could the adequateness of the  collateral arteries for  the supply
of the limb be established, it would be  proper to operate at an
early period of the disease.
  It deserves to be considered  whether, in cases where it  is
probable the blood has become  diffused, it might not be  right
at the time of the operation to open the  aneurismal bag, and
remove the blood.  I should, however, be inclined to postpone
this  attempt; for,  perhaps, no  necessity might exist, as  putre-
faction might not take place.  A few days will  determine the
degree of life of the limb, and  would make a wound less likely
to ulcerate or slough.  Should  signs of the putrefaction of the
blood ensue, or the probability of such an occurrence become
evident, I should  think it necessary to make  a small opening
into  the aneurismal bag for the removal of the contained  blood.
This being done, if no blood came  from the lower orifice  of
the artery, there would be no necessity for tying it.

                         CASE III.
  Jane Field, aged 40, who had  been in the habit  of drinking
to excess, was admitted into St. Bartholomew's hospital, with
a very large femoral aneurism, reaching as high as  Poupart's
ligament.  The whole limb was oedematous, but in  no very
considerable degree.  She was  quite incapable of using the
least exercise,  or of sitting upright;  and,  even  in bed, she
suffered  continual pain, which was much aggravated during the
pulsation of the aneurism.  The  pain was so violent as to pre-
clude sleep.  She had no appetite : her pulse was feeble and 
254
ON ANEURISMS.
  frequent,  generally exceeding 100;  but  her tongue was not
  furred ; and her bowels were regular.
    On Saturday,  11th October,  1806, the operation was per-
  formed in the same manner as in the last  case.  An incision,
  about three inches in length^ was made thr ugh the integuments
  of the abdomen, in the direction of  the  artery, beginning just
  above Poupart's ligament.   Having divided  the skin and apo-
» neurosis of the external oblique muscle, I introduced my fin-
  ger between the margin of  the internal oblique  and  transverse
  muscles and the peritoneum.   I then divided their lower edges
  upwards, in the direction of the external wound, to  the extent
  of an inch and a half, with  a probe-pointed bistoury.  Having
  thus made room for the admission of my  finger, I put it down
  upon the artery, felt its pulsations, and gently insinuated it be-
  neath the vessel; and then, with  the aneurismal needle, passed
  under it two moderately thick ligatures, carrying them upwards
  and downwards, as far as the detachment of the artery permit-
  ted, and tying  them as firmly as I could.  I next divided the
  artery in the interval,  but  much nearer  to the lower ligature
  than to the upper one.  The wound was afterwards closed, in
  the middle by a ligature, and in other parts by  sticking-plaster.
  Upon removing the patient to bed, she complained of great pain
  in the wound, and in her head ; and was very restless  artd ungov-
  ernable.  She wished for something to procure sleep, and I gave
  her twenty-five drops of laudanum.   This, instead of having the
  desired effect, made her much more restless ; she was continu-
  ally changing  her position  in bed,  and complaining of violent
  headach.  At night she became more tranquil.   The one foot
  was much colder than the other ; but the limbs  at the knees
  were nearly of an equal temperature.
    Sunday, 12th.  I visited her early in the morning, and found
  that she had  been moderately quiet  during the night; that she
  had suffered much pain  in her foot, but  none  in the  wound.
  The pain in the limb she described as having first attacked the
  thigh, next the leg, and afterwards the foot, which last pain had
  now  ceased.   The foot was warmer than it was  the preceding
  evening, and in a state of perspiration : it was four  degrees  of
  heat lower, by Fahrenheit's scale, than that of the healthy limb.
  The superficial veins of the leg were filled  with  blood.  Her
  pulse was 96.   She had no appetite.   I  left her with a promise
  to visit her again atnight, recommending her to  lie quiet, and
  take some simple nourishment.   About noon, one of the dres- 
ON  ANEURISMS.
255
sers, observing that her skin was hot, and the tongue dry, gave
her some saline medicine,  with  a small quantity of antimonial
wine, which  occasioned  vomiting, and  such continual nausea,
that she refused all kinds of food.   The limb, at night, contin-
ued in the same state as in the  morning.   She was free from
pain: her pulse  120.  As she was without an  evacuation, I
gave her a pill, containing two and a half grains of pil. aloet. e
myrrh, with the same quantity of extract of colocynth, order-
ing it  to be repeated in the morning, if necessary.
  Monday, 13th.   The foot was nearly of the same tempera-
ture with the other.   She  had had two stools,  and felt  much
more  comfortable.  Still, however, she had  an aversion  to all
kinds  of nourishment.   Her pulse  was 150  and 160,  at differ-
ent times of the day.   1 may  here mention, that every  subse-
quent day, she had one or  more stools, without having recourse
to opening medicine; and  whenever she was more irritable or
disturbed than usual,  she had  a  tendency to purging.  In the
evening of this  day,  I inquired  if she had a wish  for  any par-
ticular kind  of nourishment;  and,  at her suggestion,  gave her
half a pint of porter with some ginger and toasted bread.  This
seemed to agree with her stomach, as she slept the whole night,
and awoke much refreshed the next  morning.   Her tongue
was then clean ; she took some tea and muffin for breakfast,
and broth and bread,  in  moderate quantities, in the course  of
the day.   Half a pint of porter was allowed her at dinner and
supper.  Her pulse this  day  (Tuesday) was  95. The foot
warmer than  the other.   The  wound was dressed for the first
time;  it  appeared  well  closed,  and  discharged but  little.
Wednesday,  pulse about the same number ; had  slept  during
the night, but not so soundly  as on the  preceding one.   The
wound and contiguous parts were tender ; there was a consid-
erable discharge, which was fetid ; the lower ligature  came off
the artery.  The artery, as I have mentioned,  was divided
very near to the lower ligature;  and it is probable, that,  in the
restlessness of the patient subsequent to the  operation, the mo-
tions of the limb had  drawn the artery from out  of  the liga-
ture.*

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

thick ligature is, that it  may be drawn as tight  as possible, without appre-
hension of cutting the vessel, or of its speedily coming off from it. Should
I, in any future instance, think it right  to oppose any mechanical obstacle
to the ligatures coming off the vessel which it  encircles, I should do it in
the following manner.  Having tied a large knot at one end  of a small
thread, I would pass it, by means of a common sewing-needle, through
the middle of the artery, in front of the ligature which encircles it.   I
would then form a second thick knot on the thread, close upon  the surface
of the vessel.  These two knots would, I think, present a considerable
obstacle to the slipping of the  circular ligature from off the end of the
artery. 
ON ANEURISMS.
257
and  smeared  the  excoriated skin with lard;  to  prevent  the
acrimonious discharge from  affecting  it.   All  appearance of
granulations in the  wound had vanished.  I ordered her fifteen
drops of laudanum in her night draught;  and, instead of the
infus. menth. vitriol. I gave her decoct, cinchon. 3ij, with 3J of
tinct. card. comp. every four hours.
  Wednesday.   She had a comfortable night, with much sleep :
her pulse 80.   The  wound greatly amended.  The discharge
puriform, less  fetid,  and smaller  in quantity.  The new flesh
above the ligature florid ; and  granulations  appeared again on
the sides of the wound, below the ligature.   The  same treat-
ment was  continued.
  Thursday.  She had not rested so well,  and  complained of
headach.   The wound,  however, was rather better than on
the preceding day.  I cut out the ligature which  closed  the
wound in the middle, thinking it might tend to keep up irrita-
tion.   She attributed the pain in her  head to the opium  she
had taken : to ascertain this  point, I  ordered the  dose to be
increased to twenty-five drops.
  Friday.   She had slept  well, and  was free from headach :
her pulse under 80.  This  day,  the ligature, from the upper
part  of the artery, came  away with the dressings.  The  ex-
coriated  skin  had healed ;  the  redness  was  inconsiderable.
The wound, in every part, had a healing appearance.   It seems
unnecessary to  detail particularly the  subsequent part of the
case.  She was kept in  bed to the  end of the  third week,
when she was  allowed to sit  up, that her bed might be made.
I thought this caution requisite, from knowing that ligatures are
detached from arteries before the sides of the vessel are united.
I also confined her to bed during the whole  of the fourth week ;
but  advised her to move  the  limb  about frequently.   The
wound healed like a.healthy wound; and was nearly closed in
a month after the  operation.  During  the  third week,  when
the wound no  longer proved a source  of irritation,  her pulse
did not exceed 75 strokes in a minute; it was generally lower,
and  once I found it to be only 68.   At the expiration of the
month, she got up  daily, and walked about the ward ;  although,
on her admission into the hospital, she was incapable of walk-
ing at all.   There was not the least oedema of the  limb.   Its
circumference, at  the calf,  was  but  one third of  an inch  less
than the opposite side.   Having walked many times the length
33 
258
ON ANEURISMS.
 of the ward, she became tired, and thought that the limb which
 had been operated on, felt more fatigued than the other.  The
 aneurismal tumor remains at this  time of a  considerable size.
 It is certainly more than one third  less than at the  time of  the
 operation.
  I have related the case  thus particularly, in  order  that  the
 reader may judge  of it for himself.   To me it appears, from
 this and the former cases,  that, in an advanced state of femoral
 aneurism, the artery may   be  tied above Poupart's  ligament,
 with as little detriment to the circulation of the limb, as in other
 cases of aneurism, where the operation is attended with very
 constant  success.  The symptoms immediately subsequent to
 the operation, appear to me to-have  arisen  entirely  from  the
 irritable and weak state of the  patient.  She had  pain  in  the
 head from the operation;  and so  she had  afterwards,  when-
 ever her  health was disordered by irritation.  Her pulse, prior
 to her taking the medicine which acted as an emetic,  was 96 ;
 but the subsequent day it  was 150 or 160.  This appears to
 be the result of the state of the stomach,  for  that becoming
 tranquil,  the pulse  was again reduced to 95  or 96.  In a con-
 stitution so weak and irritable, a wound was not likely to heal
 kindly; and all the subsequent circumstances  of the  case  are
 satisfactorily explained, as the effects of an irritable  wound,
 acting upon an irritable constitution.   Upon the  wound becom-
ing  healthy, at the  expiration of a fortnight, all variations of the
 constitution ceased.  1 cannot, therefore, but consider the per-
plexing circumstances that  succeeded the  operation,  as  the
effect  of  the patient's peculiarity of constitution,  and not as
 arising from the operation  itself, or from the state  of the limb
consequent  to such  an operation.  A similar operation  has
lately been performed by  Mr. Frere, of  Birmingham, with
 success.   The  patient being  healthy, the wound healed with-
 out  difficulty.
  Mr. Tomlinson, of Birmingham also, performed a  similar
 operation with equal success,  so that it seems proved that the
 external iliac artery may be tied, in the case of a femoral aneu-
rism,  with as little detriment to the limb, as occurs from tying
the  femoral artery in a case  of popliteal aneurism.   I lately
saw die woman who was  the  subject of the last case which I
have related, and there is no  distinguishable difference in the
 size or strength of the two extremities. 
ON ANEURISMS.
259
                         CASE IV.
  J. Peterson, a Swedish sailor, about forty years of age, was
admitted into  St. Bartholomew's hospital, on  account  of an
aneurism of the femoral artery, just below the groin.   He  was
a thin man, but had strong muscles.  He had a languid appear-
ance ;  his  pulse was  small  and feeble;  his  appetite, accord-
ing to his  report, moderate, and bowels  regular;  his tongue,
however, was much furred.  As the upper and most prominent
part of the aneurismal tumor  was ascending above Poupart's
ligament, so as to make it probable, that if it increased it might
overlap the ligament, and  render the  operation difficult, delay
was inadmissible, and  the operation  was performed on  Satur-
day, 25th  February, 1809.  It was accomplished  as  in the
preceding  case.  I put my  finger behind  the peritoneum, and
clearly distinguished the cylindrical form, and firmness of the
artery  ; but I could not perceive its pulsation.  I pressed on
the vessel, and the  beating of the aneurism ceased : I remitted
the pressure,  and it was  renewed.   Having thus ascertained
that I had  my finger upon  the  artery, I tried to separate it, so
as to get my  finger  round it; but I could not succeed.   I  then
tried with the point of the aneurism needle, carrying it close to
the artery  from  without, towards the cavity of  the pelvis ; but
the vessel yielded so considerably, that I  did not accomplish it.
I tried in a contrary direction,  and  though the artery receded
from  its situation,  as I  think,  fully half an  inch, yet by
perseverance I accomplished my purpose.  I then passed an-
other  aneurismal  needle,  threaded  with a double  ligature,
through the track that I had made, and tied each ligature firm-
ly.  I  have related these  circumstances, that the  reader  may
know  why the artery was not tied  as it  was in the preceding
case.-  I could not bring the artery into view.   I might have
done so lower down nearer to Poupart's ligament; but the ap-
prehension of producing any  communication  between the air
and the blood of the  aneurismal bag, which  might occasion its
putrefaction,  made me tie  the artery at some  distance above
the ligament.  The recession of the artery in this case, before
the pressure  made  by the aneurismal needle, was so considera-
ble as to excite my surprise.
   The patient lay upon his side with his thigh  bent  upon the
 pelvis, and for the  first three days after  the operation without
 pain, or any apparent disturbance of his constitution.  He was
 fed with bread and tea, and bread and broth, and his  bowels 
260
ON ANEURISMS.
 were regular.  The wound seemed closed by adhesion, except
 at its lower part, where the ligatures came out.   On the fourth
 night, he was seized with  violent and  distressing pain  in the
 epigastric region, and on the left side of his chest:  he had not
 the least sleep, and felt very anxious and disturbed.   His pulse
 beat the next day  130 in a minute : his skin was hot and dry,
 his face  flushed, and  his tongue covered  with  a dry brown
 crust.  Two grains of calomel were given to him, and efferves-
 cing sahne draughts were taken every  four hours.  The calo-
 mel produced a purging stool during the night, which had not a
 drop of bile in it.   The following day his pulse exceeded 100
 only by a few strokes, his skin  felt  temperate,  his tongue was
 moist, and  not so brown or  incrusted.  His  pain, also, was
 much diminished,  though the epigastric region was still tender.
 His  saline draughts  were continued, and he-was  directed to
 take five grains of the pilul. hydrarg. each night.  The next
 day  he was still better; his pulse  90,  his skin moist, and his
 tongue cleaner: he took food without disgust, though not with
 much appetite.   As he had  no evacuation from  his bowels, a
 little opening electuary was given' him, and the  saline draughts
 were changed  for the infus. menth. vitriol,  with a little tinct.
 cardam.   He had  a  stool in the  night, which  was  of  a light
 ochre colour; that is, a light  brown, which  dilution would not
 convert into a yellow.  He continued  the same medicines till
 the tenth day after the operation,  with  an  evident amendment
 in his health ; though the alvine discharges which  we contrived
 to procure daily, were still of  the colour above described, but
 somewhat deeper.
   On the tenth'day, after observing his tongue  and pulse, he.
those who saw  him, joined with me in opinion, that he  was in
better .health than when he was admitted into the hospital.
   During this constitutional disturbance, the upper  part of the
 wound became open, and  the discharge was offensive and irri-
 tating, and excoriated the skin over which it flowed.  1 there-
 fore  greased it with fresh lard at  each dressing, to prevent as
 much as possible the discharge from acting  upon  it.  Some
 swelling of the parts on that side of the wound next the ilium
 also took place.  Still there was nothing very materially wrong,
 and the state of the wound gradually amended as the patient's
 health became tranquil.
   On the tenth day, the ligatures came away, and then the
 patient first complained of a pain on the inside of his thigh, just
 above his  knee. 
ON  ANEURISMS.
261
  On the 11th day he repeated his complaints,  and said that
the pain disturbed him, and  prevented his sleeping during the
night.  I knew not to what to attribute it; I thought it might indi-
cate some irritation of the anterior crural nerve; however, as the
patient remained  pretty well, I gave no directions respecting it.
  On the 12th day, when I  visited the patient, I was shocked
at his appearance.  His  countenance expressed  great anxiety
and despondency; and his  pulse was more .than  120.   His
tongue was covered with a  brown fur.  He had  missed his
regular evacuation from the  bowels.   Being clear that the cal-
omel had  been of essential service before, I gave him two grains
of that medicine, and ordered again the effervescing  draughts.
   On the 13th day he was no better, but more languid.  The
calomel had produced two copious loose stools, scarcely tinted
with an ochre colour.  I requested  Dr. Roberts to  see him,
who directed him to take a  grain of opium  at night; ordered
him sago  and wine for food, and the infusion of cascarilla with
tinct. of columbo.
   Fourteenth day.   He neither seemed better nor worse ; he
had slept four hours in the night.  A slight blush of  the skin
appeared on  the inside of the thigh, such as indicates in-
flammation of the absorbing vessels.   Fomentations  and poul-
tice were directed to this part.  Dr. R. also ordered  half a
grain of calomel, with five  of cicuta, to be  taken night and
morning.
   Fifteenth day.   He was  considerably better, though his leg
continued painful; the pain however was diminished.   He was
directed to continue the  same medicines;  and to insure a good
night,  if one grain of opium  failed  to give him rest,  he was
allowed to take another  after  four hours.
    Sixteenth day.  Not quite so well.   He  had had no evacua-
 tion for the  last twenty-four hours.   He took a little opening

 * 6SeUvXeenth  day.   He had a stool during the night  and was
 better    His  thigh was oedematous,  but not painful,   ihe pain
 was descending towards his  ankle.   Dr. Roberts  wished him
 to take the blue pill in preference to the calomel.   Five grains
 were therefore  given each  night.
    Eighteenth day.  He  was better, and continued  gradually
 to improve till the twenty-fourth day, when he declared he felt
 nuite well, and had had  six hours'  comfortable sleep.  The
 colour of the stools had been gradually improving, and on that 
262                  ON ANEURISMS.
day, when  such a marked amendment took place, the stool
might be said to be nearly properly tinctured with bile, and of
a proper consistence.
  During this time an abscess had formed on the inside of the
thigh, a little above the  knee, where  the absorbents  of the
limb began to inflame, and the matter had been discharged by
a puncture  made with a lancet.  Swelling in the ham likewise
took place, and was apparently caused by the irritation of the
absorbents  in that part, but no matter formed in it,  and the leg
also  became oedematous.  The wound made by the operation
had healed firmly, and all tumefaction  about it had subsided.
As the patient's bowels acted regularly, no medicines were now
given him.
  After about a week had elapsed, he was  seized  as  before
with pain   in  the epigastric  region, rheumatism  in  the  right
shoulder, and inability to move the right arm.  His counte-
nance again expressed despondency and disturbance ;  his pulse
was frequent and his skin hot; the  abscess also was painful and
discharged  copiously, and became  distended  with  matter, so
that it seemed necessary to enlarge the  aperture, which had
nearly  healed.   His tongue  was much  furred, and his stools
had no bile in them.
  He  again  took calomel at first, and  afterwards the  pilul.
hydrarg. and the secretion of bile was gradually renewed and
increased,  as in the preceding  instances, which  produced a
proportionate amendment in his general health.   His limb also
was so much improved  as to enable him  to  walk about the
ward, and  to go out occasionally into the  air.
  Believing that living in a better air would greatly contribute
to the  restoration of his health,  he was soon afterwards dis-
charged from the hospital; looking as  well  as he  did on  his
admission,  and  capable of walking with but little infirmity.    He
was advised to take the pilul. hydrarg. every second night, till
the secretion of bile was right, and  to take them  afterwards
whenever he perceived it to be deficient  or faulty.   He was
also enjoined to keep his bowels regular in other respects.
  The cases which I have related and  referred to, show that
the current of blood through the external iliac artery  may be
stopped, without occasioning  any material or even evident dim-
inution of  the powers of the  limb.   It also appears to  me that
this operation does  not  disturb the  constitution in a  greater
degree than a similar one performed upon  arteries  of less 
ON  ANEURISMS.                  263
magnitude.   It is true, that considerable disorder of the consti-
tution took  place in the cases which I have  related,  but it
seemed to have arisen from  the  peculiarities of  the  state of
health of the patients,  and not as a necessary consequence of
the operation.  In the  last case, every thing  went on favoura-
bly till a disorder of the digestive  organs occurred.   To such
disorder it  cannot be  doubted that there was a strong pre-
disposition ; and of which, the operation by  its effects  on  the
mind as well as the body, confinement in an hospital, and great
alteration of diet may be considered as the  exciting causes.  I
think it  probable  that the state of the constitution might have
greatly contributed to produce  the general irritation of the  ab-
sorbents of the limb,  which was first  observed  on the day
when the  ligatures  came away.   I cannot  doubt but that  the
inflammation of these vessels did,  as indeed it  generally does,
greatly  disturb the constitution and  aggravate its disordered
state.   These  conjectures appear to me to be verified  by  the
last occurrence which I have related.  When the wound was
healed,  and the limb  so well as that  it probably could  impart
no irritation to  the general system, from leaving off the mercu-
rial  medicine,  disorder of the digestive organs recurred, and
produced the effects which I  have  described.
  That the femoral aneurism, when it occurs near to the groin,
may, like other aneurisms, sometimes be  cured by  the pro-
cesses of nature, is proved by experience ; yet this is not like-
ly to be the common event of such cases.   I knew two  in-
stances  of patients dying of hemorrhage from such  aneurisms.
The sufferings both of body and mind, in these cases, were
shocking.   The patients were unable to move, and the  disten-
tion of  the integuments and pressure  on the nerves occasioned
great pain  and irritation.  The patients also lay apprehensive
and uncertain of the hour when their sufferings might be termi-
nated by a fearful and fatal hemorrhage.  I think myself there-
fore fortunate that I was first, as it were, compelled to perform
an operation, which, I trust, may be found to diminish the  suf-
ferings, and preserve the lives of  those afflicted with this  dis-
ease.
THE- END. 
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